Center for the Study of Traumatic Stress
Proceedings
Workgroup on Intervention with
Combat Injured Families

Sponsored by the Center for the Study of Traumatic Stress, part of the
Department of Psychiatry of Uniformed Services University and a partnering center of the
Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury

P ro c e e di n g s
Workgroup on Intervention with
Combat Injured Families
Tuesday – Wednesday
December 11–12, 2007
Bethesda, MD

Workgroup Sponsored by:Center for the Study of Traumatic Stress
Department of Psychiatry
Uniformed Services University of the Health Sciences!

DEFENSE CENTERS
OF EXCELLENCEFor Psychological Health& Traumatic Brain Injury

Center for the Study of Traumatic Stress
Uniformed Services University of the Health Sciences
4301 Jones Bridge Road | Bethesda, MD 20814-4799
Tel: 301-295-2470 | Fax: 301-319-6965
www.usuhs.mil/csts | www.CSTSonline.org

WORKGROUP ON INTERVENTION WITH COMBAT INJURED FAMILIES
Editor’s Note: This transcript has been edited, however, as in most transcripts some errors may havebeen missed. The editors are responsible for any errors of content or editing that remain.

IPD 2009 by Center for the Study of Traumatic Stress
Department of Psychiatry
Uniformed Services University of the Health Sciences
4301 Jones Bridge Road
Bethesda, Maryland 20814-4799
Printed in the United States of America

First Edition
Workgroup on Intervention with Combat Injured Families
Edited by Stephen J. Cozza, M.D.
1. Combat Injury. 2. Military Family Stress 3. Principles of Injury Care. I. Cozza, Stephen J.

P ro c e e di n g s
Workgroup on Intervention with
Combat Injured Families
EditorStephen J. Cozza, M.D.
Associate Editor
Nancy T. Vineburgh, M.A.
Transcript Editors
Carol S. Fullerton, Ph.D.
Danielle Marks, B.A.
Patricia Martinez, M.S.N, M.P.H.
Janet A. Schmidt, Ph.D.

Center for the Study of Traumatic Stress
Department of Psychiatry
Uniformed Services University of the Health Sciences
4301 Jones Bridge Road
Bethesda, Maryland 20814-4799

Table of Contents
Workgroup ParticipantsVII

Executive Summary
1
Session 1: Clinical Problems and Core Principles of Intervention 		with Injured Military Families
9Introduction of Workgroup Participants
9
Workgroup Aims and Agenda
11
Introductory Presentation: The Impact of Combat Injury on Military
Families and Children, Dr. Cozza
12
Introductory Presentation Discussion
17
Clinical Problems and Core Principles: Medical Center Participant
Presentations
19
Walter Reed Army Medical Center (WRAMC)
19
Brooke Army Medical Center
23
Navy Medical Center, San Diego Presentation
30
Medical Center Presentation Discussion
32
Discussion and Revision of Core Principles
36Intervention Strategies Discussion
44
Session 2: Practical Application and the Components of 		
Effective Intervention
55
From Clinical Reality to Family-Focused Intervention
55
Project FOCUS: UCLA and NCTSN
61
Practical Application and Components of Effective Interventions
74
Summary and Reflection: Day One
88
Session 3: Integration and Programmatic Intervention
Summary of Proceedings
Programmatic Application and Future Study
Family Systems Perspective
Family Communication and Connectivity
Family Meaning and Connectivity
Parenting Function and Injury Communication
Community Reintegration
Outcome Measures
Closing Comments

95
95
96
103
105
109
112
115
118
124

Bibliography
Appendix129
137

Participants
Theresa Arata-Maiers, Psy.D.
Child and Family Coordinator, Warrior Resiliency ProgramChild and Adolescent Psychology Service,
Brooke Army Medical Center (Name will change to San Antonio Military
Medical Center, effective Sep 30, 2011)
Teresa.Arata-Maiers@amedd.army.mil
William Beardslee, M.D.
Director, Baer Prevention Initiatives and Chairman Emeritus
Department of Psychiatry, Children’s Hospital Boston
William.beardslee@childrens.harvard.edu
Ryo Sook Chun, M.D.
Director, Wounded Warrior Child and Family Program
Clinical Director, Child and Adolescent Psychiatry Service
Walter Reed Army Medical Center
Ryo.Chun@na.amedd.army.mil
Stephen Cozza, M.D.
Professor, Department of Psychiatry
Uniformed Services University of the Health Sciences
Associate Director, Center for the Study of Traumatic Stress
Scozza@usuhs.mil
Carol Fullerton, Ph.D.
Research Professor, Department of Psychiatry
Uniformed Services University of the Health Sciences
Science Director, Center for the Study of Traumatic Stress
Cfullert@erols.com
LCDR Scott Kane, M.D.
Child and Adolescent Psychiatrist
Head, Child Guidance Division
Department of Mental HealthNavy Medical Center San Diego
Henry.Kane@med.navy.mil

Workgroup on Intervention with Combat Injured Families — Conference Proceedings • VII

Patricia Lester, M.D.
Physician, Child and Adolescent Psychiatry
Center for Community Health, UCLA
PLester@mednet.ucla.edu
Patricia Martinez, MSN, CNS-BC
Clinical Nurse Specialist, Psychiatry
Center for the Study of Traumatic Stress
Uniformed Services University of Health Sciences
skipat@shentel.net
LTC Kris Peterson, M.D.
Child and Adolescent Psychiatry Consultant to the Army Surgeon General
Chief, Department of Psychiatry
Madigan Army Medical Center
Kris.peterson@us.army.mil
John Richters, Ph.D.
Research Scientist
Center for the Study of Traumatic Stress
Uniformed Services University of Health Sciences
John.Richters.CTR@usuhs.mil
William Saltzman, Ph.D.
National Center For Child Traumatic Stress
UCLA
Wsaltzman@sbcglobal.net
LTC Brett Schneider, M.D.
Chief, Child and Adolescent Psychiatry Service
Walter Reed Army Medical Center
Brett.Schneider@na.amedd.army.mil
Robert Ursano, M.D.
Professor and Chairman, Department of Psychiatry
Uniformed Services University of the Health Sciences
Director, Center for the Study of Traumatic StressRursano@usuhs.mil
Observers

Rachel Kaul, LCSW
Public Health Analyst, Crisis Counseling Program,
Emergency Services and Traumatic Stress Branch, SAMHSA/CMHS
Rachel.Kaul@samhsa.hhs.gov
James McCarroll, Ph.D.
Director, Family Violence and Trauma ProjectCenter for the Study of Traumatic Stress
Jmccarroll@usuhs.mil
VIII • Workgroup on Intervention with Combat Injured Families — Conference Proceedings

John Newby, Ph.D.
Research Scientist
Center for the Study of Traumatic Stress
Jnewby@usuhs.mil
Nancy Vineburgh, M.A.
Assistant Professor, Department of Psychiatry
Uniformed Services University of the Health Sciences
Director, Office of Public Education and Preparedness
Center for the Study of Traumatic Stress
Nvineburgh@usuhs.mil
Dorinda Williams, LCSW-C
Senior Training and Consultation Specialist
Military Projects at ZERO TO THREE
Dwilliams@zerotothree.org

Workgroup on Intervention with Combat Injured Families — Conference Proceedings • IX

Workgroup Participants

Dr. Stephen Cozza,
Associate Director of theCenter for the Study ofTraumatic Stress

LTC Peterson, Chief of
Psychiatry at Madigan
Army Medical Center(MAMC), and Child andAdolescent Psychiatry
Consultant to the Surgeon
General of the Army.

Dr. Lester, a child andadolescent psychiatrist
and Director of a Childand Adolescent Trauma
Psychiatry Clinic.

Ms. Martinez, a retired
Army nurse now working
with Dr. Cozza and theWorkgroup on Intervention
with Combat Injured
Families at CSTS.

LTC Schneider, Chief ofChild and Adolescent
Psychiatry at WRAMC, an
adult, child and adolescent
psychiatrist, as well as aforensic psychiatrist.

Dr. Arata-Maiers, Child andFamily Coordinator for the
Warrior Resiliency Programat Brooke Army Medical
Center (BAMC).

Dr. Saltzman, Project Focus
Team at UCLA, a childpsychologist, Professor,
and director of a Family
Therapy Program at
California State University
at Long Beach.

Dr. Fullerton, ScientificDirector CSTS anda Professor in the
Department of Psychiatryof Uniformed Services
University of the Health
Sciences (USUHS)

Dr. Chun, Child andAdolescent Psychiatry
Service at WRAMC.

LCDR Kane, head of Childand Adolescent Psychiatryat Naval Medical Center,
San Diego (NMCSD).

Dr. William Beardslee,
Director, Baer Prevention
Initiatives and Chairman
Emeritus, Dept. of Psychiatry,Children’s Hospital Boston.

Dr. Robert Ursano, Director,
Center for the Study ofTraumatic Stress; Chair,
Department of Psychiatry,
USUHS.

X • Workgroup on Intervention with Combat Injured Families — Conference Proceedings

Combat injury is a

Executive Summary

life-altering event that

Workgroup on Intervention with Combat Injured Families

impacts not just theservice member but his/her family and children.

Introduction: Addressing the Needs of Combat Injured Families
Combat injury is a life-altering event that impacts not just the service member but his/her family and children. The affected population is significant in
number and in terms of the unique challenges that include the short-term disruptions of individual and family routines and sense of safety, to longer-term
issues around parenting and family health.
On December 11th and 12th, 2007, a number of prominent clinicians andresearchers in the fields of child and adolescent psychiatry, military medicine and family trauma met to conceptualize the hitherto unaddressed needs
and challenges of the combat injured family. This expert consensus gathering,referred to as the Workgroup on Intervention with Combat Injured Families,
included six Chiefs of Psychiatry from major military medical centers and arenowned Children’s Hospital, and the Child and Adolescent Psychiatry Consultant to the U.S. Army Surgeon General.
The Workgroup’s primary objective, which was met, was to develop anddisseminate a set of core Principles of Caring for Combat Injured Families andChildren (see appendix). These principles would serve to guide simultaneous endeavors of scientific research and evaluation, and clinical interventions
to mitigate family distress and dysfunction, and to improve communication
around the injury within and between the healthcare, family and community
settings. Other products were to include an edited transcript (attached), an
Executive Summary, and a scholarly article initiating a scientific community
dedicated to achieving the highest level of care for our nation’s combat injured
families and children.
Day One, Clinical Problems and Core Principles of Intervention with Military Families, provided an expert presentation on the scope, nature and uniquechallenges of combat injured families and children followed by presentations
from Walter Reed Army Medical Center, Brooke Army Medical Center, Naval
Medical Center San Diego and Madigan Army Medical Center. Participants
described their sites’ experiences providing care to combat injured families
in the context of identifying and developing a Core Principles of Care document. Day Two, Integration and Programmatic Intervention, examined existing
family trauma interventions to refine programmatic strategies for a manualized intervention to improve care and outcomes with this population.
The Center for the Study of Traumatic Stress (CSTS), part of the Department of Psychiatry of Uniformed Services University Medical School, sponWorkgroup on Intervention with Combat Injured Families — Conference Proceedings • 1

It is not only the painthat they are dealing
with, but it is part ofthat whole transitionof the combat mindset
complicated by the
injury process.

sored the Workgroup. CSTS is the academic arm and a partnering center ofthe newly established Defense Centers of Excellence (DCoE) for Psychological Health and Traumatic Brain Injury. CSTS conducts research, educationand consultation around the psychological effects and health consequencesof exposure to war, natural disasters, terrorism and public health threats. The
Center’s Associate Director and head of its Child and Family Program, Dr.
Stephen Cozza, spearheaded this initiative. Dr. Cozza is the former Chief of
Psychiatry of Walter Reed Army Medical Center and a leading scholar, educator and consultant to public and private sector stakeholders on understanding
and meeting the needs of families and children affected by combat injury, lossof life, as well as the larger needs of families and children affected by trauma.
Scope and Nature of Problem
So many service members invest so much of themselves in being in the military, and then they are injured. It is not only the pain that they are dealing with,
but it is part of that whole transition of the combat mindset complicated by the
injury process. We need to recognize the necessary work that allows them to once
again be available to their families and children.
Since the start of OIF and OEF, there have been close to 40,000 injuries ofwhich 16,000 have required medical evacuation. These injuries include amputations, Traumatic Brain Injury (TBI), burns and other serious injuries. Since
forty percent of U.S. service members have children, averaging approximately
two children per parent, some 24,000 military children have been affectedby serious combat related parental injuries. These numbers do not reflect thenon-dependent children whose siblings have been injured, nor the parents
of non-married and married soldiers, many of whom leave their communities and jobs to attend to their injured children in hospitals and rehabilitation
centers across the country.
The incidence of mental health problems is high amongst this population further complicating treatment and recovery. Between 10–40% of service members who suffer severe physical injuries develop depression or posttraumatic stress disorder (PTSD) after hospitalization. The literature suggeststhat combat injured veterans are at greater risk for developing PTSD whencompared to non-injured counterparts.
A deployment that results in a severe combat injury is likely to have profound effects on the service member’s spouse and children. From the initial
distress to the long-term injury adjustment challenges, children and families
face difficult emotional and practical problems. Severe parental injury disrupts the family system — its routines, cohesion and sense of safety. Combat
injury also affects existing patterns of parenting, as both injured and uninjured parents experience their own emotional response and face the difficult
reality of medical treatment and rehabilitation over time.
Combat Injury Unique Challenges
The injury inherently disrupts the constellation and function of the family
and adds stress to the family unit. It tends to widen splits in families that are
already present, and add conflict when the dust has settled. Suddenly you havethis injury event that just complicates things. Even when families pull together
closely, the impact of the combat injury on families is more likely to disorganize
than to organize families.

2 • Executive Summary

The injury inherently
disrupts the constellationand function of the family
and adds stress to thefamily unit.

Serious parental injuries, particularly those that lead to disability and/or
compromise in parental function, are likely to result in child and family behavioral or emotional problems, as well as family dysfunction. Drawing upon
their experiences, Workgroup participants catalogued some of the uniquechallenges that combat injury inflicts upon service members and their families, and the implications of these challenges on parenting, child development
and providing care.
Injuries to a service member are likely to result in a flurry of urgent activity and anxiety, leading to disruption of family roles, sources of care andinstrumental support. Often immediate information regarding the nature andseverity of the injury is limited, and sometimes inaccurate, causing increased
anxiety in families. Complicating matters further, adults often do not know
how to speak to children about the injury, or how much and what kind of
information to share. Injury communication is a new term that refers to boththe provision of information and the manner in which it is delivered. Injury
communication is a significant challenge that occurs from the outset of the
injury process and over time, and involves the healthcare setting to patientfamily, family to children, and to the outside community.
Spouses face the dual challenge of supporting their injured service member and sustaining their parenting role. Upon being notified of the injury, many
spouses travel abroad and stateside leaving their children in the custody of family or friends for indefinite periods of time. Preoccupation with serious medical issues can reduce their awareness of their children’s needs, not necessarily
in a punitive or a toxic way, but may certainly lead to change in their availability and a very real disconnect between the parent and the child. The spouse’s
most frequently reported concerns about their children include: 1) changes inparenting style and in their children’s routines; 2) the emotional health of theirchildren; and, 3) concerns about continuing to be effective parents.
Spouses also can be the recipient of the frustration and angst of the injured
soldier. According to one participant, “Oftentimes the anger that the service
member is experiencing is directed at the spouse, and sometimes at the children.
We have found an increase in the potential for abuse and we have encountered
several cases of spouse and child abuse.”
The impact of a parental injury on a child is profound and potentiallyleads to long-standing consequences. Children must integrate the meaning of
the injury within their own developmental understanding, possibly requiringthem to modify the internal images of their injured parents. Ultimately, a childmust develop an integrated and reality based acceptance of those changes. According to one participant who works with burn patients, “the extent of a facial injury may be difficult for a child, from a developmental perspective, because
the parent looks so very different. We have children who talk about knowing that
this is their parent but it may take months for them to realize that this is really
their parent.” In addition to fear, young children often blame themselves forthe parent’s injury. Adolescents may react by engaging in risk behaviors that
express anger, sadness or a sense of invulnerability.
Children are variably prepared for hospital visits. In addition, hospital
clinical staff is frequently not educated about the developmental needs of children, the risks of traumatic exposure, and the fact that parents might benefit
from guidance about the needs and likely reactions of their children in thiscontext.
Workgroup on Intervention with Combat Injured Families — Conference Proceedings • 3

Remaining culturally
minded, militaryfamilies often pride
themselves on theirself-sufficiency. They
do not necessarily
like seeking out or
demanding things.

The impact of combat injury on a service member can be devastating tohis/her personal identity and parental role. For many Marines and Army soldiers who identify with physicality and athleticism, the enjoyment of parenting is also linked to physical activities such as wrestling, tossing a ball, runningand playing games. To lose one’s physical ability complicates the transition
to post-injury health and it may also require learning to parent in new anddifferent ways. One Workgroup participant describes “a Special Forces service
member who had lost his eye and a limb and anticipates that he will not be able
to shoot or run, and he feels so lost. He is 29 years old and…feels he cannot be afather to his three-year-old son...Only after he was able to talk about his losses
and his trauma could he begin to think about his role in a different way. He decided that he was going to be a teacher; as he was teaching his physical therapy
exercises to his children, he realized that he could turn those teaching skills into
an occupation as a teacher.” The capacity to shift one’s sense of identity andto incorporate alternate pleasurable ways of parenting is a key to the healthytransition of families and children, as well. The multiple challenges unique tocombat injury coalesce to have highBarriers to Care
Remaining culturally minded, military families often pride themselves on
their self-sufficiency. They do not necessarily like seeking out or demanding
things. It is important to develop or shift the model from one of dependency toself-sufficiency or self-care.
Diminishing individual and family distress and fostering parental function and family health is a critical component of creating a recovery environment for the combat injured and his/her family. While the trajectory of combat injury care involves both the acute hospital setting (Stabilization Phase)and long-term care (Sustainment Phase), a number of barriers exist that mustbe acknowledged in developing family-based interventions.
Combat injured families tend to self-organize, caring for each other’schildren and families through the acute hospital ordeal. This can diminish
provider opportunities to educate and work with families around sensitive
issues that may exist or will exist over time. Working through parents may be
the only way to address the needs of children who may not be present at thehospital, but many parents in acute hospital settings are too preoccupied andoverwhelmed to address the needs of their children while attending to the
medical needs of their spouse. Some military and Veterans Administration(VA) hospitals recognize the need and are better resourced to treat combat
injured families, and others may or may not be.
Many injured service members may leave the military and enter communities that lack military healthcare facilities or have VA hospitals and centers
whose staff has limited clinical knowledge of working with families of the
injured. The community itself is an important support network for combat
injured families. In the words of one participant, “When the injured service
member re-integrates into the community, the community reacts positively or
negatively to seeing the injured person and the family is aware of those reactions… How does the family navigate through the community system and when
the community responds, how does the family handle the response?” There are
unique and multiple challenges that result from combat injury. Common to
many of these are challenges involved in reducing child and family distress,

4 • Executive Summary

The 10 core principles
form the basis forcomprehensive,
sensitive andmilitary-appropriate
interventions of carefor combat injured
families and children.

sustaining parenting roles, fostering effective communication, and addressing
barriers to care.
Core Principles
Ten “Core Principles of Care” were created as a result of the expert consensus discussion. These principles form the basis for comprehensive, sensitive and military-appropriate interventions of care for combat injured families
and children. The simultaneous use and study of these principles will foster
greatly needed evidence-based approaches that can support healthy family
growth and recovery. These principles may be utilized by military and civilian
hospital and/or community professionals to effectively manage clinical programs. Common to all is recognition of individual and family strength andresilience in the face of profound change and challenge. The ten principles aredescribed below:■■ Principles of psychological first aid (PFA) are primary to supporting Injured Families. Care of injured service members and families should incorporate key elements of PFA: providing safety, comfort, information,practical assistance and connection to appropriate community resources— all serving to support healthy family recovery.
■■

Medical care for the combat injured must be family focused. Care of combat injured service members must attend to family needs and specificallyshould work toward relieving family distress, sustaining parental functioning, and fostering effective injury related parent-child communication.

■■

Service providers should anticipate a range of responses to combat injury.
Serious injury will challenge our healthiest families. Most service members, their children and families will adjust to the injuries they sustain:others may struggle with the changes that they face. Some may even develop problems that require treatment. Service providers should expect
this broad range of responses and be prepared to meet family needs as
they are identified.

■■Injury communication is an essential component of injured family care.
Effective injury communication involves the timely, appropriate and accurate sharing of information with and among family members, from themoment of notification of injury throughout treatment and rehabilitation. Communication should be calibrated to address patient and family anxiety and to sustain hope. Because families may be uncertain how
to share difficult information with their children, they may benefit fromprofessional guidance on what to say and how to say it.

■■

Injured family programs must be developmentally sensitive and age appropriate. Services and programs must address the unique developmental
responses of children of varying age and gender, and recognize that distress, care needs and communication ability will change with children ofdifferent ages.

■■

Injured family care is longitudinal, extending beyond immediate hospitalization. Services need to be tailored to the changing needs of the combat injured family throughout the treatment and rehabilitation process.
Interventions must meet the family where it is at within the recovery
Workgroup on Intervention with Combat Injured Families — Conference Proceedings • 5

process, recognizing a family’s unique strengths and challenges, as wellas anticipate the future needs of families as they transition to a new community or new way-of-life.

There is an urgent need forresearch to develop effective
family focused intervention■■

Effective injured family care requires an interconnected community ofcare. Effective intervention requires collaboration and coordination ofservices between the family, the health care system, and military and civilian community resources. This collaboration fosters a community ofcare that reaches across traditional professional boundaries throughout
rehabilitation and recovery■■

Care must be culturally competent. Healthcare and community professionals who interact with combat injured families need to possess the cultural and language competence to engage families that may be traditionalor nontraditional in their composition and may be of broad ethnic andreligious backgrounds. It is essential that all healthcare and community
service providers understand and respect the unique experiences and traditions of military families.

■■

Communities of care should address any barriers to service. Barriers tointervention can complicate the healthy recovery of combat injured service and family members. These barriers may include a family’s difficultyin accessing health care or community services. In addition, a community’s lack of awareness or misunderstanding of the needs of a combat
injured family or a family’s hesitation to seek assistance can also limit
family intervention and recovery■■

Families, communities and service providers must be knowledgeable. Individuals, families, professionals, organizations and communities all havea need for access to quality educational materials to address the challenges that confront combat injured families. Effective education leads tothe development of skills in all parties, building empowerment in communities and families. Development of new knowledge is fundamental tobetter meeting the needs of this unique population.

strategies that may better
meet the short and longterm needs of combat
injured families.

Interventions: Goals and Strategies
While the problems facing families of combat-injured individuals have been
described and are addressed in clinical treatment centers, no empirical data has
been collected on the impact and severity of combat injury on families to inform
intervention and treatment planning (Cozza, Chun & Miller, in press). Thus,
there is an urgent need for research to develop effective family focused intervention strategies that may better meet the short and long term needs of combat
injured families.
On Day Two, Integration and Programmatic Intervention, participants
deconstructed the challenges of combat injury on children and families to
identify actionable intervention strategies, goals and proposed outcome measures. The three identified domains that interventions should target wereidentified as individual and family distress, individual and family function
and injury communication. Many of these strategies were drawn from Project
Focus (Families OverComing Under Stress), a program initiated by UCLA,
and used in military communities around the country to address deployment
cycle family stress. There was consensus around the following points.
6 • Executive Summary

Interventions should
also foster effective
injury communication.

Intervention in the acute hospital setting to foster parental function
should:■■ Be flexible, modifiable and strength-based (vis a vis family function) versus pathology-based.
■■

Include both a brief model and more comprehensive model focused onparent and/or child mastery sessions.

■■Acknowledge family anxiety and distress, and help parents to acknowledge its impact on the family and children.

■■

Incorporate a family system perspective that paves the way for alteringfamily function and a caring recovery environment.

■■

Anticipate child development issues, i.e. adolescent risk behavior in reaction to parental injury.

■■

Have applicability in the civilian population for children exposed to traumatic parental injury or illness.

Interventions should also foster effective injury communication. Injury
communication, in its broadest sense, refers to the provision and delivery of
information related to the injury. It is a process that encompasses notification,
the acute hospital phase (provider/patient information), the family itself (parent to children to extended family) and community (friends, schools, social
support systems and the media). Effective injury communication facilitates
connectivity within and between hospital, family and community.
Interventions to foster injury communication should address:■■ The type, role and effectiveness of communication (what is enough/toomuch/what should be shared/not shared/in what ways and with whom).
■■Calibrating the message to foster realistic hope, appropriate involvement
and reduced stress.

■■

The importance of helping a family construct an injury narrative that will
provide meaning for the family and children, and a way of communicating their experience to friends, schools, and the community.

■■

The role of communication in community reintegration. As families reintegrate into the community, effective communication allows them toadvocate for themselves through appropriate and timely help-seeking aswell as to engage in family problem-solving.

■■

Health communication materials and resources are needed to educate
combat injured families, community healthcare providers and the community at large about the unique challenges and needs of military families and children impacted by parental injury.

Conclusion/Summary
The recovery of an injured service member’s family and children is a process
and not an event. The injury experience itself is unique to the family and varies
significantly depending upon the nature of the injury, the structure of the family,
the developmental level of the children and the expected outcome, treatment,
and rehabilitation process.
Military families and children of the combat injured are a diverse andgeographically dispersed population living in military and civilian communiWorkgroup on Intervention with Combat Injured Families — Conference Proceedings • 7Taking care of militaryfamilies, especially as aresult of serious injury,
can foster recruitment
and retention and sends
an important message
to the nation that those
who have sacrificed forour national security
deserve the highest
level of care at thetime of the injury andthroughout what may
be an extensive periodof recovery.

8 • Executive Summary

ties across the United States. Their care needs are complex, unique and entwined, and necessitate informed involvement from healthcare professionals,
community service providers, and family and friends. Importantly, care must
be delivered with sensitivity and skill from the acute in-hospital phase andthroughout the long and arduous road to recovery, which includes transition
back to one’s home and one’s community.
While many children will remain healthy in the face of this stress, some
may sustain life-changing trajectories in their emotional development and/or their interpersonal relationships. Parental injury can alter the child’s viewof the wounded parent, and undermine the child’s sense of his or her own
physical strength. Indeed, it is likely that the effects of combat parental injury
on children are more complex and potentially more challenging than nonviolent and accident related injuries.
Intervention strategies need to include a longitudinal perspective. Good
post-injury care is not just about the injured service member. Health care facilities need to include children and families as part of the treatment planand process. Family members are not outsiders or visitors to the health carefacility; they are participants in the care plan. Hospitals should develop childand family friendly treatment environments, incorporate children into rehab
activities, protect them from possible traumatic exposures and monitor at riskfamily situations. Such efforts are likely to have a positive impact on the combat injured parent, family and children, as well as the health care team.
The Workgroup intends to formalize techniques to measure and address
the challenges of the combat injured family to be sure that interventions andprograms are helpful and evidence-based. While the process will be iterative,
developing interventions will correlate with the core set of Principles of Caring
for Combat Injured Families. Research and evaluation will require resourcesand environmental support, to include funding as well as active application in
healthcare settings.
It is important to recognize that the next generation of the U.S. military iscoming from the children of the current generation of military service members. Taking care of military families, especially as a result of serious injury,
can foster recruitment and retention and sends an important message to thenation that those who have sacrificed for our national security deserve thehighest level of care at the time of the injury and throughout what may be an
extensive period of recovery.

S ession O ne :Clinical Problems and Core Principles ofIntervention with Injured Military Families
Introduction of Workgroup Participants■■

Dr. Cozza: Welcome to our Workgroup on Intervention with Combat Injured Families. We, at the Center for the Study of Traumatic Stress (CSTS),
have been planning this Workgroup for some time and are very pleased
to be hosting it today. It is good to have everybody here to address theconcerns that combat injury is having on children and families of our service
members. This topic has been important to me and in my work for many
years now. The impact of combat injury on military families and children
is also a topic of tremendous significance to you, and to our Nation. Let’s
begin by introducing ourselves to each other.

■■

LTC Peterson: I am Chief of Psychiatry at Madigan Army Medical
Center (MAMC) and the Child and Adolescent Psychiatry Consultant, to
the Surgeon General of the Army. I was born and raised in Tacoma, Washington. I am glad to be here and I am very interested in doing researchand supporting our military children. I completed my adult residency andchild and adolescent psychiatry training at Walter Reed Army Medical
Center (WRAMC).

■■

Dr. Lester: I am a child and adolescent psychiatrist and serve as the Director of a Child and Adolescent Trauma Psychiatry Clinic. I also work at
a research center, the Center for Community Health at University of California at Los Angeles (UCLA). Bill Saltzman and I have developed Project
FOCUS. I am the Director of the Project FOCUS Initiative for the Marines
and Navy, and I will talk about this project this afternoon.

■■

Ms. Martinez: I am a retired Army nurse who is now working with Dr.
Cozza and the Workgroup on Intervention with Combat Injured Families
at CSTS. I had the pleasure of working with Drs. Cozza, Chun and Wain,and his staff, at WRAMC where I worked on the Post Deployment Health
Assessment Tool Project completing initial and follow-up assessments on
selected, battle injured service members.

■■

LTC Schneider: I am the Chief of Child and Adolescent Psychiatryat WRAMC, and an adult, child and adolescent psychiatrist as well as aforensic psychiatrist.

Workgroup on Intervention with Combat Injured Families — Conference Proceedings • 9

Everybody here will

Dr. Cozza: And, an Iraq War Veteran. We are pleased to have a numberof combat veterans at this Workgroup meeting.

address the concerns■■

Dr. Richters: I am local, and was trained as a child psychologist. My
research and writing for the past 20 years have been in the area of child andadolescent psychopathology focusing on children who are living in highrisk environments exposed to violence. I was at the National Institute of
Mental Health (NIMH) for most of those years. I have recently joined thestaff at the CSTS Workgroup on Intervention with Combat Injured Families.

■■

Dr. Arata-Maiers: I am the Child and Family Coordinator for our
Warrior Resiliency Program at Brooke Army Medical Center (BAMC). I
have been working with military families for about 12 years. I am working
with Steve on a couple of projects related to military families.

■■

Dr. Saltzman: I am part of the Project Focus Team at UCLA with
Trisha Lester. I am also a child psychologist, a Professor, and run a Family Therapy Program at California State University at Long Beach. I havebeen developing programs for children and families for a long time. John
reminded me that it was 20 years ago that we developed the survey forchildren exposed to violence.

■■

Dr. Fullerton: I am the Scientific Director at the CSTS. I am alsoa Professor in the Department of Psychiatry of Uniformed Services University of the Health Sciences (USUHS). I work closely with our Center’s
Director, Robert Ursano. As a developmental psychologist, my interest in
our disaster, trauma and terrorism projects has been related to children
and families. At CSTS, we initiated some of the first research on spouses ofdisaster workers, and have studied a wide range of disasters and traumas.
I have known Steve for many years and I am glad that he has joined us at
the CSTS.

■■

Dr. Chun: I am working on the Child and Adolescent Psychiatry Service
at WRAMC. I have been working with children and families since the 9/11
terrorist attacks when we ran our Family Assistance Center at the Pentagonsite. With the start of Operation Iraq Freedom (OIF) and Operation Enduring Freedom (OEF) in 2003, the Child and Adolescent Psychiatry Services
at WRAMC added a new service called the Psychiatric Consultation andLiaison Service, part of the Walter Reed Child and Family Service Center.
The Center’s service model is based upon the DoD Family Assistance Center and the principles learned from 9/11. The Psychiatric Consultation andLiaison service provides preventative psychiatric consultation to combat
injured service members’ families and children recognizing that they are
under a great deal of stress and at risk for traumatic responses.

■■

LCDR Kane: I have been the head of Child and Adolescent Psychiatry at
Naval Medical Center, San Diego (NMCSD) for about three months. Prior
to this assignment, I was a Fellow at WRAMC working with Dr. Schneider
and Dr. Chun.

■■

Ms. Williams: I am a clinical social worker at Zero to Three, which isa national nonprofit organization dedicated to the needs and interests ofinfants and toddlers. Within the Zero to Three Program, we have a Military Projects Division that performs a variety of initiatives. I work with the‘Coming Together around Military Families Initiative’, and have experi-that combat injury is
having on children andfamilies of our service
members.

10 • Session 1: Clinical Problems and Core Principles of Intervention with Injured Military Families

ence with family advocacy and a home visitation program. Zero to Three
is supporting 12 military installations and two medical centers aroundthe country focusing on stress, trauma, grief and loss. I am also a Marine
Corps spouse who has always supported military families.

As a result of thisWorkgroup, we would
like to: 1) develop a
set of core principles■■

Ms. Kaul: I am with the Substance Abuse and Mental Health Services
Administration (SAMHSA). I am a Federal Project Officer for the National Child Traumatic Stress Network (NCTSN), an organization that has astrong interest in serving this particular population. We recently enteredinto an agreement with the CSTS to bring the Center into the NCTSN asa non-funded Category II network site. I want to keep current on Workgroup activities to facilitate collaboration with other members of our
NCTSN across the country.

■■

Ms. Vineburgh: I work at the CSTS as Director of the Office of Public
Education and Preparedness. I have been in the field of health communication and mental health communication for nearly 30 years. I am here
because of our Center’s interest in developing information for behavioral
health change. We have completed many different projects and publications around that focus. We developed Courage to Care, an electronic fact
sheet campaign that is distributed to military healthcare leadership, andlast April, our team led by Steve, developed a campaign for the militarychild called Courage to Care for Me. Our public education work is very
innovative. On page nine of Center for the Study of Traumatic Stress, 2007
Report, there is a very nice description of our Center and the very important role that Steve played in a Sesame Workshop and public education
initiative, as well as the Courage to Care for Me initiative.

■■

Dr. McCarroll: I work at CSTS and oversee our Family Violence andTrauma Project; my work area is in family violence research.

that would informthe intervention withinjured families;2) catalogue family
problems associatedwith combat injury;3) describe theevidence-informedinterventions that areappropriate to address
those problems…

Dr. Cozza: We will be spending the next day and a half together and I
look forward to being your host. For clarification, this meeting is not a conference. It is a workgroup. Because of that, there are some products that we
expect to create from this Workgroup meeting. There are some other people
who will be participating at some level. Dr. Bill Beardslee from Children’s
Hospital Boston will join us soon. Bill was a major participant in the development of the FOCUS intervention and he has a great deal of experience working with families with parental mental illness. Dr. Robert Ursano, Chairmanof the Department of Psychiatry at USUHS and Director of the CSTS, will
join the group tomorrow. Dr. Doug Zatzick from University of Washington
who has developed collaborative care models of intervention for the injured
will be participating in future Workgroup efforts. Dr. John Newby, one of our
CSTS doctoral level social workers will be joining us as an observer. COL
Bruce Crow, Chair of Behavioral Health at BAMC and Capt. Warren Klam,
Chair of Psychiatry at Naval Medical Center, San Diego, were not able to attend, but did send representatives.
Workgroup Aims and Agenda
Dr. Cozza: I will now review the information that was passed out. There
were several electronic attachments that I hope you all had an opportunity toperuse, the Workgroup Agenda, Participant List and a copy of the PsychologicalFirst Aid Field Guide, Second Edition, which was published by the NCTSN. In
this guide, you will notice the core Principles of Psychological First Aid.
Workgroup on Intervention with Combat Injured Families — Conference Proceedings • 11

“The impact of a parental
injury on a child is
profound and potentiallyleads to longstanding
consequences. Children
must integrate themeaning of the
injury within theirown developmental
understanding, possibly
requiring the child tomodify the internal imageof the injured parent.
Ultimately, a child must
develop an integrated
and reality based
acceptance of thosechanges.” 		

As a result of this Workgroup, we would similarly like to: 1) develop a setof core principles that would inform the intervention with injured families; 2)catalogue family problems associated with combat injury; 3) describe the evidence-informed interventions that are appropriate to address those problems;and, 4) refine programmatic strategies for a manualized intervention.
The Workgroup process will be product focused. We will develop an editedtranscription text and an Executive Summary of this meeting. We will havea strategic discussion focusing on the objectives. Thinking about core principles that would apply to these families in any setting is important. We also
want to be thinking about intervention strategies that are appropriate in theacute hospital setting (Stabilization Phase) and in long-term care (Sustainment Phase). We will be working to manualize this intervention (to create anintervention manual) leading to scientific study and evaluation. Using a tiered
model, we will start with core principles and narrow them down to protocoledinterventions recognizing that scientific study may not occur at everybody’ssite, but that the core principles should apply at every site.
As noted, several Workgroup products will come out of this meeting, andothers will continue to be developed beyond this meeting. In addition to developing group consensus on what are the core principles of intervention with
combat injured families, and developing intervention strategies for use with
combat injured families, this Workgroup can be viewed as an opportunity todevelop a scientific community where everybody participates and assists indeveloping a scientific paper with multiple authorship. This paper will describe the clinical problems, core principles and the intervention strategies touse with combat injured families.
To start, we will describe the experiences that we have had with injured
families, and then have an opportunity for the different clinical sites represented here, which include Walter Reed Army Medical Center (WRAMC),
Brooke Army Medical Center (BAMC), Naval Medical Center, San Diego(NMCSD), and Madigan Army Medical Center (MAMC) to provide tenminute presentations about their work with injured families. The focus will
be on identification of core principles. Please address your five most importantlessons learned, and include the most important things that you are doingwith injured families that could inform our core principles.
In the afternoon, we will talk about intervention strategies. Bill Saltzman
and Tricia Lester will discuss the FOCUS Model. We will then review different
intervention models and their applicability to injured families. Then we will
do a round up and have dinner. In the evening, our Planning Committee will
get together to digest and integrate today’s discussion materials and develop
the agenda for tomorrow. We wanted to have an opportunity to pull things
together, bring the results back to the group, and then address those distilledideas with the group participants.
Introductory Presentation: The Impact of Combat Injury on Military
Families and Children, Dr. Cozza“The impact of a parental injury on a child is profound and potentially leads tolongstanding consequences. Children must integrate the meaning of the injury
within their own developmental understanding, possibly requiring the child tomodify the internal image of the injured parent. Ultimately, a child must develop
an integrated and reality based acceptance of those changes.” — Dr. Cozza

12 • Session 1: Clinical Problems and Core Principles of Intervention with Injured Military FamiliesWe need to rememberthat any identified core
principles or intervention
strategies may be used byboth military and civilian
health care professionals
in either hospital orcommunity settings, andplan accordingly.

Figure 1.1: Range and Prevalence of Combat Injuries.

Cozza: While there are a host of military family challenges, our main
focus today is on combat injury and the unique needs of military families related to these injuries. Using a power point presentation, I will discuss the
CSTS experiences and work in this area. Also, some of this work was done at
WRAMC when I was the Chief of the Department of Psychiatry.
Figure 1.1 presents a description of the range of combat injuries. Injury severity may vary depending upon your clinical site, however most of the military medical center sites are receiving service members who have received serious injuries including amputations, Traumatic Brain Injury (TBI) and burns.
Given the range of combat injuries, any intervention should be applicable tothese different clinical populations.
Figure 1.2 is a summary slide of casualties that have been reported since
the start of the war. There are close to 40,000, although most of them did not
require air evacuation. About 16,000 service members suffered injuries thatwere serious enough to require air evacuation (combat and non-combat related combined). Many of the injured will leave the military and return to communities where there may not be military health care facilities. Some combat
wounded service members may return to communities that have a Veterans
Hospital whose staff may have limited clinical understanding of the impactthat the combat injury has on a service member’s family and children.
We need to remember that any identified core principles or intervention
strategies may be used by both military and civilian health care professionals ineither hospital or community settings, and plan accordingly. In work that wasdone at WRAMC, Pat Martinez and her staff used the Post Deployment Health
Assessment Tool (PDHAT) with combat injured service members to assist
clinicians with the management of their care. The PDHAT as distinguishedfrom the Post Deployment Health Assessment and Reassessment (PDHA andPDHRA) tools, which are purely screening instruments for detecting mental
disorders in returning soldiers over time, is a more comprehensive instrument
Workgroup on Intervention with Combat Injured Families — Conference Proceedings • 13

As we consider core
principles, the importanceof family cannot be
underestimated.

Figure 1.2: Reported Casualties Since the Start of IOF.

used for research purposes. These purposes may include collecting information about combat exposures, prior trauma history, as well as screening for
posttraumatic stress disorder (PTSD), depression, alcohol abuse and otheranxiety disorders.
The rates of PTSD and depression in this combat injured population wereretrospectively examined using these screening tools, and results were published in the October 2006 issue of the American Journal of Psychiatry. Oneof the most interesting findings was the fluctuating status of PTSD and depression. The findings suggest a population at risk, where the development ofsymptoms can occur at various times during injury recovery and for unclear
reasons. We can hypothesize that illness development is related to stress, andfor our purposes and considerations are related to family stress. The combat
service member’s injury and subsequent psychiatric symptoms or illness impact the service member as well as their family and children. As we consider
core principles, the importance of family cannot be underestimated.
There is little if any literature examining the impact of parental combat
injury on children. Some scientific literature reports the impact of parental
traumatic brain injury (TBI), spinal cord injury and chronic illness on children and families. There are probably unique child responses resulting fromcombat related parental injury. Existing literature does recognize that the impact of any parental injury on the family and children relates to the natureof the injury and resulting parental dysfunction. This is another importantconsideration for our deliberations.
Child and adolescent psychiatry staff members at WRAMC have piloted
the use of the Parent Guidance Assessment Inventory (PGAI), which was recently modified to the Parent Guidance Assessment-Combat Injured: PGA-CI,
with selected families and children of combat injured service members. The
instrument, developed by the CSTS in conjunction with WRAMC, attempts
to foster a working relationship with injured families. It assesses when there
14 • Session 1: Clinical Problems and Core Principles of Intervention with Injured Military Families

Hospital clinical staff
is not particularly welleducated about thedevelopmental needsof children, the risks oftraumatic exposure, andthe fact that parents
might benefit fromguidance about theneeds and likely reactionsof their children in thiscontext.

is significant distress in parents or children, and encourages parents to think
through the complex needs of children resulting from parental injury. It also
helps parents make appropriate decisions to meet those needs. Recently, the
PGA-CI has been expanded to include items that provide quantifiable data
responses.
As not all children of the injured service members were able to visit theirinjured parent in the hospital, parental reports were generally used in the assessment of children. Given the reality that many children do not come totreatment facilities we need to consider the importance of developing interventions that meet those children’s needs by working through their parents. In
looking at anecdotal information collected from WRAMC, we see that mostparents did not report elevated symptoms in children. This may indicate childhealth, or the possibility that the parents were so impacted by the injury thatthey were not attentive to the impact of the injury on their children. Often
parents were so preoccupied that there was less time for their children.
Frequently, parents reported that they did not know how much information
to share with their children about the injury. Additionally, there were often major disruptions in the lives of the children due to the length of hospitalization,
the distance from the medical center to the family’s home, the absence of the
non-injured parents, or the dislocation of children from their homes to livewith relatives or friends in different parts of the country. Any or all of these
could impact school, home and peer relationships. Children seemed to havefears or concerns about the nature of their parents’ injuries.
Children who visited the hospital were variably prepared for the hospital
visit, and their meeting their injured parent remains a significant concern tothe clinical team. At times, some older children in the family were talked toabout the injury while younger children were not. Some parents also might assume that their children would figure it out when they walked into the injured
parent’s hospital room, clearly representing a potentially destructive decision.
In addition, hospital clinical staff is not particularly well educated about thedevelopmental needs of children, the risks of traumatic exposure, and the factthat parents might benefit from guidance about the needs and likely reactions of
their children in this context.
Additional anecdotal information collected from non-injured parents(spouses of combat injured service members) indicated their most frequently
reported concerns about their children included: 1) changes in parenting styleand in their children’s routines; 2), the emotional health of their children, and:3) concerns about continuing to be effective parents. The impact of a parental
injury on a child is profound and potentially leads to longstanding consequences. Children must integrate the meaning of the injury within their own
developmental understanding, possibly requiring the child to modify the internal image of the injured parent. Ultimately, a child must develop an integrated and reality based acceptance of those changes.
The drawing in Figure 1.3 was completed by the five year old son of acombat injured father who had bilateral lower extremity amputations. The son
was asked to draw a picture of a person, not to draw a picture of his parent.
But his initial reaction was to draw a picture of a man with artificial legs. Although most children his age would start with the head and work down, thischild started with the two feet (which he was profoundly interested in) andthen added segments of legs up to the shoulders including no torso. When the
Workgroup on Intervention with Combat Injured Families — Conference Proceedings • 15

There are many
challenges that militaryfamilies face… including
financial concerns,
interpersonal family
issues, concerns about
continuation of military
service, the nature ofhealth care decisions,and disruptions tochildren’s lives by family
moves, changes inschools and loss of peer
relationships.
Figure 1.3: The drawing of a child of a combat injured service member.

child reached the second segment, the legs must have felt wobbly or unstable
to him because he drew a line between the legs, a supporting beam to provide
stability to the drawing. In his own mind he likely was questioning how aperson can remain an integrated being when they have suffered that level of
injury. The son then drew large deltoids on the figure suggesting some semblance of remaining strength. In the ankles of the figure he drew (with greatinterest) small computer chips that represented prosthetic devices. Clearly,
this five year old was working hard to integrate his emotional reactions to hisfather’s serious injury.
A three year old son of a lower extremity amputee father was asked to
draw a picture of a person. He started by drawing the head, but then scribbled
around the head and said that his was a picture of a person who had been in
an explosion. His father had been injured by an incendiary explosive device(IED). Again, this child’s drawing reflects great effort in integrating an emotional understanding of his father’s injury. Both drawings clearly demonstrate
the powerful organizing effects of parental injury on these children and theirhealthy struggle to appropriately integrate these events.
There are many challenges that military families face as a result of combat
injury. Some of these include financial concerns, interpersonal family issues,concerns about continuation of military service, the nature of health care decisions, and disruptions to children’s lives by family moves, changes in schools
and loss of peer relationships. We have talked about disruptions to family
structure, but need to specifically mention the impact on the injured service
member’s own sense of his or her capacity to parent. For many Marines andArmy soldiers who identify with physicality and athleticism, the enjoymentof parenting is also linked to physical activities such as wrestling, tossing aball, running and playing games. To have lost physical ability can complicate
their transition to post-injury health as it may also require learning to parent
in new and different ways. Their capacity to shift their sense of identity and16 • Session 1: Clinical Problems and Core Principles of Intervention with Injured Military Families

“Sometimes the children,
although they feelvery lonely, anxious
and depressed, are notready to share theirown need and painwith their parents when
their parents are in thisturmoil. Young children
want to protect their own
parents.” 		

to incorporate alternate pleasurable ways of parenting is a key to the healthytransition of families and children, as well.
We have discussed some of the goals of health care providers, which include (but are not limited to) working with the injured family to promotemastery and facilitating the rehabilitation process, both of which are collaborative efforts. This leads us to an additional core principle and an importantconsideration in working with injured families: recognizing the importance ofstaying involved longitudinally. The recovery of an injured service member’sfamily and children is a process and not an event. Intervention strategies needto include a longitudinal perspective. Doug Zatzick’s Early Collaborative Caremodel is helpful in that regard. Good post-injury care is not just about the
injured service member. Health care facilities need to include children andfamilies as part of the treatment plan and process. Family members are notoutsiders or visitors to the health care facility; they are participants in the careplan. Hospitals should develop child and family friendly treatment environments, incorporate children into rehab activities, protect them from possible
traumatic exposures and monitor at risk family situations. Such efforts arelikely to have a positive impact on the combat injured parent, family and children, as well as the health care team.
Introductory Presentation Discussion“Sometimes the children, although they feel very lonely, anxious and depressed,
are not ready to share their own need and pain with their parents when theirparents are in this turmoil. Young children want to protect their own parents.”— Dr. Chun
“One of the themes we are going to hear about is injury communication — howmuch do children hear (both what is appropriate and inappropriate) and understand about what this injury experience is about? How much are they able
to talk to their parents about what has happened to them? How can the parents
talk with the children in a way that supports the family integrity and family
communication?” — Dr. Cozza
LTC Peterson: Something that resonated with me regarding the lackof parental insight is that they are often so preoccupied with their own injuries
that they do not pick up on what is going on with their children. Some of theliterature about mothers with severe PTSD reports that the more these mothers are not in tune with their own anger and aggression, the more that anger
is being perceived by the children and actually increases the rates of thesechildren’s depression and anxiety. Are you getting the same kind of resonancewith the parents who are so preoccupied with their own issues that it is having
a negative impact on the children?
Dr. Cozza: There are several short and long term issues to consider. In
the short term there are many decisions that are made by the spouse in particular. One of the things we cannot forget about injured parents is that they arecombat veterans as well. They come back from war with acute stress reactions;some are probably related to the injury, but also are likely related to their
combat experience. This frequently can make them distant and unavailable totheir families. If a spouse is particularly worried about the level of injury, thisWorkgroup on Intervention with Combat Injured Families — Conference Proceedings • 17

It is important to better
understand the uniquecharacteristics of thedifferent types of injuries
and their impact onfamilies.

preoccupation can cause lack of awareness of the children’s needs, not necessarily in a punitive or a toxic way, but almost a neglectful way. The spousemay be unaware or have to defer those child-specific responsibilities to others. They may make choices to put the children in the custody of other family
members or friends who may or may not understand or have the capacity tocare for those children. This can lead to a very real disconnect between theparent and the child. In the longer term the service member and the parent
spouse must integrate the realities about the impact of the injury. Emotional
responses can vary considerably and oftentimes go unmentioned within thefamily. One of the themes we are going to hear about is injury communication— how much do children hear (both what is appropriate and inappropriate)
and understand about what this injury experience is about? How much arethey able to talk to their parents about what has happened to them? How can
the parents talk with the children in a way that supports the family integrity
and family communication?
Dr. Chun: Our experience is that there are different ways that parents
demonstrate their lack of awareness of what their children’s symptoms or experiences are. Sometimes the children, although they feel very lonely, anxious
and depressed, are not ready to share their own need and pain with their parents when their parents are in this turmoil. Young children want to protect
their own parents. Parents cannot always deal with children’s risk behavior
and the degree of their activity levels. I had an experience with a 16 year-old
boy who used a lot of humor to deal with chaos. His father had been in the Intensive Care Unit for weeks. When the 16 year-old visited his father, he would
crack jokes. Neither of his parents could deal with that. Telling jokes was how
the son dealt with his stress. He kept telling jokes hoping that his parents
were going to say, “Stop!” and then set some limits. But the parents were too
preoccupied. The father was too sick and the mother was too focused on her
spouse. They ignored their son and sent him out of his father’s hospital room,
but could not say, “Stop!” Here we see miscommunication between the son
and the parents. In some cases, parents, especially fathers, have been away solong, some for many months, or in other cases for about a year. They do notunderstand that in their absence the children have grown and changed, as has
the non-military parent. There can be real isolation. Sometimes children are
isolated from their parents even when they are physically present.
Dr. Saltzman: It is important to better understand the unique characteristics of the different types of injuries and their impact on families. I know
there is commonality, but what are the distinct injury presentations and how
do they variably impact parenting and communication in the family? An article by Collins provided an approach to adaptive interventions that are really
tailored to specific needs. There are many dimensions that could be adapted
to individual family needs.
Dr. Arata-Maiers: Over time, we have noted that families benefit
from a great deal of work to help them adjust to the changes and emotions
surrounding the injury. Often there is initial fear and then relief that the injured family member survived. These families tend to return to BAMC a year
or two later as the children enter another developmental phase. Not uncommonly the issue then is the caregiver role that the child is placed in. There isminimal literature addressing the challenges to children as caregivers, especially in families dealing with amputations, burns and other profound inju-

18 • Session 1: Clinical Problems and Core Principles of Intervention with Injured Military Families

“What we learned is thatfamilies have the supportof other families of
injured service members.

ries. We are concerned for both the children and the parents. It is difficult for
the injured service member who has a child and does not have any family orother support available to assist with their care except for the child. The childcan become the longer term treatment solution, assisting the parent in dealing
with chronic problems that he or she will be dealing with for the rest of theservice member’s life.
Dr. Lester: Is that true for school age children as well as adolescents?
Dr. Arata-Maiers: Yes, in some instances, school age children are
also providing care for their injured parent. If the child is capable of doing
personal care and the child is the only person in the home, the child may beenlisted to do that.
Dr. Chun: My experience with the children is that that they have mixed
feelings helping their parents versus seeking other activities. At WRAMC,
children want to go out and do sightseeing in D.C., but then part of themwants to be helpful and take care of their wounded parent. Often children do
not know how to respond to or help the injured parent. For instance, the child
who comes to visit the amputee parent and hugs him and it creates pain. The
child and parent both have emotional responses to this. It is very complicatedand creates conflicted feelings.
LCDR Kane: Working with the families of injured service members, I
was struck by the fact that in addition to the parent service member who
was injured there were situations in which the injured service member had ayounger brother or sister. In those cases, we did not usually receive a referral tovisit with the injured service member. We just stumbled into it. That is probably a larger population than we are aware of. Obviously, this sibling has been
somebody who has been involved in the life of the injured service member
in profound ways. This situation may have as much impact as a parent being
injured, but maybe in a different way and is worth thinking about if we arelooking at whole families.
Clinical Problems and Core Principles: Medical Center Participant
Presentations
Walter Reed Army Medical Center (WRAMC)“What we learned is that families have the support of other families of injured
service members. They help watch each other’s children when they have appointments or need to run errands. They use their own network, rather than going towhat the military creates for them. How can we support those kinds of activities
at our facilities?” — LTC Schneider“Injured service members know they have to be parents; they cannot escape being parents. Cognitively, you can think to yourself that you may not be able to bea service member anymore because you have lost your arm; however, you cannever abdicate your parental responsibilities.” — Dr. Chun
Dr. Cozza: Our Workgroup participants who represent the different
Medical Centers will now give a ten minute presentation highlighting their experiences in working with the siblings, families and children of combat injured
service members. Again, let’s focus on recognizing clinical family problems andhighlighting core principles for intervention. We will start with WRAMC.
Workgroup on Intervention with Combat Injured Families — Conference Proceedings • 19

What we have learned at
WRAMC is that families
form their own support
groups within their own
support system, rather
than depending on us topreside over the support
group.

Dr. Chun: I will share some case examples and programs that we introduced at WRAMC. Since 2003, the Preventive Medical Psychiatry Teamhas provided care to about 2,570 combat injured service members. As of November 2007 about 1,658 injured service members had children. We started
a Parent Education Group that included three modules of classes on how toparent the children of combat injured service members: Module One dealt withparenting children when one parent has been combat injured; Module Twocovered parenting children when the parents are distant due to the hospitalization of the injured parent, and; Module Three covered how parents canhelp children deal with loss.
Dr. Cozza: Please frame your presentation within the context of core
principles. One core principle involves understanding our knowledge (or lackof knowledge) related to the impact of injury at the parent level, the provider
level, and the facility level.
Dr. Chun: Parent Education Classes were cancelled because the attendance was poor even after we changed the time and the site of the class. The
classes were set up on the premise that if you come, we will give you educational information.
Dr. Richters: Do you know whether the parents did not attend theclasses because they were too busy with other things, or might they have felt
they understood the topic well so as not to need such classes?
Dr. Chun: Parents were too busy to come to the locations where we
presented the classes.
LTC Schneider: As Ryo-Sook talks about the content of the classes, I
also believe we need to think of the focus. We must focus on the family in theprocess of treatment and meet them where they are at. If the family is with
the injured service member in one of the clinics such as Physical Therapy, we
have to forward deploy (to use a military term) our personnel to where thefamily is at.
Dr. Richters: Focusing on where the family is at, within the courseof treatment, is very important; we might also think of this within the larger
principle of barriers to intervention.
Dr. Chun: We also tried to provide a Parent Support Group. Again, we
tried to make it palatable, but we were not successful.
LTC Schneider: What we have learned at WRAMC is that families
form their own support groups within their own support system, rather thandepending on us to preside over the support group. How do we facilitate helping that process go forward, helping them do what they would do naturally?
At a meeting with the families of the injured service members, the families
complained that there was no child care facility available for their children.
We created free childcare for the injured families at Walter Reed. It is staffedwell and is very close to the hospital, but there are usually only two to threechildren there. What we learned is that families have the support of otherfamilies of injured service members. They help watch each other’s children
when they have appointments or need to run errands. They use their own
network, rather than going to what the military creates for them. How can we
support those kinds of activities at our facilities?
Dr. Chun: One of the most poignant things that we have learned is
how important a skill self-advocacy is. For example, injured service member
parents who have lost a limb; you can help them to continue to be successful

20 • Session 1: Clinical Problems and Core Principles of Intervention with Injured Military Families

By focusing on parenting
skills and helping themto see how they can dothose better, it actually
helps their whole
recovery process.

parents by giving them examples of different ways that they can accomplishsome of their parenting responsibilities. By focusing on parenting skills andhelping them to see how they can do those better, it actually helps their whole
recovery process. Injured service members know they have to be parents, theycannot escape being parents. Cognitively, you can think to yourself that you
may not be able to be a service member anymore because you have lost yourarm; however, you can never abdicate your parental responsibilities.
We also tried to conduct classes for the nursing staff about important concepts to consider when interacting with the injured service member’s children, and we were not successful. Classes set up for the Child Development
Center staff were also not well received. We then tried an individual approachand discussed specific cases with the staff. Again, this kind of organized effort
did not get the kind of reception we were anticipating.
What we continue to do, and believe is helpful, is to meet with injured
service members and their spouses at the bedside. One of the things that welearned is that discussing their concerns about their children is not what they
may want to deal with during the initial treatment period. Of course, they are
worried about their children, but they are also concerned about their own
pain and their loss, and they want to deal with their own trauma first. We havechanged our approach and we meet the injured service member parent where
the parent is at, both physically and emotionally. We have to be willing to hear
what they have lost and the despair they are feeling.
A case example is a Special Forces service member who had lost his eye
and a limb and anticipates that he will not be able to shoot or run, and hefeels so lost. He is 29 years old and he is dealing with the challenge of what
will he do for the rest of his life. All he knows how to do is to be a Special
Forces sharpshooter. When meeting with this service member, we talked firstabout his losses and then about his concern, feeling he cannot be a father to
his three-year-old son, which of course he can. To be a father to his son, hedoes not need to be running around or to have a sharp shooter’s eyesight. We
talked and focused on what he could do to be a good father to his three year
old son. This service member began to think about what he could do as a parent. Only after he was able to talk about his losses and his trauma could hebegin to think about his role in a different way. He decided that he was going
to be a teacher. As he was teaching his physical therapy exercises to his children, he realized that he could turn those teaching skills into an occupation
as a teacher.
Dr. Cozza: So many service members invest so much of themselves inbeing in the military, and then they are injured. It is not only the pain that they
are dealing with, but it is part of that whole transition of the combat mindset
complicated by the injury process. We need to recognize the necessary workthat allows them to once again be available to the family and children.
Dr. Arata-Maiers: A number of these service members stay in andreturn to a military position after they recover from their injuries. They transition into and out of their ‘battlemind’. Knowing that they are going to remain in the military may be a factor if they are not able to return to the job
duties they had with their former unit. The adult providers must differentiallyhandle the therapy with the service member who returns to a new type of job
or a new military unit compared to the service member who is re-integratingback into his former unit.
Workgroup on Intervention with Combat Injured Families — Conference Proceedings • 21

Given the tendency ofyoung children, they aremaking attributions in
the face of ambiguity;
making attributions
about why their parent
would choose toredeploy and not staywith them.

Dr. Richters: What proportion of the combat injured service members are going to be redeployed?
LTC Schneider: Of the combat injured service members who were inpatients at WRAMC, hardly any of them redeployed.
Dr. Richters: Is that because their injuries were so severe?
LTC Schneider: Yes, but of the 16,000 and some who do not have severe
injuries, a significant percent will return to their unit and redeploy.
Dr. Arata-Maiers: The Institute of Surgical Research (ISR), whichis the Burn Center, indicated that about 33 percent of this subpopulation’s
injured service members redeployed. Many of them return to the military to aclerical/administrative job and they are in a non- deployable status.
Dr. Chun: Another issue that I wanted to bring up is recurring redeployment and what it means to the parent and the children. The service members
have been asking for assistance with how to tell their children that they aregoing to re-deploy.
LTC Schneider: It’s important to note that there is a choice involved.
Most of these service members have the option to stay on active duty. Mostof them could opt to have a medical board and be released from active duty.
If you are saying, “I am going to stay in and go back,” you are making a conscious choice to put your family and yourself back into that position again.
Dr. Chun: One issue that I am also faced with is that the children comeand say, “Will my dad go back and if he does, what kind of injury is he goingto get?” That adds more uncertainty.
LTC Schneider: Military injuries in combat are so much more complex, cognitively and emotionally, than civilian injuries. Civilian injuries are
typically accidents. While what has happened to somebody is traumatic andunfortunate, a military injury is much more complex. It is easier in a civilian
injury to say that the cause of the injury was accidental or, for example, thefault of a drunk driver. In the military, it is much more complicated. Do you
blame yourself because you were injured? Do you blame your injury on the
military or not blame anything or anyone? How you handle the fact that you
were injured while deployed is complex.
Dr. Richters: It is similar to the role that a police officer or fireman isin. They choose that occupation and the risk of injury is high.
Dr. Fullerton: We know from the literature that in all disasters attribution plays a large role in the recovery process. Whether it was a motor
vehicle accident or an airplane crash there was always a searching for attribution. I think that is critical and very important.
LTC Schneider: However, it is much more complex with military related injuries.
Dr. Richters: Given the tendency of young children, they are making attributions in the face of ambiguity; making attributions about why theirparent would choose to redeploy and not stay with them. I would think theymight tend to sink to the most negative attribution with reference to themselves.
Dr. Chun: One issue that may come up is that children want the parent to get better, but they are also scared that when their parent has recoveredfrom the injury they may redeploy. What this is doing to the children must be
so complicated.
LTC Peterson: I do not think that we have looked at tailoring our

22 • Session 1: Clinical Problems and Core Principles of Intervention with Injured Military Families

Families are often toldthat things will get better.
However, families reportthat they do not get better;they just get different, andthat type of reassurance
is bothersome to a lot ofthem. Everyone in thefamily misses their lives
and everyone has been
affected.

treatment for children whose parents must redeploy. How do we tailor ourinterventions to make them appropriate for that child or adolescent who has
to watch their dad or mom redeploy, even though they have had an injury ofsome sort. How do we help when the child has been impacted just by deployments? There may not be an injury and Dad or Mom is doing fine, but thereis the impact of that redeployment. How do you get the children ready tohave their Dad or Mom redeploy multiple times? Five redeployments are notunheard of, and the impact on the children may be detrimental even if theparent is doing fine.
Brooke Army Medical Center
Dr. Arata-Maiers: I am going to go over the types of injuries of theservice members for whom we provide care. One thing that is unique to us isthat we have the Institute for Surgical Research (ISR) for burn patients. We haveboth inpatient and outpatient treatment settings. We provide care for both
civilian and military burn patients. Civilian burn cases are primarily causedby accidents, while the military burn cases are war-related. We also provide
in-patient and out-patient care for amputees. The outpatient care is provided
at the Center for the Intrepid that opened in the last year, and also provides
care for selected burn patients. Additionally, we provide care for medical andsurgical patients who oftentimes get forgotten due to the less critical nature of
their wounds — wounds caused by gunshots for example. Psychological disorders such as PTSD, cognitive and other clinical disorders are usually treatedon an outpatient basis unless the service member also has a medical or surgical problem that is being treated with an inpatient stay. In that case, all of theservice member’s problems would be treated during his inpatient hospitalization. Service members who have mild to moderate TBI are usually transferred
to us to be treated as outpatients.
Specific concerns that we observed during the service member and family
acute injury recovery phase include: family’s roles, other factors affecting thefamilies and their training needs in the area of clinical problems (see Figure1.4). We have talked about the shift in the focus of treatment over time fromthe adjustment to the caregiver role, and the emotional reactions that changeover time. Families are often told that things will get better. However, families
report that they do not get better; they just get different, and that type of reassurance is bothersome to a lot of them. Everyone in the family misses theirlives and everyone has been affected. The service member is often the one
whose changes have been identified, but everyone in the family is taking on
different roles. Service members and their families and children tire of being
identified as Operation Iraqi Freedom (OIF) or Operation Enduring Freedom(OEF) veterans. They want simply to be service members again. Families also
tire of the focus on the service member and the service member’s injuries.
Families and children want to live other parts of their lives and enjoy activities
that are age appropriate or appropriate for the spouse.
The children have difficulty with the caregiver role. There is anger about
the chronic nature of the impairment and the loss of that service member’srole as a parent. Since 2001, the schools at Fort Sam Houston have reported anincrease in the number of students who have been identified as academicallyat-risk, which represents one step before you are placed in a special educa-

Workgroup on Intervention with Combat Injured Families — Conference Proceedings • 23

When the injured service
members are discharged
from the hospital, thespouses may havedifficulty with the caregiverrole. They may spend up to
five hours a day providing
wound care, which canbe very demanding anddraining physically andemotionally.

Figure 1.4: Emotional Reactions to Acute Injury Phase.

tion program. As clinicians we find that there are more children with unclear
diagnoses. A six year-old may be referred to you because of problems thatthe child is having. Is it an adjustment issue, a learning disability that is justnow being identified, a clinical disorder like Attention Deficit Hyperactivity
Disorder, or is it some combination thereof with post-traumatic implication?
It is difficult for us to assess and evaluate these children and difficult for thepediatricians who are providing medication for them.
LTC Schneider: Are these Department of Defense schools?
Dr. Arata-Maiers: No, they are public schools on the Fort Sam Houston installation and we have good relationships with the staff who work there.
I worked in the schools for about six and a half years for a half day a week at
each site until we had to discontinue that service. We are now starting to offer
those services again.
LTC Schneider: What percentage of the population at Fort Sam is typically
deployed? Is it similar to WRAMC where the percentage of service members
who deploy is not large?
Dr. Arata-Maiers: No, at BAMC both the deployment factor andthe fact that we are a referral center for sick children have an impact on theschool system. However, the largest impact is the number of children of injured service members because when the injured return and they are at theguest house or the Fisher House, their children attend Ft. Sam schools. We also
have a large number of families who have children enrolled in the Exceptional
Family Member Program. In addition, we provide care for children who havecancer or are diagnosed with hemophilia, and their families usually accompany them. However, the combat injured service members are probably more
prominent.
When the injured service members are discharged from the hospital, thespouses may have difficulty with the caregiver role. They may spend up to five
hours a day providing wound care, which can be very demanding and drain24 • Session 1: Clinical Problems and Core Principles of Intervention with Injured Military Families

Although, the types of
injury do not seem to bea problematic factor forthe burn patients, theextent of a facial injury
may be difficult for a child,from a developmental
perspective, because
the parent looks so very
different.

ing physically and emotionally (see Figure 1.5). This can contribute to the
spouse being overwhelmed and less responsive. The injured service member
often becomes very irritated that his wife is both the caregiver and the spouse,a situation that can create significant frustration. There is also a subpopulation of dual military families. In these families the military spouse who isalso a service member is treated as a spouse. They are not treated as service
members. Often their PTSD, or other combat related conditions, is overlooked
because they are viewed as in the spouse role. This may be true even though
they may have experienced more combat than their service member spouse
who was injured. This is something that can be overlooked.
I want to focus on the changes that symptoms such as anger and forgetfulness can cause, and the effect that the symptoms can have on parenting.
Oftentimes the anger that the service member is experiencing is directed at
the spouse, and sometimes at the children. We have found an increase in thepotential for abuse and we have had several cases of spouse and child abuse.
It has been difficult to find data on the increased potential for abuse in the
injured service member population. I know there is some data on deployment
related abuse cases. I believe that Dr. McCarroll is in the process of publishing an article on that topic, but the potential for abuse in the injured service
member population is an area in need of attention. Is this issue a large or asmall problem?
Dr. Fullerton: There is also a concern regarding the neglect of children of combat injured service members.
Dr. Cozza: I think the issue for the neglect is specific to the absence ofthe parent during the deployment in the young military families. The situation
described by Dr. Arata-Maiers sounds more anecdotal. You may not have thedata, but are we talking about physical abuse or neglect?
Dr. Arata-Maiers: We are talking about physical, emotional and verbal abuse.

Figure 1.5: Complex Role of Spouse of Injured.
Workgroup on Intervention with Combat Injured Families — Conference Proceedings • 25

The girls tend to watch
over their dads andif someone refers totheir dad in a negative
manner, they stand up
for their dad. They also
check to find out if theirfathers need assistancewhen they have to movearound or get out of bed.

Dr. Cozza: More active maltreatment as opposed to passive withdrawalof parenting.
Dr. Arata-Maiers: Yes, when I spoke to a Spouse Group and a Service
Member Group on the Burn Unit about anger symptoms that they might beexperiencing and how it can affect their parenting, everyone in the group was
nodding. We were talking about the severity of the anger and how it can be
destructive to their child. We discussed the need for assistance in dealing with
their anger such as the availability of counseling services to help with anger
control, and in some cases the need for medication to help control the anger.
One of the service members who was very forthright, said, “Yeah, been there,
done that. We are all in therapy and on medications because we are all dealing
with the anger and our response to it.” Some of the parents’ stress behaviors,
substance abuse, numbness, or trauma triggers seem to put the children at
physical and emotional risk.
Although, the types of injury do not seem to be a problematic factor forthe burn patients, the extent of a facial injury may be difficult for a child, froma developmental perspective, because the parent looks so very different. We
have children who talk about knowing that this is their parent but it may takemonths for them to realize that this is really their parent. The burn patientstend to understand. We also have amputee patients, but it is usually the children whose parents are burn patients who seem to have more difficulty overthe long term with the changes in their parents. In talking about developmental stages, the adolescents are the ones who do not seem to be interested ingroup activities. They also become really tired of being identified as OIF/OEF
Service Members’ children; they want to be seen as teenagers.
We have very little information about what role the gender of the child or
parent plays in this process. We also don’t know the impact of culture or ethnicity on the family and children of injured service members. We are findingthat there are a lot of protective behaviors that the daughters of the injured
service members are displaying (see Figure 1.6). Since most of the injured parents are males, they prefer to have their sons perform any personal care thatis necessary. We have little information about daughters of the injured maleparent performing any personal care. There is minimal information about the
impact on the family and children if the injured service member parent is female. I believe that the gender of the injured service member may affect howthat injury is experienced by the family and children. Several of the Hispanic
families who relocated to the Fort Sam Houston area to be with their injured
service member have school age and young adolescent children who were notgiven any information about their father’s injury. We do not know if this typeof communication is based on a cultural dimension about a desire to be more
protective of their children or not.
Dr. Lester: When you say protective behaviors, can you explain that in
the girls?
Dr. Arata-Maiers: The girls tend to watch over their dads and if
someone refers to their dad in a negative manner, they stand up for their dad.
They also check to find out if their fathers need assistance when they have to
move around or get out of bed.
Dr. Cozza: Girls are protective of their dads?
Dr. Arata-Maiers: Correct, also the girls that we are talking about
tend to be school age and their behavior may be developmentally driven as it

26 • Session 1: Clinical Problems and Core Principles of Intervention with Injured Military Families

We want to provide
treatment that is basedon resiliency rather thana pathology model.
People are unique.
Everyone does not havethe same problems
or the same level ofreactions to problems.

Figure 1.6: Psychosocial Issues for Children of Combat Injured.

is primarily with their dads. The communities need additional training andinformation on the impact of combat injury on military families and children. One of the lovely things about working in San Antonio is that people aremuch attuned to the military. We have injured service members who are from
Oregon retiring to San Antonio because the community knows about the
military and wants to be very responsive. The hospital staff needs additional
training and information on the impact of combat injury on the families andchildren, and we are trying to accommodate their needs. Some of the barriers we have encountered included challenges within the hospital. There is alack of developmentally appropriate information about the impact of parental
injury on a child that is available to the staff and family. The severity of theservice member’s combat injuries and the difficulty in accessing the spousemakes it complicated to obtain information about the spouse and children. It
is also difficult to talk with the injured service member and spouse when thechildren are present.
Another challenge to meeting the family’s needs is the immediacy, the primacy, and the time consuming nature of the service member’s medical needs.
This reality can sometimes mean that meeting the family’s needs may have tobe delayed. Reference childcare issues, in addition to the problems with theavailability and accessibility of child care services, the mothers’ comfort levelwith leaving their children is an important issue. When mothers have recently
almost lost their husbands, they are skeptical of leaving their children andwant their children to be at their side and that makes marital therapy more
problematic.
We have also found that there is a process of crisis referrals in which families are referred to us when there is a crisis. Then there is a lack of follow-up
by the family after the referrals are made and the crisis has passed. Other challenges include the paucity of research to guide our interventions, staff shortages and new staff training needs.
Workgroup on Intervention with Combat Injured Families — Conference Proceedings • 27

It speaks to the fact thateven if you have developed
helping relationships in
the health care setting,once the family has moved
back to the community you
are not in a position to beable to support that family
over time. They become
disconnected.

Regarding the core principles, it is important to focus on the needs of thefamily, not just the injured service member. We are trying to institute a systematic, proactive service provision rather than a service that is provider-driven
and reactive (see Figure 1.7). We want to ensure that we meet all the injured
service members who have families and children and be viewed as part of thetreatment team. Hopefully that will reduce the stigma that is associated withmental health services. We want to avoid the impression that one is being referred to a psychologist because the family is broken, in addition to everythingelse that is going on. It’s better if our intervention is seen as part of the treatmentthat every injured service member receives.
We want to provide treatment that is based on resiliency rather than a pathology model. People are unique. Everyone does not have the same problems
or the same level of reactions to problems. There are a lot of factors that have acontributing role. In addition to current family and individual stressors, previous stressors, including the child’s relationship with both of the parents, must
be considered. Some of the children have parents who have deployed multiple
times and may have missed significant developmental milestones. If the deployment occurs during the very early period of a child’s life, the returning
parent may actually have to develop a relationship with that child becoming
familiar with their personality and coping repertoire.
Cooperation with other departments in your health care facility and theavailability of community resources is important. We collaborate within thehospital with ISR Case Management Analysts and the Pediatric staff and withschool and community agencies. We are also involved with a Substance Abuse
and Mental Health Services Administration (SAMHSA) Grant and visit local
hospitals to provide information on military families and combat injury. The
number of our staff limits additional outreach activities.
Ms. Vineburgh: Something that you said reinforced a concept ofstrength that Dr. Chun had discussed. One of the most powerful commentsthat you made was that oftentimes hospital services that are organized are
not well received, and that families have been shown to self-organize. Would
you consider that a strength of the family? To what extent, when you are in
the process of developing interventions and principles of intervention, might
you want to think about recognizing and acknowledging a family’s strength inresponse to such stress?
Dr. Arata-Maiers: It seems like people have to identify having a problem that is large and pressing enough to take time away from everything elsein order to attend a free standing group meeting. We had the same problems
with providing deployment groups. Everyone was saying that they needed
these, but when you set the groups up nobody comes.
Dr. Cozza: It really is the way you said it, Brett, in terms of meetingthe family where it is at in a particular time of treatment. The important idea
is that interventions must be offered on the family’s terms as opposed to theclinician provider or service delivery system’s terms. I do think that this is acore issue here, and in trauma responses as well. One of my friends who wasinvolved in Operation Just Cause put out a mental health sign for his mental
health clinic to support soldiers during the war, but nobody came. He realizedthat the best way to work with them was by spending time where they ordinarily worked — in the gym or in the emergency room where they came in, asimilar concept to providing services in a forward deployed area.

28 • Session 1: Clinical Problems and Core Principles of Intervention with Injured Military Families

In the Navy, and to a certain
extent the Marines, there
is an expectation that the
Chaplains are really on thefront line. In the fleet andon the Marine bases, theChaplains are embedded,
and the families feel very
comfortable going to them.

Figure 1.7: Core Principles of Combat Injury Care.

LTC Schneider: If you do not do that, you cannot get access to theresilient because they do not come to us. They do not come to see a mental
health provider. If they know me as Brett, then they might happen to ask me amental health question, but if they know me as a psychiatrist with no face, no
name, they are never going to interact with me.
Ms. Williams: That speaks to the transition needs of a family when
they leave the health care facility. When those who have self-organized andfound that kind of peer support at the hospital move to the civilian community again, they need to redevelop that linkage and support.
Dr. Cozza: That is a really good point. It speaks to the fact that even if
you have developed helping relationships in the health care setting, once thefamily has moved back to the community you are not in a position to be able
to support that family over time. They become disconnected. Even when you
do the best you can in passing a case off, there are a lot of disconnects whenthat service member or family moves onto the community. They may not feel
comfortable talking with people that they do not know.
Dr. Chun: You have identified a real issue, especially when the service
member goes back to a community that is not very military-oriented. You may
have a family who is specifically requesting to see a military provider becauseof their fear of rejection and stigmatization, but none may be available in thecommunity that they are moving to.
I also want to comment about meeting the family where the family is at.
When new injured service members and their families arrive at Walter Reed,
all of the spouses are invited to a get together for an administrative briefing. We participate in that briefing and provide the families with information
about our services. We are also trying to familiarize them with resources thatare available both in the hospital and in their communities and to be a resource for their needs and as a mental health provider. If the family identifies
a particular need that their child has, we will direct them or take them to theWorkgroup on Intervention with Combat Injured Families — Conference Proceedings • 29

As we are seeing more
and more families due toredeployment and issues
related to that, there seems
to be a normalization of
the symptoms families
can experience. If families
begin to feel their stress isa normal response in our
culture, they may become
more accepting andreluctant to contact thehealth care provider.

service that can best help them. In a case where a parent remarked, “Oh, mychild is going to have a birthday, but I am stuck here,” we brought the parent
to the Red Cross so they could provide some help connecting the parent forthis special event.
Dr. Cozza: That also speaks to the principles of Psychological First Aid.
Often, simply connecting people with resources can be tremendously valuable.
Dr. Arata-Maiers: There is one other small piece that I think is important: the literature we have available for burn patients is for siblings of burnpatients because prior to OIF and OEF our patients were primarily children.
We do not have any prepared literature that describes the potential impact ofa burn injury on a service member’s family and children. We are conducting
literature searches to find similar information.
Dr. Cozza: That also speaks to a certain type of neglect, an awarenessof a kind of medical traumatization that occurs to children in children’s hospitals, and a lack of understanding on how these powerful parental events canaffect children. There has been very little literature related to how to preparea child for a visit to a seriously injured parent. There are a couple of articles
that nurses have written about interventions for children in the Intensive Care
Unit or Coronary Care Unit setting, but a lot of work needs to be done here.
Navy Medical Center, San Diego Presentation
LCDR. Kane: I would like to reference what Dorinda has talked about,which is that this model of being a referral center does not necessarily result ina lot of appropriate patients. In Child and Adolescent Psychiatry at the Navy
Medical Center in San Diego, I have noticed that families are being assessed
outside of our facility and then referred to us. We do not really see a lot ofreferrals related to combat injured families. When I was invited to attend thisworkgroup and talk about our clinical problems and core principles, I needed
to find out how the children we provide care for are referred to us.
The information I am going to relate is not based upon my experience, buton the experiences of other providers with whom I work. This includes Captain Klam, our Navy Psychiatry specialty leader and head of the Directorate of
Mental Health for NMCSD and one of our Clinical Psychologists in our C-5
program, our equivalent to WRAMC’s Wounded Warrior Care program. Captain Klam emphasized that the family is as equal and important as the service
members. We want to ensure their access to care. It is true when families withchildren do come to us they get excellent care, however we are not seeing thehigh volume that we had expected to see.
NMCSD realized that there was disparate care for the combat casualty
group. They created a C-5 Center that recently opened and provides comprehensive, complex combat casualty care for the combat injured service members. Services include Physical Therapy (PT) and Occupational Therapy (OT).
They also hired two mental health providers, a neuropsychologist and a clinical psychologist. I met with Dr. Kim, our clinical psychologist who echoedexactly what we are talking about: the family members do not come to see
the clinical psychologist. When the clinical psychologists were in the Mental
Health Building, families did not come to see them there either.
Dr. Kim now meets the families when they come with their injured spousefor PT and OT appointments. When the mental health providers are recognized

30 • Session 1: Clinical Problems and Core Principles of Intervention with Injured Military Families

Sometimes the task is justtrying to diffuse a conflict
between the family
members. During theacute and sustainment
phases of the injury
recovery process, we needto incorporate the core
principles.

as part of the team, the injured service member and his/her family opens up andstarts talking about issues related to the impact their injury is having on the entire family. However, the emphasis is not on the family. The clinical psychologist knows the importance of including the spouse who is invited to some of
the meetings where they educate the spouse about PTSD, etc.
The mental health providers are doing some marital counseling, which I
do think represents a hierarchy of needs such as helping the couple maintainconnectedness and modeling for their children. How the family goes throughrecovery in a manner that fosters developmentally appropriate changes may
also address those needs. Only about 20% of the injured Marines and Sailors
have children. I do not know if there is a focus on the families and children of
the combat injured service member, but certainly we are available.
The other area that Captain Klam discussed was the involvement of theChaplain Corps. In the Navy, and to a certain extent the Marines, there is an
expectation that the Chaplains are really on the front line. In the fleet and on
the Marine bases, the Chaplains are embedded, and the families feel very comfortable going to them. Using this model of the deployment operations, theChaplains are involved in the pre-deployment, deployment, and the post deployment assessments. Theoretically they are also referring if the family is inneed. The Chaplains do not always refer to Child Psychiatry or Mental Healthand instead probably make referrals to the Fleet and Family Services, which isa major area of support in the Navy. This organization provides basic education about parenting, social work level counseling on parenting, individual
counseling for children and access to family advocacy for any kind of abuse.
I did not have a chance to talk to with the Fleet and Family Service staff, but
I believe that this is an avenue for a lot of work that is going on. It is not
psychiatry-based, but it does provide services at the social work level. One of
the reasons to include a Chaplain as a resource on the traumatic injury teamis the issue of stigma that exists in saying, “I am going to talk to the psychiatrist.” The other change at Camp Pendleton is the establishment of a Marine
Corps Community Service Program (MCCSP) that is hiring 24 new social
workers. They want to establish the equivalent of the Navy’s Fleet and Family
Services and offer services closer to where the families live, particularly since
the existing Navy program is about an hour away. The MCCSP will offer basic
educational services, outreach and therapy services for families.
In terms of core principles, the family is as important as the service member, and access to mental health care is available by referral. All families are
now treated within a seven day access standard, as a result of recommendations from the DOD Mental Health Task Force that CAPT Klam served on.
Additional personnel are being hired, and more outreach services should beavailable.
From the Navy’s perspective, if we want to increase the amount of moneythat is allocated for psychiatry related programs we need to demonstrate efficacy. If we do not have outcome measures, evidence of our productivity andeffectiveness is limited. Timeliness of care is an additional problem. With aclassic tiered system, Child Psychiatry is often the last service to be involved.
This makes it difficult to inform Navy and Marine families of combat injured
service members about the developmental needs of their children. An increased emphasis on longitudinal care is needed to know if the interventions
provided to the family are effective over the course of time.
Workgroup on Intervention with Combat Injured Families — Conference Proceedings • 31

We try to tackle the issues
that the service member
and his/her family wantto address while they are
in-patients on the ward
and receiving treatment.

In our system, there is a great deal of reliance on specific reports. In our
C-5 Center when the report references how the children are doing, a childpsychologist may report that the children are doing well and then they moveon to the next issue. There does not seem to be an incentive to find out what
the impact of the parental injury on the child is. If we have an opportunity tomeet with the parents and educate them, we might discover many more issues
we might be able to assist with.
As we are seeing more and more families due to redeployment and issues
related to that, there seems to be a normalization of the symptoms families
can experience. If families begin to feel their stress is a normal response in our
culture, they may become more accepting and reluctant to contact the healthcare provider. No one is going to request assistance if they feel their responses
are considered normal. As the whole community shifts to an acceptance that
there will be a great deal of redeploying service members who are dealing
with PTSD issues, providers may be less inclined to feel, “we should do something about this.”
Medical Center Presentation Discussion
Dr. McCarroll: To what extent are you seeing involvement of theparents of the injured service member?
LCDR Kane: We are not seeing parents of the injured service members.
Dr. Cozza: The Preventive Medical Psychiatry Service/PsychiatricConsult Liaison Service at WRAMC provides assistance to the parents of theservice members at WRAMC.
Dr. Arata-Maiers: We as the Child Psychiatry Service do not see theparents of the injured service members. The case managers seem to be involved in the process of assisting and/or referring the parents of the injured
service members for additional services.
Dr. McCarroll: Do you find that there is enough established literature and practice to deal with this issue or is this a new area?
Dr. Arata-Maiers: I do not know because I do not work with theparents of the injured service members. From what I’ve been told, there does
not appear to be much literature on that particular topic.
Dr. Cozza: From my experience on the Consult-Liaison Service andworking with Dr. Hal Wayne and his staff at WRAMC, families can be tremendously complex in terms of both their constellation and their relationships. You can have parents who are in conflict with each other and/or withthe spouse or significant other of their injured service member. It becomes avery complicated process as you forge a relationship with the family members
and significant others who may be providing support to the injured service
member, particularly when the spousal relationship is where efforts should
be directed.
Sometimes the task is just trying to diffuse a conflict between the family
members. During the acute and sustainment phases of the injury recovery
process, we need to incorporate the core principles. An injury disrupts the constellation and function of the family inherently and adds stress to the family. It
tends to widen splits in families that are already present and add conflict where
the dust has settled. Suddenly you have this injury event that just complicatesthings. Even when families pull together closely, the impact of the combat injury on families is more likely to disorganize than to organize families.

32 • Session 1: Clinical Problems and Core Principles of Intervention with Injured Military Families

In terms of developing
relationships in thecommunity, I could speak
for a long time about the
shortages in the military,
however there are also
national shortages ofchild and adolescent
psychiatrists.

Dr. Fullerton: I also think about the impact that injury has had on
siblings of the injured service member, and do not know if there is much research on that. I know there has been research on the impact that children’s
long-term illnesses have had on the family, but how does the response of siblings to this current injury of their family member hearken back to the original family interactions, and how is this handled when the siblings no longer
live in the same house? I think that is important not just for parents but also
the siblings.
Dr. Arata-Maiers: Dysfunction within the families is one of the other things that are sometimes revealed during this injury period. On the Burn
Unit, the case manager discussed concerns that were raised during which time
the wife of the service member found out that there was a pregnant girlfriend
in her husband’s life. The injury event brought the relationship to light when
this individual, who was notified of the service member’s injury, came to thehospital to visit him.
LCDR Kane: I would like to clarify what I meant by (services that are) ‘notavailable’, and provide examples. One involves first-degree relatives of the injured service member. If there is a child who has been negatively impacted, thatchild has access to mental health and medical care. The child can be identified
as needing individual therapy when the family comes in for Family Therapy.
We can refer the child to the Child and Adolescent Clinic for services. However, if the parent of the injured service member needs assistance, you can dosome work at the service member’s bedside and do some counseling. If you saythat person needs a referral because of the impact that their son or daughter’s
injury is having on them, there is no mechanism for that because the parents
are not usually covered for their medical care by the military. The same would
be true for the siblings. These are first-degree relatives who may not have access to that larger military health care system, but who are part of the service
member’s family and have concerns that we have previously discussed.
LTC Schneider: At WRAMC, the Command has allowed for a family
member exception policy to occur when we bring families to WRAMC while
their injured service member is being treated. If something happens and ahealth care provider has determined that a family member needs health careservices, we allow the family member to be treated. This includes parents who
may not ordinarily be eligible for care. If we made arrangements for the family
member to come to WRAMC, and they are displaced from their own systemof care, there is a system in place that allows us to do what is right, rather thanreferring to an outdated procedure book for guidance.
In the outpatient Behavioral Health Clinic, the policy that OIF/OEF service members are evaluated within 72 hours has impacted the availability ofproviders to see family members. To provide assistance in this area, I have
unofficially renamed our service. Instead of being called the Child and Adolescent Psychiatry Service, I now refer to our service as the Child and Family
Psychiatry Services. I have explained that child psychiatrists are also adultpsychiatrists, and, when the situation warrants it, I have allowed our service
to start seeing adults who are the primary patient rather than always focusing
on children.
LTC Peterson: From my experience, I would underscore what everybody else has already said. In terms of our patient populations, there is aslightly different mix at Madigan. Madigan is more of a deployment platform
Workgroup on Intervention with Combat Injured Families — Conference Proceedings • 33

From the military side,
there is recognition that
we should be out there
providing care for thefamilies and childrenof the combat injured
service members, orthe care will not beprovided.

with about 30 percent of the population deploying at any one time; 30 percent coming back, and; 30 percent gearing up to go. We see less of the service
members who have medical-surgical, amputee, or orthopedic injuries. We see
and treat service members who have PTSD and moderate TBI related issues.
We also treat service members who have deployment cycle related issues. We
are primarily providing services to the ‘walking wounded’. We also provide
services to families of service members who were killed during their deployment; we see that the children who are dealing with the death of a parent receive some assistance before their family moves from the installation. In most
instances, the family moves out pretty quickly.
We try to tackle the issues that the service member and his/her family
want to address while they are in-patients on the ward and receiving treatment. Trying to get them to return for follow-up appointments can be problematic. As Chief of the Psychiatry Department at Madigan, my primary challenge has been to meet the needs of the active duty population in terms ofaccess to care, and this has been to the detriment of services for the family.
We want to provide services to the families of the injured service members
but we do not have the necessary staff. In terms of the core principles I wastrying to ensure that we had adequate resources to execute programs looking at lessons learned and interventions that were needed while having interventions provided downstream to execute programs. What I see happening
Army-wide is that the emphasis is on screening programs. It is doubtful that
we would have sufficient staff available to treat the service members if all theservice members who screened positive tried to access our facilities for careat the same time. At Madigan we plan to hire an additional general psychiatrist so the child psychiatrists can do child psychiatry. In the Army we haveabout 50 child psychiatrists in the inventory and probably ten, not including
trainees, who are practicing child and adolescent psychiatry. The remainderof the child and adolescent psychiatrists are practicing adult psychiatry. It ischallenging because we have some of the resources and solutions within oursystem to provide care to the children of the injured service members, however doing that would take a significant toll on providing psychiatric care to
the adult population. Madigan is known for their screening programs. The
Service Member Wellness Assessment Pilot Program (SWAP) is touted as being, and is, a very good program. It will be important however to ensure that
there will be the necessary resources downstream in the military, as well as in
the community to provide the services that will be needed.
In terms of developing relationships in the community, I could speak for along time about the shortages in the military, however there are also national
shortages of child and adolescent psychiatrists. There is also a shortage of civilian child and adolescent psychiatrists who will accept the Military TRICARE
insurance payment. In the short term, we are looking at what can be done toaugment resources currently in place, such as ancillary support staff and nurse
practitioners in order to extend the services that our providers can offer. Longer term we need to find the means to expand resources in the network andin the military to focus on military issues such as recruitment, retention, andmatriculation.
Research is ongoing at Madigan, therefore we want to capitalize on developing partnerships for research. We are looking at the possibility of doing a
research study with Drs. Lester and Saltzman on the impact of deployment on

34 • Session 1: Clinical Problems and Core Principles of Intervention with Injured Military Families

The family focus
applies not only to theintervention but also to
the institution. Unless theinstitution has a family
focus, it will become
problematic to provide
services.

children. The core principle is to partner with those who know how this research works and learn from them. We cannot do this type of research on ourown because we are trying to meet the core missions that are changing andpresent to us at a very rapid pace. If we bring the experts in our area on board
who are willing partners for research activities and who can teach us and help
us to obtain resources, we would be in a win /win situation.
In reference to school-based programs, Dave Callies has implemented a
Resiliency Program at Madigan. Dr. Faran at Tripler Army Medical Center(TAMC) has done a very extensive integration of mental health and childand adolescent mental health into the school systems there, leading to a veryfine synergy between the community and the military. This is a model thatshould be looked at and rolled out in other places depending upon available
resources. The Madigan Resiliency Program consists of a psychologist goingout and teaching resiliency to school counselors. The TAMC Program is resource heavy with psychiatrists, child psychiatrists and other providers whoare partnering with the school systems and doing everything from preventative work to running clinics at the school. This requires a coordination ofefforts. Unfortunately, pediatrics and adolescent medicine are thought of firstwhen people think of child mental health issues, and that just defies reason.
When Nancy Pelosi had her summit on America’s Children, Child andAdolescent Psychiatry was not invited to the table. We were eventually invited
to the table, but the people who were there speaking on the panel did not include one child and adolescent psychiatrist. When this was brought to their attention, they were quick to include us. We have to do more in terms of advertising and capitalizing on the existing partnerships, leveraging the lobbyists
from the professional organizations, and leveraging our professional organization, the American Academy of Child and Adolescent Psychiatry (AACAP),
to speak for us at the Congressional level about issues such as retention.
Deployment and redeployment is another issue that concerns me. For example, how do we ensure access to care and appropriate interventions to treat
the service members and their families to include their children? When you
look at the impact of deployments, there are children who are being affectedby this. The active duty population may be looking fine and there may not be
any issues of concern for the service member who has deployed five times,
e.g., he is hard charging, making rank and he is doing everything he needs
to do. Behind that service member you have the child, the brother, the siblings,
and the spouse, many of whom are suffering. If the service member is doing
fine, there is a sense that there are no problems. We have to re-tailor what weare doing and try to reach the family members in some way without asking
directly if they have problems and then not having the needed services. Thisapproach risks a loss of faith and trust. This goes back to what everybody
has been saying: focus on services for the family not just the injured service
member. We need to work to leverage partnerships, amplify what we have got,
synergize where we can, but fundamentally we have got to be asking for moreat all levels — Congress, the military and the community.
Dr. Cozza: From the military side, there is recognition that we should
be out there providing care for the families and children of the combat injured service members, or the care will not be provided. When we talk about
the impact of parental injury, I have not seen it tackled anywhere. Workgroup members and military participants should feel very good and emWorkgroup on Intervention with Combat Injured Families — Conference Proceedings • 35

Understanding
and mobilizing
resources within
the individual, thefamily, the extended
family, the caresystem, the church,
the military and thelarger community will
eventually result in an
effective and healthyadjustment.

powered to be contributing not only to the health and well being of militarychildren, but potentially the health and well being of civilian families andchildren of parents who face serious injuries. There is very little information
available on the impact parental injury has on a child. This group is in theprocess of developing and refining the scientific information in ways thatwill answer some of the questions and provide information on interventions
that are evidence-based.
Discussion and Revision of Core Principles
Dr. Cozza: Now that we have heard from the presenters about the clinical problems they have been experiencing, and are getting a better understanding of the challenges families and children of the combat injured service
members face, we may want to think about expanding or changing the five categories of general problems that are listed in your folder and updating the core
principles. The kinds of core principles we have discussed include: 1) the topic
of family health and wellbeing as central to the recovery of the combat injured
service member. Additional core principles that we want to consider are: 2)
injured family care is longitudinal; 3) the needs of injured families changeover the course of treatment and recovery; 4) education at multiple levels isneeded; and, 5) barriers to interventions exist, therefore when we think about
understanding the health of the family as integral to combat recovery, there isinformation to support that.
Dr. Cozza: Regarding the core principles, we want to make sure that
we are comprehensively addressing the needs of the children and families ofcombat injured service members. We have the following core principles that
we will review and discuss:
1. Combat injury is a challenge to our healthiest families and requires support at varying levels in the health care system and community.
2. Interventions need to be longitudinal and tailored to the changing needsof combat injured families throughout the treatment and rehabilitation
process.
3. Family health and well-being are reciprocally connected to the health ofthe combat injured service member.
4. An integral component of effective intervention includes a family focus.
5. Interventions must engage the family “where it is at” and respect the family’s unique differences and strengths.
6. Children of varying age and gender are likely to have unique developmental responses to the injury that must be addressed.
7. Effective intervention requires collaboration and coordination of services
between family, health care, military and community resources so as todevelop a community of care.
8. There is a need for awareness and consideration of the unique militaryand ethnic contributions that need to be addressed as part of combat injury intervention.
9. Education is required at the individual, family, professional, and facility or
institutional level to best meet the needs of injured families.
10. There are multiple barriers to interventions that include access to care andstigmatization, which can limit family involvement and effective intervention.
11. Additional scientific study is required to better understand the needs of

36 • Session 1: Clinical Problems and Core Principles of Intervention with Injured Military Families

Our National Guard andReservist service members
may receive some of theirmental health services intheir home communities.
Community education
will become vital to theirwell being. An informed
community will be better
equipped to address thechallenges that confront
the injured service
member and his family.

combat injured families and to study the effectiveness of the proposed
outcomes.
Dr. Arata-Maiers: The family focus applies not only to the intervention but also to the institution. Unless the institution has a family focus, it will
become problematic to provide services.
Dr. Cozza: Would that fall under our educational requirements?
Dr. Arata-Maiers: It might fall under barriers to care because it is abarrier to care that has not been acknowledged.
LTC Schneider: Our own preconceived notions and perceptions are
as big a barrier to care. An example of this would be stigma.
Ms. Vineburgh: The intervention should be able to be communicatedbeyond the specific setting in which you envision it.
LTC Schneider: Do you mean it cannot be so specialized it becomesinaccessible to people when they get back to their community?
Dr. Fullerton: In a broader sense the issue is, “how do we address
this in terms of public education?”
Dr. Arata-Maiers: Perhaps the education principle should have“community” added to it. Education is required at the individual and familylevel as well as at professional, institutional and community level to best meetthe needs of injured families.
Dr. Chun: We found that we needed to reframe our services in a waythat was not going to create more patients or require additional resources.
If we were going to provide this type of service, it would require resources
whether we were resourcing it up front or later. Otherwise, we were not only
creating more patients, but we were going to use the same resources that wehad. That was how it was when we started our service at WRAMC.
Dr. Fullerton: One of the important points that a couple of people
touched on is this issue about indebtedness, and the chaplain was an exampleof this, i.e., working with someone already in the system who has the trust factor. Service members will come to a Chaplain. Additionally, using buddies andspouses is an example of a natural resource.
LTC Peterson: The issue is the ambivalence and risk of adverse stancethat the Command has regarding service members who need mental healthassistance. This sometimes interferes with our endeavors in terms of programs
and research. At the Corp’s level, the Commander’s view of mental health isso essential for the success of mental health programs in terms of expansion,intervention and research. Commanders have the ability to approve or disapprove your requests.
Dr. Cozza: I want to make sure that we are thinking about the core
principles. Is the ambivalence of the service member’s Commander a barrier
to mental health intervention? We could put that into education, but we arelooking for anything uniquely present, absent or overlapping that we need tobe considering in terms of intervention.
Dr. Lester: Is it the concern about making mental health patients orgenerating a need for which there are no resources?
Dr. Chun: Both are concerns.
Dr. Lester: If it is framed as prevention then it is not about patients atall. Could we call it resilience training? If it can be framed for what it really is,
it could be focused on secondary prevention.
Workgroup on Intervention with Combat Injured Families — Conference Proceedings • 37

The audiences can vary
but the wording of thecore principles needs
to be generic enoughthat it can be similar
to the approach thatwas used in developing
the Psychological First
Aid principles. If it isbroad, families andprofessionals will beable to read it.

LTC Schneider: My experience with Commanders is that you have to
put things in their terms for them to understand it. If you explained it in termsof a Humvee that is leaking some oil, you might suggest having to check theoil more frequently. Prevention and preventative maintenance is what you arelooking at. Otherwise you are going to end up with a dead lined Humvee if
you do not do what you need to keep it running. We are looking at an at-risk
group of service members, and we want to make sure they are functioning
properly so they do not become victims. If you communicate your need inthat manner that has much more traction than by saying we want to create
another service.
Dr. Cozza: So the wording here is in terms of prevention and keeping
everything in the prevention framework.
Dr. Lester: I do not think it is just semantics. It is actually what you aredoing.
Dr. Beardslee: And then you could also add a statement about healthyadjustments; something like, adjustment is a longitudinal process that involves
all family members. Understanding and mobilizing resources within the individual, the family, the extended family, the care system, the church, the military andthe larger community will eventually result in an effective and healthy adjustment. The adjustment results in healthy functioning in the face of this adversity
or this injury.
Dr. Cozza: What if we said injury recovery is a longitudinal processthat involves all family members and mobilizes resources within the individual, the family, extended family and community.
Dr. Beardslee: Many people could recover without receiving services
if they had access to resources. I am sure many people do, but then you arepositioning the interventions as fostering resiliency and prevention. Does thatmake sense? That is the way we have done it working in related areas.
Dr. Arata-Maiers: We should add what Nancy said earlier about education to the education-based core principle, and we should include education
at the professional, institutional and community level. Our National Guard
and Reservist service members may receive some of their mental health services in their home communities. Community education will become vital totheir well being. An informed community will be better equipped to address
the challenges that confront the injured service member and his family.
Dr. Fullerton: The school systems also need the education component.
Dr. Cozza: Nancy, you had discussed targeting the helpfulness of education materials. The target is the communication.
Ms. Vineburgh: We need to be able to disseminate the principles atother levels that may be points of entry for an injured service member.
Ms. Kaul: It is more the way it is perfected or developed so that it is accessible, useful and targeted.
Dr. Cozza: We just want to get the idea out that it is available and makes
sense to the population.
LTC Schneider: The Battlemind program gives service members a
vocabulary that is in their own words enabling them to talk about and deal
with the impact that their deployment is having on them and their family. The
vocabulary facilitates talking about the Battlemind skills that helped them tosurvive in combat and how they are trying to adapt those same skills to thehome and community environment. They can also provide more buddy care

38 • Session 1: Clinical Problems and Core Principles of Intervention with Injured Military FamiliesBy using our core
principles to develop
family-focusedinterventions that willaddress the needs of thefamilies and children of
our combat injured service
members and following
this cohort, we will bebetter equipped to provide
care for the families
and children of our next
combat operation.

if they have the vocabulary to help them explain what is going on and what
action needs to be taken.
LTC Schneider: How would you do the same thing with regard tochildren and family?
Dr. Fullerton: A similar thing happens when children are at a developmental stage where they can put a word to something, versus not being able
to articulate or say it.
Dr. Cozza: Acting out if they cannot express their feelings.
Dr. Fullerton: Or using play as a method of expression.
Dr. Lester: We need to address the unique military considerations. The
military culture piece needs to be included in all of these interventions. You
also brought up the cultural differences around communication, how people handle difficult information. Roles of families are going to be different
across different communities. In our Latino sample, the older children werea great source of self-efficacy. They took responsibility when a parent was ill
and helped with family tasks that needed to be accomplished. Do you want toinclude that in the cultural piece?
Dr. Cozza: Yes, there is a need for awareness and consideration ofunique military and ethnic contributions.
Dr. Arata-Maiers: I was also concerned about gender effects.
Dr. Cozza: Gender effects are included in the core principle: Childrenof varying age and gender have unique developmental concerns that need to beaddressed.
Dr. Arata-Maiers: Are the parent characteristics included?
Dr. Fullerton: Yes, but we do not know much about that. It may be
a factor.
LCDR Kane: When you pluralize genders that may invite the idea that
we are talking about sexual orientations as well. In this group we do not meanthat.
Dr. Cozza: Varying age and gender are included in the developmentally appropriate core principle.
Dr. Cozza: Should the core principles be framed in an active voice? Dowe want the principles to communicate a concept or is the principle something that directs the intervention? Here is an example of phrasing an intervention in the active voice: “This intervention must engage the family where it
is at.” Here is an example of phrasing it as a concept that directs the intervention: “Services need to be tailored to the changing needs of the combat injured
family throughout the treatment and rehabilitation process.” Do we want tomix these? We will be using an umbrella type of formatting for the core principles and the core principle will be bolded and in color with one or moreparagraphs underneath that will outline what that principle incorporates. The
principle itself does not need to have all of the specifics included in it.
Dr. Newby: From a marketing perspective and to consider the use ofterms that the Commanders are familiar with I noticed that we do not use theword ‘service member’ or ‘service members’. I do not know whether that is intentional. I do not see specific places where I would put it, but I am wondering
whether it could be incorporated.
LTC Schneider: That is a good point because it asks the question, ‘whois the audience’.
Dr. Cozza: The audiences can vary but the wording of the core princiWorkgroup on Intervention with Combat Injured Families — Conference Proceedings • 39

…A great deal of theprincipal work is doneby the peers, supervisorsof service members,
and non-mental healthcare providers. This
concept of resiliency isreally fostered when the
military community has
the expectation that thefamilies will function
together.

ples needs to be generic enough that it can be similar to the approach that wasused in developing the Psychological First Aid principles. If it is broad, families
and professionals will be able to read it.
LCDR Kane: One core principle that may not be addressed concerns the
Navy’s very narrow definition of ‘family’ as spouse and child. If we use ‘family’,
it might be worthwhile to use a broader definition to include parents, siblings, children and spouse of the service member. We can then get the service
member into the family definition, and the constellation around the service
member is what the family is. The use ‘family’ is then implied.
Dr. Saltzman: Do you want to extend that to the care of the child?
LCDR Kane: How ‘family’ is defined is a very sensitive topic that weneed to discuss. However, it needs to be broader than how the Navy defines it.
If we try and expand it too far and start including the whole larger communityof the uncles and godparents, it could become too expansive.
Dr. Cozza: We could use the words ‘immediate’ and ‘extended’. People
would understand that.
LCDR Kane: I want to include siblings and parents.
Dr. Cozza: You could have non-traditional kinds of constellations in
the family, i.e., where a grandparent is primarily the parent.
Ms. Kaul: I would include parents and caregivers.
Dr. Arata-Maiers: Siblings. The younger siblings are especially affected.
Dr. Arata-Maiers: In the Workgroup literature, we talk about familyintervention, but when you read most articles, the content concerns the careof the children. It is not about the spouses, siblings or the parents. The absenceof the spouse part concerns me because if we do not address the concerns of
the spouse who is overwhelmed and who is usually the person bringing her
injured husband to his medical appointments, we will not be addressing theconcerns of an important family member.
Dr. Fullerton: There is literature on that topic, but the impact combat injury has on the spouse addresses different issues that I think are important; issues such as anger.
Dr. McCarroll: There is a need to consider the use of an epidemiologic framework of collecting new information. Wars always end up witheither a new diagnosis or a new constellation of problems. To avoid concluding that we have all solved the problems and all we need to do is provide theinterventions, some thought needs to be given to collecting information thatis going to inform us where we need to go; using an epidemiologic frameworkthat will detail the needs, problems and issues, and using a standardized datacollection system. When you are looking for new information, you develop
an epidemiologic framework of what has being done on a large scale in thecommunities and in the hospitals. You are looking for new information that isgoing to populate different positions on how to deal with these issues as opposed to what we are doing now. Now we take interventions that we know ofand that are being used, which is great, but now consider collecting information that would be used to develop a framework leading to interventions thatwould better meet our future needs.
Dr. Cozza: The use of our core principles would serve as the framework
we would use to facilitate the development of interventions that we would
use for the families and children of the combat injured service members.

40 • Session 1: Clinical Problems and Core Principles of Intervention with Injured Military FamiliesWe are talking about
a broader primaryprevention role, whichis to consult withother community andhealth care service
providers who workin various healthand psychosocial
related fields, but notnecessarily limited toother mental healthcare.

For example, our leadership at the Army or facility level would use theseprinciples when developing services or programs that would include interventions for caring for combat injured families and children. The core principles would then become actionable at the level that they were applied. The
military could also apply them if they wanted to develop a system to measure
the health and well-being of combat injured families. While at hospital level,
they may want to measure the effectiveness of a particular intervention thatthey were using at their facility. What we have been talking about is collecting new information that is core to what we think needs to happen, but that
may be enacted upon in different ways depending upon the level of implementation.
LTC Schneider: It has been over 30 years and we still talk about theVietnam War and the Vietnam veterans, and 15 years later we are still talking about the Gulf War. Years from now we will be talking about OIF andOEF veterans and their families. We are now recognizing that the family andchildren of the OIF/OEF combat injured service members and veterans havebeen an important part of the OIF/OEF deployment cycles. Developing a way
to include them in our body of knowledge is important. By using our core
principles to develop family-focused interventions that will address the needsof the families and children of our combat injured service members and following this cohort, we will be better equipped to provide care for the families
and children of our next combat operation.
Dr. Cozza: We will have an opportunity to advance to the level of application; however, right now we are at the concept level of developing the core
principles. Additional scientific study will be required to better understandthe needs of our combat injured families and to study the effectiveness of ourinterventions.
Dr. Fullerton: There is more than just assessing and evaluating theintervention or a program, which gets back to Ed’s discussion about using an
epidemiologic framework.
Dr. Cozza: Using an epidemiological framework to collect information
to advance the knowledge of military children and families.
Dr. Beardslee: The key issue here also, to go back to what Ed said, isthat this is an evolving problem. There are more and more families that are
being affected. We do not know a great deal about them but we probably know
more than anybody else. That is another reason to gather data.
And then your point is, even if there were no more families being injured,
there would be much to be learned by following these families over the longterm. These are two different points, but both are very important. This is aproblem you have that is growing and it is epidemiologic.
LTC Schneider: And a much more utilitarian issue is that with a volunteer Army at war, the leadership has to recognize that unless the family isattended to, people are going to vote with their feet. The quality of the Army
will degrade if we do not incorporate dealing with the needs of families andspouses into how we deal with retention issues.
LTC Peterson: I underscore that point. The next generation of the
Army is coming from the children of this generation of Army soldiers andtheir families. If we want to recruit and retain service members, we need totake care of their families.
Dr. Saltzman: Yes, we should incorporate that concept as justification
Workgroup on Intervention with Combat Injured Families — Conference Proceedings • 41

There arecollaborative pieces
such as the public
education piece, butpublic education
does not necessarilyrefer to the generalpublic. It may also
include the military
public.

of why it is important to care for the families of injured service members, but
not necessarily as a core principle.
Dr. Cozza: Military children are a national resource.
Dr. Saltzman: I want to address the importance of the mental healthpractitioners being forward deployed and the importance of primary care
physicians developing an early and ongoing relationship with the service
member and the family. These relationships will improve the likelihood ofservice members and their families receiving mental health services.
Dr. Richters: They would kind of naturally migrate to you when theycome back in a crisis.
Dr. Saltzman: Right. And the key would seem to be, and it is in Doug
Zatzick’s work as well, talking about this long-term relationship that starts
with the primary care but then is handed off to mental health when services
are needed. It becomes an easier transition to mental health.
LCDR Kane: We might consider including the concept of the militarycommunity and the importance of the family. In other words, a great dealof the principal work is done by the peers, supervisors of service members,
and non-mental health care providers. This concept of resiliency is really fostered when the military community has the expectation that the families willfunction together. Then when the family is separated from their service member, their ability to overcome setbacks and obstacles may be less likely to bechallenged. Military communities can bolster the family’s resiliency, and that
could be a core principle. Within the military there is resiliency fostered bythose who have been through it before, who can assist those who are new. We
do not need to immediately refer families and children to their pediatricians
and the mental health providers for assistance. This is just how it works, e.g.,when you are with the Navy Seals you look out for each other’s families — thisis part of our military community of care. To be able to say that as a principle
would be helpful.
Dr. Cozza: We need to be framing this for the injured families specifically. So how could we frame that?
Dr. McCarroll: Do you think a core principle might be the development of consultation models to be able to pass the knowledge on to all
the providers who are out there in the caring community such as Family Life
Consultants and Chaplains. There are not sufficient mental health providers tomeet the access standards in all communities. One of the models for providing care might be through consultation to other providers by passing on newmodels of care that they can use.
Dr. Cozza: Let us look at the core principle: Collaboration and coordination of services between health care and community resources.
Dr. McCarroll: A consultation model would be different though.
Dr. Cozza: Would it be to develop a community of care?
Dr. McCarroll: You can say that, but the idea is to be able to pass off,pass on, or consult with to develop resources that can be provided by others,
rather than solely by mental health people. Consultation is a model.
Dr. Saltzman: It is really consultation upstream rather than downstream. The first service provider who contacts the injured service member’sfamily should be knowledgeable in the area of providing services for the family.
Dr. Richters: Ideally you would want to ensure that the first time the42 • Session 1: Clinical Problems and Core Principles of Intervention with Injured Military Families

The use of the core
principles we aredeveloping should
foster evidence-based
approaches that canbe used to support
the family’s healthy
growth and recovery.

family is faced with the reality that their spouse has become an injured service
member. The individuals who contact the spouse need to have the appropriate
information about what services and contact sources are available to help thefamily.
Dr. Cozza: This is in the education principle. We are talking aboutbaseline knowledge, sort of universal knowledge. Effective care is informed byexisting knowledge and seeks new knowledge
Dr. Beardslee: You are looking for a broad public health principle thatis applied to healthy recovery and to recognizing the difficulties of recovery.
Dr. Fullerton: And to an understanding of the military environment.
Dr. Beardslee: Within the military environment, within the militarycontext.
Dr. Cozza: Ed, I want to make sure we do not lose this point about
consultation, which is an equally important point.
Dr. McCarroll: We are talking about a broader primary preventionrole, which is to consult with other community and health care service providers who work in various health and psychosocial related fields, but notnecessarily limited to other mental health care.
Dr. Richters: I know there are different variants of it, but is it sensitizing people who work in various front line positions to know when to recognize problems in order to refer them appropriately?
Dr. Cozza: You are talking about developing an informed system ofcare that can broadly meet the needs of these family members.
LTC Schneider: Yes, a collaborative relationship that is based on you
as a resource person, someone who has some knowledge and experience tooffer possibly in the area of implementing interventions, who can assist combat injured families. Additionally this would be someone who will share theirknowledge and experiences with you over the next six months and follow up
with you to check on your progress and to offer guidance where needed.
Dr. Arata-Maiers: That fits under the collaboration principle.
LTC Schneider: Yes, that is reaching across traditional boundaries.
I think a lot of people here have contributed to that in a number of different ways and it will continue to develop, but I just wanted to put the idea inplace.
Dr. McCarroll: That is important, but the relationship is not part ofthe core principles.
Ms. Kaul: Are we talking about the systems that people come into, e.g.,school systems, medical systems, groups of faith, Lions Clubs, and you want
the intervention to do something, and the consultation model to be set up
so that it can flow either way? I look at it as pertaining to professional andpara-professional staff, not just from a disciplinary perspective. Most of thesystems that families will initially interact with will be the school systems,
their faith-based communities, and their primary care providers who havephysician technicians. Your point is that the consultation model is different
than just rolling out a teacher who is going to teach and who then is going topromptly leave. There has to be some way of integrating, particularly for the
injured families who are leaving the hospital system and going back to theirhome communities, but I do not know.
Dr. Chun: There are collaborative pieces such as the public education
Workgroup on Intervention with Combat Injured Families — Conference Proceedings • 43

As we develop theintervention, we want
to look at the evidencebased information that
we have available andstart to think about thestrategies that would be
useful in linking clinicalproblems to strategies.

piece, but public education does not necessarily refer to the general public. It
may also include the military public. The Casualty Assistance Officer receives
information that the service member was injured, and he or she will call thefamily and notify them about injury. The Casualty Assistance Officer needs tohave some basic information about the injured service member such as marital
status and living arrangements. For example, are there any children and what
are their ages? Who are the children living with, and where do the children
live? Usually it is the Mom who is receiving the call, and will she be able tohandle the call? The kind of sensitivity and information that is needed before
contact with the spouse is made is nowhere in this notification protocol.
Dr. Cozza: Are you saying that the casualty notification process needs
to be more descriptive?
Dr. Chun: Yes, the process needs to be more descriptive.
Dr. Fullerton: We participated in a study within an Air Force community that lost seven squadron members. This loss affected the entire community. There was a very strong spouse group that assigned some of theirmembers to accompany the Base Commander’s wife, the Casualty Assistance
Officer, the Chaplain and other individuals to inform the spouses that theirhusbands had been in one of the planes that went down in flames. The importance of that spouse group is that they had a folder that contained informationthat would prepare them for the visit, which included a checklist of helpful
things to offer assistance with. It was a list of supportive services that wereavailable, military related activities that needed to be accomplished, a script toassist them with what they were going to say, and information on how many
children each spouse had and their ages. This was not an all inclusive list.
Dr. Arata-Maiers: That is triggering something in me. I do not know
if it is a barrier to intervention, but the information on family members within
the military typically has to be searched out. It is difficult to access. Whether
or not service members have children and whether or not the children arepresent or not present is information that is not standardized anywhere. The
information usually comes through a case manager whom you want to havea good relationship with in order to obtain the information that you need. An
additional challenge is trying to identify which family members are here andwho needs assistance. These challenges would probably fall under barriers tocare in military hospitals.
Intervention Strategies Discussion
Dr. Cozza: We are going to refine our core principles now. We are developing a certain level of depth and specificity to them. We need to further
define some of the principles and determine which principles can stand alone,
and which principles may be combined. We have principles which refer to systems of care, education, and barriers to care. There is some crossover between
them, but they probably need to stand independently.
Dr. Saltzman: As I am listening to the course of injury treatment andrecovery, it seems to me that there are critical windows in which different interventions or target interventions are more or less appropriate. I am talking
about interventions or different components within them that are appropriate
for different phases of the treatment and recovery process.
LTC Peterson: I would not dispute that, but it is pretty blurry in termsof which interventions are appropriate for which window of time. There may

44 • Session 1: Clinical Problems and Core Principles of Intervention with Injured Military Families

Whatever intervention
we develop, the training
received should bebroad enough toenable the provider
to work with children
and to recognize
where the parent is at
and what the parent’s
psychological needs are.

be different windows of time during the deployment cycle, but many havegone through the windows multiple times. It is the series of windows that they
are going through.
Dr. Saltzman: Some interventions like Psychological First Aid andeven Battlemind Training may be appropriate for the acute phase or the very
early stages whereas the FOCUS interventions may be not appropriate to use
during the acute phase.
Dr. Richters: That is an excellent point. Refining the principle pertaining to interventions, which may be used to assist families with some of thechallenges they will face during a particular phase of treatment or recovery
would make that clear.
Dr. Cozza: We will refer to the Session 1 Information and Worksheets,
and we will review the injured family challenges and intervention strategies.
The intervention strategies should reflect the core principles of intervention
that demonstrate our current understanding of the injured families experience and needs. The use of the core principles we are developing should foster
evidence-based approaches that can be used to support the family’s healthy
growth and recovery. This review is going to get us into an actual discussion of
the clinical problems and intervention strategies. Page one of this document
describes several evidence-informed interventions, which provide the background and important strategies of intervention that this workgroup will be
developing. The worksheets really get into clinical problems. We may divide
the clinical problems or challenges for the families and children of the combat
injured service member into three major domains: 1) Family Distress and Recovery, 2) Parental Functioning; and, 3) Injury Communication.
We have been talking about core principles, and we are now ready to start
discussing specific interventions which could be used in medical center facilities. We want to develop general strategies. Remember the plan for thisproject is to develop core principles, general strategies that can be applied,
and to develop a manualized treatment intervention. Only a couple of people
in this room are going to be participating in the research study and using
the intervention; however, you all are now involved in helping us to refine
programmatic strategies for the manualized intervention. As we develop theintervention, we want to look at the evidence-based information that we haveavailable and start to think about the strategies that would be useful in linking clinical problems to strategies. We may come back to look at our core
principles, but now we will review the list of combat injury related family
problems and the adapted evidence-informed interventions. They do not always match up perfectly one to one, but the purpose was to begin developing a way to approach the problems we were seeing. Page 3 is an overview
of all the problems and interventions. The combat injury related problems
are: 1) acute parent and child traumatic stress symptoms, 2) reduced parent availability and awareness, 3) parent-child communication problems, 4)
disruption of children’s lives; and, 5) the long-term impact of injury on child,parent, and family function.
We will look at the problem side and determine whether it needs to be
integrated into the core principles, and we will then send it out to the workgroup for comment. As we focus on the broad categories of clinical problems,
we need to ensure we are inclusive. Do we need to add more problems? Also,
because care of the injured family is a complex, we need to decide if there
Workgroup on Intervention with Combat Injured Families — Conference Proceedings • 45

There are young children
who have only seen theirparent as injured, andthey are on a unit where
there are a lot of injured
service members. Whenthey meet people whoare not injured, they areafraid. They are not afraidof injured people.

are other evidence-informed interventions we need to be thinking about or
incorporating into our existing interventions.
Dr. Lester: At whatever stage of treatment or recovery you are in, would
the core principles guide whatever interventions you use?
Dr. Cozza: Yes, the core principles will always guide our interventions.
Dr. Lester: But your goal is to develop a manualized protocol for theimmediate hospital setting. Is that accurate or not?
Dr. Cozza: Yes, we are now identifying the clinical problems. In the afternoon we will look at the evidenced-informed interventions that we recommend using in different sessions to address the specific needs of the injured
families. For example, we have child mastery sessions that would use different
adaptive interventions during different sessions in the stabilization and sustainment phases. We want your input to ensure the sessions have the right mixof activities in them to be able to do the job that we are asking.
Dr. Saltzman: Is the time frame we are considering more for the hospital stay and the immediate period after that, or are we also including thelong term phase?
Dr. Cozza: We are talking about both, but we are talking about it fromthe health care facility vantage point; not every health care facility is going
to provide these interventions. We anticipate medical centers may offer theseinterventions in the acute and sustainment phases. We have models of followup with our injured service members where there is telephone contact, such as
calling service members post discharge and checking in with them. The focus
for the family at that point would really be at the time of transition: how are
they transitioning and integrating back into their communities and are theyreceiving the care they need?
We want to think about the child and family, and the impact combat injury is having on them in what we have identified as potentially challenging
areas. Are the following problem areas that we identified the right problems
to be thinking about? We conceptualized the problem areas as falling into five
major clinical categories: 1) acute child and parent traumatic stress symptoms;
2) reduced parental availability and awareness; 3) parent-child communication problems; 4) disruption of children’s lives; and 5) the long-term impact
on injury on child, parent, and family function.
Dr. Arata-Maiers: They seem to be the right categories, however, myconcern is that there should be some mention about the child as the caregiver,and I do not see that addressed. The long-term rehabilitation care for the parent comes close to that, but it seems more focused on the parents.
Dr. Cozza: You are right. Would you see that included in the disruptionof children’s lives category?
Dr. Lester: The disruption in the child’s life affects his or her developmental trajectory.
Dr. Arata-Maiers: The child as a caregiver does not occur during theparental absence.
Dr. Cozza: The disruption of children’s lives category was actually intended to mean children who are placed in the care of other parenting figures,
however, there may be some crossover here, but the child as caregiver is an
important problem to consider.
Dr. Chun: A concern that I have is that once we develop a model tofollow, additional requirements such as training will be mandated. Flexibility

46 • Session 1: Clinical Problems and Core Principles of Intervention with Injured Military Families

There are a set ofenormously challenging
developmental tasks forthe spouse who learns
their partner is so severely
injured as to require
hospitalization. There
are also a huge set ofenvironmental tasks for the
person who is injured. And
then on top of those two,
there is some responsibility
to the children.

is another important concept to consider. Whatever intervention we develop,
the training received should be broad enough to enable the provider to workwith children and to recognize where the parent is at and what the parent’s
psychological needs are. That type of flexibility needs to be emphasized.
Dr. Cozza: We are talking about embedding that type of flexibility inthe use of the intervention. The intervention would be adapted based upon anumber of different factors such as the needs of the family and the presenceor absence of family members. What you are referencing is the presence orabsence of resources, and the concern about being placed in the position of
being asked to do things that an institution may not be able to provide resources for.
LTC Schneider: There is a concern that if the intervention becomesmanualized, it may become a program that requires additional resources.
However it is more likely to be accepted if the intervention is introduced as
an evidenced-based approach that will provide us with interventions that assist us in supporting the family’s and children’s’ healthy growth and recovery,
and is presented as looking at what we really do and the outcomes. The result
will be providers feeling empowered to study the interventions and the stages,
sessions, and challenges they will address. Then this is not a barrier for professionals. On the other hand if you require the providers to learn and use theseinterventions, it may communicate that someone is not capable of doing thison his/her own.
Dr. Cozza: It is the distinction between the clinical application and thescience application.
Dr. Cozza: We are now moving from principles to general strategy. The
strategies will be general and the interventions will be specific. We are shifting
now to intervention strategies that are problem-based strategies as opposedto general principles.
Dr. Arata-Maiers: Are we looking at interventions with the families
rather than interventions within the settings?
Dr. Cozza: At this time we will look at interventions that will effectively address problems arising during the injury stabilization phase, which isthe acute phase that occurs during the service member’s hospitalization anddischarge from the hospital. That is the information on page 3 of the Session 1
Information and Worksheets handouts. This is family-focused. We may needto do some things within the hospital setting such as educating the staff.
LTC Schneider: This would assume that some of the core principles
underlie the care for the combat injured families and children.
Dr. Cozza: Yes, your assumption is correct.
Dr. Chun: When I was reading articles about caring for the service
members who had TBI there were no references to what impact the injury hadon the family and children, or the care that you would provide to support the
injured service members’ families and children in their recovery. We do notwant to do the same thing here. We want to provide care for combat injured
families and their children.
Dr. Arata-Maiers: The other thing about that literature is that it provides information and descriptions about the problems, but there is very little
about the interventions with those families. We want to move beyond thatpoint.
LTC Peterson: Does that speak to the lack of depth of the intervenWorkgroup on Intervention with Combat Injured Families — Conference Proceedings • 47

When you think of
Psychological First
Aid, the first thing
we think of is safety.
For example, are thechildren in a safe
place? Is the spouse ina safe place? You wantto make sure that thefamily constellation issafe, and then begin
discussions of theirmore acute needs
followed by longer
term issues.

tions that are available?
LTC Schneider: What we have are actually specific treatment goals
that have a specific intervention that will apply to a specific problem.
As a group, our consensus is that these are the kinds of goals that need to
be attained if a particular issue or problem is identified such as the difficulty
the parent has in appropriately sharing or modeling emotional responses toinjury. There will also be a recommended, evidence-informed intervention,and this type of information will be addressed in the manual. There could beother interventions, but this is a nice way of studying and manualizing it whilestill communicating that the goal is, for example, to prepare the child to visit
the injured parent.
Dr. Lester: I do not work primarily in an in-patient hospital setting. I
am wondering how much reactivity to loss and trauma reminders are actuallyinterfering in that acute phase. It is generally referenced as fear, anxiety, or
behavioral disturbances related to trauma, but I wonder about loss reminders
for the injured and even for spouses in the community. My sense is that it isfairly pervasive. People are reacting to loss and children are aware that theirparents lost a buddy, but nobody is talking about it very much.
Dr. Arata-Maiers: And then there are oddities. We have burn children who are afraid of normal looking adults, but who are comfortable beingaround adults who have been burned.
LTC Schneider: Where does that transfer to?
Dr. Arata-Maiers: There are young children who have only seen theirparent as injured, and they are on a unit where there are a lot of injured service
members. When they meet people who are not injured, they are afraid. They
are not afraid of injured people.
Dr. Cozza: Are you referring to a problem that is not listed here suchas protecting children?
Dr. Beardslee: In reference to my visit to WRAMC and my work withyou, there are a set of enormously challenging developmental tasks for the
spouse who learns their partner is so severely injured as to require hospitalization. There are also a huge set of environmental tasks for the person who isinjured. And then on top of those two, there is some responsibility to the children. The first thing one wants to do is to have a set of psycho-educational information or cognates which would describe for the spouse the kind of things
people wrestle with and the uncertainty of what to do about the children. You
are also thinking about how the initial contact occurs and then presumably
the spouse coming to the hospital with children for the first time. This is adifferent situation than the spouse who is returning with her children for a repeat visit. We are talking about the facilities. One of the points you have madeis that facilities may not have places for children to stay when spouses come tovisit the injured service member. Trying to think about it that way will explain
the possibility for parent anxiety and child distress after that initial contact.
You may want to frame this as a potentially normal developmental experience that is also enormously challenging. If I were a spouse in this situation,
I would be bewildered by the amount of information I am receiving and notunderstanding it at all. I might be given a detailed explanation of the nature of
the wound, the nature of the surgery, or the nature of the recovery process, but
I would not know what to ask about my children, or any of the other things
parents usually ask as they are trying to figure it out.

48 • Session 1: Clinical Problems and Core Principles of Intervention with Injured Military Families

There is a hierarchy of needthat dictates the needof the parent to come togrips with what the injury
situation is, to plan on how
to talk to the child about
the parent’s injury, to plana visit to the injured service
member spouse, and thenmaybe to bring the child tovisit the injured parent.

To go back to your list, what I am saying is things like anxiety, distress ortrauma reminders come in the process of coming to grips with this experience.
Dr. Lester: I was thinking about disclosure and notification. Is there
something in that process that needs to be attended to? Are there any important medical disclosures at pivotal impact points or when the spouse is first
notified about the injury event?
Dr. Cozza: Yes, however we are now focusing specifically on the healthcare environment. The education needs to be inclusive to include educationof the health care system employees about the needs of the combat injured
service members and their families and children. Assuming that you have theavailability and willingness of the institution to participate, what are the typesof problems that you might encounter within the health care setting?
Dr. Beardslee: And you were thinking of the parent here as the noninjured parent or both parents?
Dr. Cozza: Both.
Dr. Beardslee: As was previously stated, one might encounter the reenactment of trauma or the stirring of past traumas. Everybody sees the partof the elephant that they work with. For example, I work with depression, andI think there would be a great deal of depression with both the injured service
members and their spouses. Assessing for that or at least being aware of its
possibility is probably important.
Ms. Vineburgh: It would be critical in this first early stage to have thehealth care system understand the basic needs around the security of the actual visiting of the parent, e.g., does the spouse have a place to stay? Did family
and children accompany the spouse?
Dr. Beardslee: Saying that, an assessment should include whom thefamily is or who the stakeholders are from the patient’s perspective.
LTC Schneider: This includes the family demographics including whothey are and where they are living?
LTC Peterson: That is going to be a moving target because there arefamily and close friends who will be coming and going. In some ways it is refining who you are targeting, and you will have limited resources. Therefore it
is important to identify whom we are going to target in terms of intervention
and identifying those individuals.
Dr. Fullerton: And the first step is why they should be there.
Dr. Beardslee: You also need to identify how many children are there
and their ages because you are going to do something different for a three year
old than you are going to do with a ten year old.
LTC Schneider: The information discussed is in the Parent GuidanceAssessment-Combat Injured (PGA-CI) interview tool. The issue with the
PGA-CI is not the questions. The problem is having sufficient resources tocomplete the assessment. It is a question of priorities, and that will need to be
discussed with the department chief.
LCDR Kane: What do we do first? When you think of Psychological First
Aid, the first thing we think of is safety. For example, are the children in a safe
place? Is the spouse in a safe place? You want to make sure that the family
constellation is safe, and then begin discussions of their more acute needs followed by longer term issues. When you initially meet with a spouse, they are
dealing with all the medical/legal decisions; therefore, family oriented conWorkgroup on Intervention with Combat Injured Families — Conference Proceedings • 49

There are somethings like getting theinformation, speaking
up, taking care ofyourself, and thinking
about your children that
help people throughthis experience. This willbe the beginning of thetool kit, and then you
have more measured
responses after that.

cerns may need to be prioritized and addressed during follow-up visits.
Dr. Arata-Maiers: One of the things that we are instituting at Brooke
Army Medical Center (BAMC) is the use of the PGA-CI that we are calling the“Pegasus.” This is a parent-child assessment that we complete with the spousesof injured service members. The need for an intervention in the hospital setting is what I discussed earlier. We have tried to implement the use of thisPGA-CI “Pegasus” assessment since November 2006. We conducted a needs
assessment in January 07, and we are now inaugurating the systematic useof the PGA-CI “Pegasus.” It required a lot of refocusing of resources in orderto have a policy in place that mandated completion of the PGA-CI “Pegasus”
with all spouses of the injured service members. We coordinated with casemanagers to set up appointments that work well for the spouses when they
have the time and emotional availability to meet with us and complete the assessment. The PGA-CI “Pegasus” is both a setting and a family intervention.
LCDR Kane: The service member’s prognosis is another decision point.
Is he or she ever going to regain consciousness and be cognitively intact? If the
prognosis is poor we will use different kinds of interventions than we might
use with the spouse and family of a service member who had an orthopedic,
eye or soft tissue injury and whose cognition is intact. The child will be able
to interact with the parent and see that their Dad or Mom may be injured but
will recover. This would be a hospital intervention, and the type of family intervention will depend on the prognosis of the injured service member.
Dr. Cozza: Our intention now is not to develop a longitudinal intervention strategy but to understand the problems and the disruption to thefamily and children in broad ways. I know as clinicians, we would be interested in how we approach the problem, starting at Time A. This table was not
set up in that way. It was set up to catalogue the types of problems families arelikely to have that would need to be addressed in some kind of way. We would
then identify our intervention goal and the components of our intervention
in order to ensure our core principles are addressed and look at problems ina time driven and flexible format. In other words, we have a broad understanding of what those problems are likely to be for any given family. The
fact that problem 1.1 is “acute parent and child traumatic stress symptoms”
does not necessarily mean it is the first thing we deal with. We do have broad
categories of problems within families that can be assessed and treated using
evidenced- informed interventions. Problems may not be addressed in any
particular order. It may not even be feasible to address all of them based upon
the resources that we have. Do we have the categories of problems addressed?
Are we missing big chunks of material?
Dr. Beardslee: That was very helpful. Somewhere you may want to saythat each of these problems is preceded by some awareness of the dimensions.
In other words, who is in the family and what is the nature of the injury? Is
the service member in the Intensive Care Unit (ICU), on the Neurology Unit
being treated for a severe TBI, or is the service member’s condition listed as‘very seriously ill’? What you are going to do is going to be different depending
upon the extent of the service member’s injuries and prognosis.
There is a larger issue for me: taking problem1.3, parent-child communication problems and the sub-problem relating to the inability of the parent tooffer developmentally appropriate notification of the injury to the child. How
do you communicate notification information? You can frame that as a diffi-

50 • Session 1: Clinical Problems and Core Principles of Intervention with Injured Military Families

We want to haveinformation
available. Providing
information about
how to communicate
with children canbe anything fromproviding a sheetof paper to optimal
discussion. There arelots of different ways to
educate parents.

culty, or you can frame that as a developmental challenge. The developmental
challenge is what any parent would face in trying to describe a very serious
injury of a service member who is being treated at WRAMC. There is a hierarchy of need that dictates the need of the parent to come to grips with what
the injury situation is, to plan on how to talk to the child about the parent’s
injury, to plan a visit to the injured service member spouse, and then maybe
to bring the child to visit the injured parent. There are a set of strategies thatwill guide this intervention. It is a question of whether you frame these as
developmental challenges, and the problems are then the situations where it
does not go well.
Dr. Cozza: This is an important point. Is it a language problem?
Dr. Beardslee: It seems to me that every family in this situation is going to be challenged by how to explain the injury notification to the children.
But it seems to me that by saying ‘communication problems’, you believe there
is a subset of families that are going to get into real difficulties or difficulties
that are other than the norm, such as an inability to offer developmentally
appropriate notification, or difficulty in sharing or modeling emotional response. And then there are other families who may be able to do this. That is
how I understand problems.
Dr. Richters: There are a number of things that we do not necessarily think of as problems. If we thought of them as needs, what are the normal
ranges of needs in the injury situation? You would think of a number of otherthings to do preventively that you might not otherwise think about.
Dr. Beardslee: You can do it either way. You can put a definition at the
top that says, “These refer to responses that are beyond the range of normal inthis situation.” I just want to pick up on something that Patricia said. I try tothink about the mental model of the parent who is having this experience. The
mental model will be conditioned by having lived on the Army base where
many families may be experienced in living with an injured service member.
Dr. Cozza: The emphasis on challenges is an important one to be thinking about, and it is almost self-explanatory. If challenges go unnoticed and unaddressed, they become problems. Keeping it within a prevention context is
important. To phrase it as developmental challenges or symptom challenges,
some of those things in some ways are expected, and then some of them areproblems. Do we need to think about the relationship between challenges andproblems as we develop this? In other words, there are certain things we aregoing to provide that we think are important in developing strategies within
the hospital setting. How should we consider the range of responses? Should
it be within each of these subcategories, or should it be in its own category interms of when problems develop?
LTC Schneider: It is like the Battlemind Training where the issues are
identified. For example, ‘emotional control versus detachment’, and under that‘what worked well in combat’, and why that same skill set will not work well in
the home, i.e., transitioning the combat skill to the home environment.
Dr. Beardslee: You could easily do a paragraph or two about the huge,
expectable and normal developmental challenge it is for a family to adjust toa service member spouse and parent who is hospitalized for a period of time.
That is the challenge; some families do this on their own and others do not.
You frame it as a normal reaction, namely that it would be normal to be heavily challenged by this.
Workgroup on Intervention with Combat Injured Families — Conference Proceedings • 51

Ultimately, getting
information toparents in a way thathelps them meet theimmediate needs oftheir children in thehospital setting andthen beyond is very
important.

Dr. Lester: It is the self-care approach that Doug’s model rolls out too.
Similarly to the medical tool kit we use for everybody who goes through aphysical injury and is hospitalized. There is an assessment piece embedded init. Then somehow you have some decision-making point for who gets followed
over time. Maybe everybody does, because maybe the risk is high enough thateverybody gets followed over time, but then there are points where some will
receive additional modules.
Dr. Beardslee: Nancy really engineered this piece (a brochure) that
we wrote for National Depression Screening Day, entitled Can a Depressed
Parent Be a Good Parent? You Bet! Bet stands for believe in yourself, educate
yourself, and talk to your children. And it took a huge amount of work to reduce the information to two, eight and a half by eleven sheets of paper. I think
the public health intervention would be to generate a knowledge set, and thenput it in some format available to a parent that says that this is enormously
challenging and here are the things that families wrestle with. There are somethings like getting the information, speaking up, taking care of yourself, andthinking about your children that help people through this experience. This
will be the beginning of the tool kit, and then you have more measured responses after that.
Dr. Chun: I was just going to say that we present the situation to families in just this way. Otherwise we are going to overwhelm the family and become more of a barrier. We let the family know that this is an enormous challenge and that we are here to answer any questions they have and to support
them. Those are the kinds of statements that we use before we do anything. We
do repeated visits to give the family an understanding that, ‘this is a normal
response to an extremely challenging situation,” and we will support them inusing the coping resources they have and be there if additional assistance isneeded.
Dr. Cozza: The lunch break will help us as we shift to the idea of challenges and the relationship between challenges and problem development,
which is important. We will then discuss the intervention goals and strategies.
The strategies could be anything from handing a spouse a fact sheet with information on it versus engaging in more conversations. There will need to besome flexibility in how this intervention is integrated at the particular healthcare facility.
Dr. Beardslee: I would agree. The piece that Nancy and I did was to begiven out as a stand-alone document on National Depression Screening Day.
We had no control over it other than to make it as good as possible. Your pointis that this is probably better than a face-to-face interview in which one is very
careful about not overwhelming the parent.
Dr. Richters: It is getting the information down and how it is going to
be used that is different.
Dr. Cozza: Although there are some settings where the resources may
not be available, we do not want to develop an elitist strategy that can only
be implemented in a very well resourced place. We want to have information
available. Providing information about how to communicate with children
can be anything from providing a sheet of paper to optimal discussion. There
are lots of different ways to educate parents.
LTC Peterson: I want to underscore what Dr. Cozza said. My concern
is when there are no resources to implement programs like this. We are one

52 • Session 1: Clinical Problems and Core Principles of Intervention with Injured Military Families

Providing information
about how tocommunicate
with children canbe anything fromproviding a sheetof paper to optimal
discussion. There arelots of different ways
to educate parents.

provider deep for Child Psychiatry and Child Psychology. You are not goingto go after the parent who is not eligible for care to begin with, even though
it is the right thing to do. You are not going to go after the multiple, no-show
family. You are going to go after the person who is presenting in trouble.
Dr. Cozza: If it was a stratified strategy where there were multiple waysthat goal could be achieved, it might work.
LTC Peterson: That would help here. It needs to be able to be used ina manner that the providers, who are under-resourced, can utilize it in an effective manner.
Dr. Richters: It should be communicable at all levels from the level
Bill was just talking about where they were required to reduce the information
to two eight and a half by eleven sheets of paper to increasingly more detailed
and more complex forms of communication.
Dr. Cozza: That is the reason why we need to have a complete problem list. Then we understand and can come up with multiple strategies to approach the problems or challenges on a varying number of levels.
LTC Peterson: As this manualized intervention gets rolled out, it will
be very important in the deployment of this intervention to include an information sheet that will identify the phases, the session worksheet functions,and the participants for the various sessions. Will there be specific instructions for the use of this intervention at medical centers versus community
hospitals? The sessions are intended to be combined flexibly, which will allow
an appropriate mixture of meetings with parents and children in varying formats to address the specific needs of a family during injury recovery.
LCDR Kane: Another thing that would be helpful is to include information about how to obtain additional resources if you want to expand yourprogram. This is helpful because sometimes when you are given funds; youare trying to prioritize what programs to implement and where to obtain resources.
Ms. Williams: I just wanted to bring out the possibility of another challenge or problem, which is the post-hospitalization transition that should be
addressed while the family is still in the acute care setting in order to prepare
the family for their next phase of treatment. For example, if the family has
been together in this very artificial environment, what is it going to look andfeel like when they are trying to go about doing the everyday tasks of being afamily when they have not seen their child in a year or more because the childhas been watched by another provider?
Dr. Cozza: You are referring to reintegration issues. We can probably
put that in the problem or challenge section that addresses the long-term impact on child, parent, and family function.
Dr. McCarroll: Bill commented on providing knowledge to parents
as part of a tool kit. It seems to me that we are talking about two, different
things. I thought this conference was organized to provide information forproviders. If we have information for providers and we are also trying to develop information for parents, are we saying these are two separate topics or
can they overlap?
Dr. Cozza: The intention was that the product roll-out would notnecessarily be the immediate outcome of the Workgroup, although I expectthat would eventually be where activities would go. The Workgroup was notbroadly defined as core providers only, and it was more narrowly defined as
Workgroup on Intervention with Combat Injured Families — Conference Proceedings • 53

Ultimately, getting
information to parents
in a way that helps themmeet the immediateneeds of their children
in the hospital setting

we got to the point about what to do in the immediate hospitalization setting
and post hospitalization setting. However, that would also include the providers and the parents. It is really more related to the parents and the engagementof the parents, and we will want to make sure, based upon our core principles,that the hospital and health care providers are educated and everybody is saying the same thing. Ultimately, getting information to parents in a way thathelps them meet the immediate needs of their children in the hospital setting
and then beyond is very important.

and then beyond is very
important.

54 • Session 1: Clinical Problems and Core Principles of Intervention with Injured Military Families

S ession T W O :Practical Application and the Componentsof Effective Intervention
I believe we need to
add another core
principle: combat
injury is a challenge to
our healthiest families
and requires support
at various levels in thehealth care systemand community.

From Clinical Reality to Family-Focused Intervention
Dr. Cozza: Regarding our previous discussion and Bill’s comments, I
believe we need to add another core principle: combat injury is a challenge to
our healthiest families and requires support at various levels in the health caresystem and community. We need to acknowledge the nature of the challenge.
If we neglect that, then we move immediately into illness-based models. The
focus on prevention is extremely important. Without concerning ourselves
about how the interventions are carried out, do the categories we have identified on the Session One worksheet reflect all of those challenges and problems? Terry, I thought your comment about the care-giver status is an important one.
LCDR Kane: One area we should include is spouse communication.
How is the relationship between the parents? At some level we need to assess
how the parents are communicating.
Dr. Cozza: We might change that to family communication challenges.
LCDR Kane: That would be broader and help us to assess how the parents are functioning, i.e., the marital relationship.
Dr. Cozza: Can you give a succinct example of that? What is the challenge?
LCDR Kane: I encounter families where one parent has one parenting
style, and they use it as a battle or conflict between the two of them. They needtime to reintegrate into the role of parenting so they are not stepping on thoseboundaries.
Dr. Cozza: Can we specify it a little bit more for the injured party?
Dr. Lester: Could you talk about sustaining parenting and maintaining
the injured parent’s role while away or while injured?
LCDR Kane: My concern is about marital conflict and its implications.
Many of our interventions at Walter Reed are spouse focused. If we are intervening with the spouse, we want to make sure we assess how the marriage isdoing. A great deal of the parenting work falls out because of that. If we aredoing a family paradigm, you really want to do a marital assessment.
Dr. Cozza: I like keeping it at a pre‑clinical level. The goal and challenge is sustaining the marital relationship through injury, treatment, and recovery. The goal is helping couples recognize the challenge and some specificWorkgroup on Intervention with Combat Injured Families — Conference Proceedings • 55

It can be a slippery slope
when you go down theroad of marital conflict andmarital therapy. Sometimes
it is more than you can
do in the circumscribed
context. You have to assess
it, acknowledge it, and set
it to the side and get people
to focus on the task at
hand.

approaches to dealing with communication or relationships during the periodof treatment and rehabilitation.
Dr. Lester: It can be a slippery slope when you go down the road ofmarital conflict and marital therapy. Sometimes it is more than you can do in
the circumscribed context. You have to assess it, acknowledge it, and set it to
the side and get people to focus on the task at hand. Or, focus on parenting
per se, because they may be able to come together around children, or aroundinjury recovery. The marriage is something that is a longer-term issue.
DR. Arata-Maiers: Do you want to look at the spousal communication as a part of the family, or the spousal communication as it relates to theability to parent?
Dr. Cozza: These are really challenges to the family. I think it is reasonable to just recognize the injury-related stressors on marriages.
Dr. Chun: We have a menu that lists situation examples identifying periods of time during which the family and the spouse expect almost a breaking
point. Soldiers being deployed many times have drawn out narratives. Whenthey come back with the injury, there is that issue of the communication. Our
approach has been to focus more of the communication around the parenting, but we do have to address the marital situation. An example is a soldierthat comes to us with an injury and when he opens his eyes, his wife is signing
divorce papers. This creates another level of complexity. We could work withhis family around parenting, but their marital conflict is something they needto address later on with someone else.
Dr. Cozza: If we are talking about the family in terms of how theyfunction, it might be helpful to keep it communication based as opposed torelationship based.
Ms. Vineburgh: What if the injured parent cannot communicate?
Dr. Cozza: That is part of the challenge through injury treatment andrecovery. It is also sustaining parenting through injury. For example, one ofthe difficulties is that some parents who have traumatic brain injury thinkthey are parenting acceptably, and they want to be involved. Part of what you
must teach them is that it may be better to defer to the healthy parent at thispoint in time.
DR. Arata-Maiers: There are two things I would like us to look at.
Under 1.2, reduced parent availability and awareness, we have parental problems related to the injury. Do we have parental lack of availability and awareness related to the care-giving responsibilities? That might be included under
reduced parental awareness of child’s emotional needs. We may want to fit thechild’s distress related to encountering reminders of trauma in the hospitalsuch as seeing other injured folks or medical procedures related to combat
injury.
Dr. Cozza: We might want to add child traumatic exposure under 1.6
and not leave it as 1.1. This idea of exposures being a challenge to the child in
the hospital setting is important.
DR. Arata-Maiers: There are many triggers within the hospital settings, not necessarily gruesome medical trauma. Children could see a nurse
and get concerned about shots when they are young. So coming into the hospital setting and seeing or hearing that their parents are going to have surgery
and connecting that to the time when they had surgery.
LTC Schneider: Yes. Some are counter-intuitive, like children with56 • Session 2: Practical Application and the Components of Effective Intervention

Reintegrating a deployed
member is a challenge forany family. It may be evenmore challenging if thecontext of reintegration isan injured family member.

burned parents who react negatively to those that are normal-looking.
Dr. Chun: The really important issue is about reintegration.
Dr. Cozza: Are we talking about 1.5, long-term impact?
Dr. Chun: Say Dad has been in Iraq for fifteen months. His three year
old becomes a five year old and the first time they see each other is in the hospital. There are a lot of reactions or adjustments. In some instances the childhas been told in the picture, “This is your Dad,” and the child comes to visit
Dad, and says, “He is not my Dad.” This could fit under disruption of a child’s
life.
DR. Arata-Maiers: In your initial remarks, you talked about thechild’s integration of the change in the parents. That seems to be what you are
discussing now.
Dr. Cozza: It is not just the re-connection, but the long-term change ininjured child-parent interactions, activities, or function under 1.5.
LTC Schneider: Reintegrating a deployed member is a challenge forany family. It may be even more challenging if the context of reintegration isan injured family member.
Dr. Beardslee: You asked us to think about difficulties at different levels. How much do you see existing conditions exacerbated by either disruptions in routine or other associated child needs? An example is the child who
has ADHD and needs the structured setting, medication at a certain time ofday, and so on. Then, the person who is doing that is not available and thecondition becomes exacerbated. I think that belongs under either disruptionof children’s lives or long-term impact exacerbated by preexisting difficulties.
LTC Peterson: Our patient population is the same as before, but theintensity of need is greater having been exposed to the stress of parental injury, i.e. the ADHD child whose attention worsens. It is also a reflection of
the stress of the parent who remains behind and not having that co-parent,
co-pilot thing.
DR. Arata-Maiers: We are having difficulty also with identifying
whether this is a pre-existing condition, a new condition that is an adjustment response, or a co-morbid condition. Because we see them at the pointof injury, we don’t know. Oftentimes they are young enough that they are justentering a time period when you would identify them as ADHD or ODD, so
you don’t have a good history to depend upon.
Dr. Richters: It raises interesting questions. Would it have relevanceto how you would intervene, or would it have relevance as a possible rule-out?
For example, if this is a continuation of a pre-existing problem, do we concern
ourselves with it during the intervention?
DR. Arata-Maiers: We have found that our pediatricians are assuming this is a reaction to stress. If we deal with just the stress and not the ADHD,
and then you put them together, you’ve got chaos, such as kids being thrownout of school, or academic problems. So not identifying what may be a prelude
to a behavioral disturbance exacerbates it and creates more problems for thefamily.
Dr. Richters: Granted, they may have many problems. The question iswhat do you do in this intervention from the best practice standpoint? We talked about core principles. A good strategy in the hospital setting is to be awareof children or families that were at risk prior to the injury taking place. That’s
not a core principle, but it’s an important strategy to get our hands around.
Workgroup on Intervention with Combat Injured Families — Conference Proceedings • 57

We have not talked about
how to help the child deal
with the loss of the physicalfunction of his/her father. It
could be just appearance,
it could be body parts, or it
could be other things. For
example if the father used tobe big and now is a bilateralamputee, he is small.

Dr. Cozza: I think it is reasonable. It is an informing part of trauma
work that at risk populations are going to have worse outcomes.
Dr. Richters: Co-morbidity is going to be the rule rather than the
exception.
Dr. Lester: There is another problem that comes from the network
medical trauma toolkit. It is helping children plan for communication withothers. There is the potential stigma experienced when going back to schoolor going back to their community. They can actually model and practice what
they want to say about it. They don’t have to tell everybody everything.
Dr. Cozza: Can we put that under family communication challenges?
Dr. Lester: Yes. It could be helping your child communicate about theparent’s injury to others.
Dr. Saltzman: In terms of 1.2 and 1.3, it might seem a little narrow.
Parent-child communication does not speak to some of the broader family
communication issues.
Dr. Cozza: We have changed it to family communication challenges.
Dr. Saltzman: Excellent. In 1.2, there is more than reduced parental
availability and awareness. We are seeing a change in parenting styles, i.e. becoming more rigid. Is this subsumed in 1.2?
Dr. Cozza: No, and that is a good idea. What we should say is changed
parental availability awareness and style. For example, some parents do notprescribe to disciplining their children. They feel the situation is hard enoughon them already so they will just ease up on them.
DR. Arata-Maiers: Is that different from what is in 1.5 in terms ofthe change in injured parent-child interactions or activities in the parenting
function?
Dr. Cozza: The part of this table intended to have a temporal sense is
1.5 as opposed 1.1 to 1.4 being more short term. We may want to adjust thetable to reflect that especially if we are thinking about the idea of stabilizationand sustainment phases of treatment and intervention. As we have redefined
this table the distinction between family based challenges, as opposed to systems based challenges, becomes evident. We may want to define certain systems based challenges separately, and use 1.7(the blank page) to do that.
Dr. Chun: We have not talked about how to help the child deal with theloss of the physical function of his/her father. It could be just appearance, it
could be body parts, or it could be other things. For example if the father used
to be big and now is a bilateral amputee, he is small.
Dr. Cozza: Could we add that to childhood stress?
LTC Schneider: Perhaps we should consider a key frame, child reaction to injury, as a heading of 1.1, and then bereavement or loss could becomea point under it.
Ms. Kaul: I am wondering about the issue of a defined lack of role fora child, not in the acute phase, but in the early rehabilitation. When is it appropriate and helpful for a child to have a role? Would that create some senseof stability?
Dr. Cozza: Yes, disruption of children’s lives, 1.4.
Ms. Kaul: Instead of normal routine disruption, this is a new activity
and concern going on in this family. For many children, depending on the setting, there is no role for them. There may be ways of creating an adaptationalrole for even smaller children so they feel part of this process.

58 • Session 2: Practical Application and the Components of Effective Intervention

We need to think aboutdevelopmentally sensitive
challenges to the individual
child. There may be adifference between aschool aged boy being
pulled back into the family
to be helpful versus ateenager being pulledback who is searching forindependence.

Dr. Cozza: A sense of self organization, safety and security.
Ms. Kaul: Can you link the injured service member to a sense of efficacy
about parenting?
Dr. Cozza: In the disruption of children’s lives, we may want to incorporate loss of a sense of safety, role, and efficacy. We talk about loss of parental
efficacy.
LTC Schneider: The challenge may be maintaining connectedness
through treatment from the child’s perspective.
Dr. Cozza: Yes. Should 1.3 just be communication, or should it be communication and connectedness?
Dr. Lester: What about communication and connectedness challenges?
Dr. Cozza: Yes, that makes sense.
Ms. Vineburgh: Building on what Pat said, another challenge is theexternal communication problems. Helping families regulate this as they are
assaulted by so much communication.
Dr. Beardslee: This would be regulating external information. I wastrying to think about the challenges that are different at different developmental stages for children. I’ll give two made-up sexist examples. The first involves
a family with an older girl who is caretaker. We see this with the depressedfamilies all the time — tremendous pressure on that child to step in and do
things for the parent. And then, imagine a family with a younger boy who isactive, and the pressure on him to be quiet and passive. Both examples are
expected. The challenges for different children are going to be different depending on their ages and roles in the family. But the roles will change and thedemands on them will change. Or the expectations about them will change.
Dr. Richters: It is also a role redefinition. From parents, injured parent, spouse, and child, those things are going to be redefined by the nature andextent of the injury.
Dr. Beardslee: They push children into areas because there is no one
else to do it or because there is a tremendous premium on behaving.
Dr. Richters: An interesting piece just came out this year on the phenomenon of parentification.
Dr. Beardslee: I have written about children who become caretakers
in families with depression. It is not a bad thing as long as they have somechoice about it. The natural response, if somebody in your family is ill, is totake care of them.
Dr. Lester: We have six year outcome studies showing that children
who took on parentification roles experienced some initial distress, but six
years later they were actually doing better than written about in Judith Stein’s
article.
Dr. Richters: There should be a distinction between a functional andemotional parentification role.
Dr. Lester: That may be important in a family with an ill or injured
parent.
Dr. Cozza: We need to think about developmentally sensitive challenges to the individual child. There may be a difference between a school aged
boy being pulled back into the family to be helpful versus a teenager being
pulled back who is searching for independence.
Dr. Beardslee: Developmentally sensitive changes in roles. The roles
are going to be different at different developmental epochs or stages.
Workgroup on Intervention with Combat Injured Families — Conference Proceedings • 59

Pre-discharge, there is a setof issues relevant to planningand preparation for thetransition. With discharge
imminent, the non-injured
spouse may wonder, ”What if
I have to be the bread winnerand a care taker?”

DR. Arata-Maiers: Under reduced parental availability and awareness,
you may need to put in something about the parents’ distressed or clinical behaviors that impact the family, for instance substance abuse, parental numbness and avoidance. Substance abuse can endanger a child in many ways
Dr. Cozza: That probably should be included in 1.1. We have childtrauma-related psychiatric disorders, but there are also parent trauma-related
psychiatric disorders and stress symptoms.
Ms. Vineburgh: What if the uninjured spouse is disabled?
Dr. Richters: Would that be subsumed under the parenting role?
What if one of the kids is disabled?
Dr. Cozza: Somewhere in 1.2 we need to include change in parental
availability, awareness and/or efficacy.
LTC Schneider: There may be more instances where the other parent
is disabled with psychiatric issues.
Dr. Cozza: We need to add changes in parental ability, awareness, styleand challenges to at-risk parents, such as prior illness or disability.
DR. Arata-Maiers: Are we talking about both the service member
and the spouse?
Dr. Cozza: Yes.
LTC Schneider: Where do we put that?
Dr. Cozza: Under 1.2, change in parental availability, awareness andstyle.
LCDR Kane: Another problem relates to long term financial loss andcareer issues.
Dr. Cozza: Yes, change in a family’s financial status.
LCDR Kane: Financial resources.
DR. Arata-Maiers: And vocation as they are related.
Dr. Chun: When they get injured they also lose their combat pay, which
is a double whammy.
Dr. Cozza: So there is change in family constellation, roles and financial status.
Dr. Richters: Pre-discharge, there is a set of issues relevant to planning and preparation for the transition. With discharge imminent, the noninjured spouse may wonder, ”What if I have to be the bread winner and a caretaker?”
Dr. Cozza: How about putting transition and long term impact under
1.5?
LTC Schneider: Would a program like this focus on the anxiety related to financial issues?
DR. Arata-Maiers: I believe that is somebody else’s responsibility.
Dr. Cozza: We are not focusing on the intervention, but rather on understanding the broad problems that families address.
LTC Schneider: Should our role include connecting them with resources?
Dr. Richters: Should we advise or give guidance on how to be proactive as resource seekers and recipients?
DR. Arata-Maiers: Regarding the vocational implications, if a National Guard member is injured, and their former employment involved physicalactivities, they are going to face a lot of change. Those who stay in the military
may face job changes also. Both create anxieties and stressors for the family.

60 • Session 2: Practical Application and the Components of Effective Intervention

I added a fourth principle:
combat injury is achallenge to our healthiest
families requiring support
at varying levels in thehealthcare system andcommunity.

Dr. Cozza: I have included change in family financial/vocational status;changes that take place long term.
Dr. Cozza: We can discuss barriers to care later. We have talked aboutfour principles. I added a fourth principle: combat injury is a challenge to ourhealthiest families requiring support at varying levels in the healthcare systemand community. This is kind of a PFA type principle. We also have discussed
core problems for the families. We have not talked about specific strategies,
just broad strategies to address them. Some methodologies have strategies
within them, like PFA, the Parent Guidance Assessment Instrument, and FOCUS. Many of you have said you would be more interested in core principles
and strategies as opposed to specific interventions that would obligate you to
implement them.
LTC Schneider: Sometimes they are 100 percent necessary if they
have outcome evidence to apply to a new population and can be validated inanother. I am not saying it should not be part of what we are looking at, but itshould not be a barrier to going forward.
Dr. Cozza: It is not an obligatory intervention. It is a development of
an intervention that would be available for use and study, but would dependon resources and resourcing.
Project FOCUS: UCLA and NCTSN
Dr. Cozza: I would like to shift to project FOCUS and use it as a jumpoff point for discussion of intervention for injured veterans.
Dr. Lester: Bill and I are going to present this together. Project FOCUS,
with its own version of core principles and components, is the collaborative
effort of the UCLA Center for Community Health, UCLA Trauma Psychiatry,
and the National Child Traumatic Stress Network (NCTSN). Bill and I workat the National Center developing a work group on family-centered interventions for child trauma. We worked with Bob Pynoos to develop and adapt
this intervention from our existing ones. The UCLA Center for Community
Health develops, evaluates, and disseminates prevention and treatment interventions for high-risk and traumatized children and families. We have a large
profile in families affected by HIV as well as other kinds of high-risk children.
We work with communities, international and national, to adapt and integratethese interventions to make them relevant to their communities.
You are familiar with NCTSN, and the SAMHSA funded Traumatic Stress
Network. Over the last four or five years, working closely with the National
Center, we have integrated some of the strategies and methodologies into ourwork at UCLA Division of Child Psychiatry. UCLA Trauma Psychiatry, originally developed by Bob Pynoos, has done consultation and intervention services nationally and internationally. We have collaborated to integrate someof the traumas, like the medical trauma toolkit, developed for physically injured children and their families into our services. I run a Child and Family
Trauma Clinic, and Bill co-runs it with me one third of the year. Our trainees
go through this clinic. While they circulate on our service, they are trained touse the trauma toolkit. They do psycho-education for all physically injured
children including those felt to have high levels of traumatic exposure, suchas transplant and cancer children. Those who are experiencing high levels of
distress are referred to the clinic to receive more intensive evaluation and services of which FOCUS is one. When I give this talk, I usually have to set theWorkgroup on Intervention with Combat Injured Families — Conference Proceedings • 61

We developed thisintervention with a specificinterest on how trauma
affects parenting andfamily functioning. So, it
is applicable for physicallyinjured parents withco-morbid psychiatricproblems, or people justdealing with combat
operation stress.

context for the challenges facing military children and families.
We developed this intervention with a specific interest on how trauma
affects parenting and family functioning. So, it is applicable for physicallyinjured parents with co-morbid psychiatric problems, or people just dealing
with combat operation stress. It is not just a deployment support intervention.
The military does those things, for example the Fleet and Family Service, very
well around the deployment cycle. We were really interested in what we could
bring to families at higher risk.
I normally summarize that we do not know a great deal about the impact
of wartime deployment. We know that military children look good compared
to non-military children in the study, a community based sample. Militarychildren usually experience some level of transient distress around one wartime deployment cycle. Certain groups appear to be at higher risk — boys,
younger children, children with prior mental health or developmental problems, particularly children with caretakers who have high levels of distress.
One of the most interesting findings from Doug Zatick’s work is thatamong children who sustained physical injuries, one of the strongest predictors of PTSD is prior trauma in the parent. Parent functioning, their priormental health functioning and their experience with trauma, are relevant factors to how their children are going to do long term. There is also the emerging data about child maltreatment, primarily an elevation in neglect, from theimpact of repeated deployments.
We really looked at what we knew about parent emotional distress andchild adjustment, which is that they typically track together to tease out what
are the aspects of parent adjustment? We know parental depression, in particular irritability, important in PTSD, has a strong negative predictive affecton child adjustment. Then we looked at the literature on non-combat traumatic stress and parent and child adjustment. We are still doing some of thiswork around one of my community-based samples and finding that it is not
avoidance or re-experiencing that predicts parent and child conflict, but rather symptom severity across domains. In my HIV positive and neighborhood
moms with trauma, parent and child conflict seems to be the most powerfulpredictor of poor child adjustment in the family.
We tried to develop an inventory of the components of PTSD and its impact on parenting. Avoidance and emotional numbing have been talked about
in the literature, and there are separate studies to support them. It is difficult literature because everybody uses a different family measure, draws upon
different parenting literature, and finds slightly different variations. The idea
exists that parents can be either highly authoritarian and over-protective or
avoiding with poor monitoring. Both things can occur.
This is our model. To some extent there are baseline moderators — theevents that happened to the military personnel and the kinds of problems wehave talked about today such as parenting challenges, changes in family atmosphere and roles, financial problems, relational changes. Our interventions
are targeted at those mediating factors with the hope of having an impact onchild, spouse, and service member adjustment over time.
We collected a great deal of data when we went to Camp Pendleton threeor four years ago. The research revealed that people would be more likely toseek services for their kids than for themselves. Even divorcing parents might
be willing to do a parenting intervention. This is a gateway to getting people

62 • Session 2: Practical Application and the Components of Effective Intervention

Dr. Beardslee’s intervention
for parents with a serious
mood disorder is the only
family-centered intervention
in SAMHSA’s National
Registry of Evidence-based
Programs and Practices. Its
results, based on long-term
longitudinal randomized
control outcome data, show
it increases understandingof parental illness in thefamily.

in to be assessed, to do some early intervention and do prevention for thefamily.
To Chris’s point, this is not just a recovery model. It could be used to support ongoing readiness and is useful for multiple deployments. How do weneed to change and shape our interventions with that in mind? This may beless relevant for the injured population as many of these people are leaving theservice or not going to be deployed again.
Dr. Beardslee’s intervention for parents with a serious mood disorder isthe only family-centered intervention in SAMHSA’s National Registry of Evidence-based Programs and Practices. Its results, based on long-term longitudinal randomized control outcome data, show it increases understanding ofparental illness in the family.
Dr. Beardslee: I had two active interventions; one with lower intensity and one with higher intensity.
Dr. Lester: Yes, and both groups got better to some extent. The intervention I have worked with is called Project TALC, an intervention for parents
with HIV and their adolescent kids, which has been used with children of different ages in different countries. A randomized control trial in New York thattook place early in the HIV epidemic, when it was thought to be a fatal illness,
had a bereavement component. There are many similar issues such as dealing
with the parent’s chronic illness, change in function, change in roles within thefamily, and hospital exposure to parental physical decline.
This was a 12 week family intervention involving parent groups, kidgroups, and then combined meetings. We had positive outcomes in parent andchild emotional adjustment, risk taking behaviors, self-esteem, and a decreasein early child bearing in the adolescents as they aged into young adulthood.
At six years, the adolescents were more likely to be in school, to hold a job, lesslikely to abuse alcohol and more likely to be satisfied with romantic partners.
We even enrolled the grandchildren in this intervention, and we found they
were doing better also.
Dr. Cozza: Did you have a specific model you used around protectingfrom medical exposures?
Dr. Lester: In its original incarnation, TALC was not trauma informed.
It had Irwin Sandler’s bereavement modules in it and integrated some of Bob’s
work, but it was not trauma informed regarding the exposure to medicine. We
have integrated that because we found, in terms of mental health problems,
PTSD was the biggest problem for those teenagers. Now we have a rigorous
assessment for it. It is less of an issue now as parents are not hospitalized verymuch.
Dr. Cozza: Did you have educational materials around exposure?
Dr. Lester: We do now. We also have educational materials on how
traumatic reminders may interfere with treatment adherence, going to thehospital and taking medications. Project FOCUS itself used to be called ‘Families Overcoming and Coping Under Stress’. We learned that coping was a little
low-functioning for some of our military partners and that the term overcoming was better. Our group, NIMH, and Mary Jane Rotheram who developed
Project TALC, spent a lot of time on the NIMH intervention core component
workgroup for preventive interventions. We agreed that you cannot replicate
the manual everywhere to make sure it is truly evidence-based. We cannot
do that with HIV because it is a changing epidemic. When you go to another
Workgroup on Intervention with Combat Injured Families — Conference Proceedings • 63

If we learn that Dad
is barking orders andtreating his children
like little Marines, weaddress that. We do a lotof problem solving withthe family, developing afamily plan that addresses
their specific difficulties,
and building support
within the family andwithin their community.

country, you cannot do the same intervention. So, how can we know what isrobust and what really works about our interventions? They reviewed all the
RCT, having at least one RCT in positive outcomes, and came up with a listof what they considered the robust components of preventive intervention.
They called it ‘framing the problem’. It is putting the issue in a context, doing
cognitive behavioral skill building. You see our list: Communication, Problem
solving, Goal setting, and Emotional regulation skills, Dealing with environmental barriers, and Building social support. I believe I am missing one. We
took those and integrated them very systematically with Bill Beardslee’s intervention and tried to change it from a group model to an individual familymodel. With these issues, we felt groups would be problematic, especially inthe military.
We took trauma-informed, developmentally appropriate psycho-education, much of which is embedded in PFA and in the work from the network.
We do family level skill building, which are typical CBT skills, but done at a
family level, taught both to the parent and the child, and then done together.
These are integrated across all the sessions, as needed by the family. The systematic piece is that the family develops a narrative time-line that Bill will
demonstrate. We agree that parents can not do this work with their children
until they have reflected on their own experiences.
The first two sessions are parent sessions in which they are asked to reflect
on what this experience has meant to them, how it has affected their parenting,their relationship and their functioning. Only then can they turn and attend to
the family issues. We linked skills to the family’s particular experience. This is
not handing them information, rather linking specific skills and information
to what they are experiencing. We do an assessment piece before we start. If
we learn that father is having reactivity to reminders such as driving fast, andswerving whenever there is bag in the road, we will spend time talking about
reminders. If we learn that Dad is barking orders and treating his children likelittle Marines, we address that. We do a lot of problem solving with the family,
developing a family plan that addresses their specific difficulties, and building
support within the family and within their community.
Dr. Saltzman: As Patricia said, the architecture of this is based a lot
on Beardslee’s work. We have a series of parent-child, parent and family sessions. We start by engaging and assessing the parents to learn their concerns,
what they want and what they are the struggling with. We have great tools to
help them develop very specific goals that they would like to achieve throughparticipation in the program. It is important to frame what is doable in thisbrief span of time and what they hope to accomplish later. We also start theparent piece of work. We want to help them process what this experience has
been like. The separation in the deployment situation creates many opportunities for different experiences on the home-front and in the field. Frequently
there are not mechanisms or opportunities in the family to talk and bridge
those differences.
In the first couple of sessions, we provide opportunity for parents to graphout their individual timelines, their experiences of pre-deployment, deployment, and post-deployment. It is a graphic means of mapping these experiences in terms of their reactions and levels of distress. It is an important firststep to getting these parents to lock arms, so they can work more effectively
as parents. By the time we finish those first sessions, we have the parent narra-

64 • Session 2: Practical Application and the Components of Effective Intervention

Key events we havelearned from the parents
constitute the flow, and themethodology we use to getthese narratives is based
upon their developmental
level.

tives and goals. Then we move to the child sessions. In those sessions, as withthe parents, we are weaving together psycho-education about the program,but also about normative reactions to the difficulties they are contending with— multiple deployments, combat related mental health problems, or injury.
We are working with the children to get a sense of what their experience has
been across these multiple deployments as well.
Dr. Lester: We have a developmentally different task for younger children versus older children. As every child provider knows, children do nothave the greatest timeline in their head for events. We actually do this timelineon the floor. It looks like a game board with pre-mapped-out pathways andnodes of critical moments that we have learned from the parents. We havethem do it that way around eight or less, depending on their developmental
level.
Dr. Cozza: Prompting the child based upon the parents’ input into thefamily’s experience?
Dr. Lester: Yes. It is mostly chronological, i.e., your Dad’s first deployment to Iraq, your Dad’s hospitalization.
Dr. Saltzman: Key events we have learned from the parents constitutethe flow, and the methodology we use to get these narratives is based upon
their developmental level. We have this Candy Land-like track in which the
key events are linked. They can put in the ones that were important to them,but they also have the opportunity to draw pictures of the different experiences and incorporate that into their graphic representation of what this experience has been like for them.
This is geared towards preparing for family sessions in which parents canshare appropriate portions of their experience. It is important for the kids totalk, share their experience, their concerns and their questions, and even the
artwork they have done. Sometimes we do these child sessions individuallyespecially if there is big spread in terms of the age, special issues, or sensitivities that individual children might have. Or we can do them together, which
presents some real advantages.
Dr. Fullerton: Did you ever do it where the child mapped it out, andlooked to see what was salient in the child’s memory?
Dr. Lester: We do, if they grasp the chronology. If you do it with teenagers they can do that. When you map them together, it is very informative.
Dr. Saltzman: Yes, and often there is a difference between what thechildren and the parents consider important or traumatic. The next piece isgetting back with the parents, so they’re not blindsided by any of the questions
that might arise in the family session. Our goal is to empower the parents sothey can take a leadership role and respond appropriately to their children’squestions and concerns.
Dr. Richters: When you have the child-only sessions, what age ranges
are we talking about?
Dr. Lester: Six up through eighteen.
Dr. Richters: How do you deal with confidentiality?
Dr. Saltzman: It is with the child’s permission. We make it very clear,
and we ask for permission for which parts they feel is okay for us to share with
their parents. Sometimes they do not want to talk about some of the things
that are important to them. We go with what they’re comfortable with. After acouple of sessions with help and structure, they able to share some things theyWorkgroup on Intervention with Combat Injured Families — Conference Proceedings • 65

The question ofconfidentiality is really
important. What you’remodeling for the family isthat different people canhave different experiences
and they can choose toshare them or not. If they
do choose to share them,it’s probably because theymastered them somewhat,or they feel safe to share.

initially felt uncomfortable about.
Dr. Lester: Most of the younger children want to talk to their parents.
I do not think we ever had anybody say, “No, I don’t want to.”Dr. Cozza: Is it because they do not know how, or they just need somebody to facilitate it?
Dr. Lester: My sense is there are a lot of unwritten rules about secrets
in families. There was an eight-year-old girl who said, “I know my Daddy’ssad, and I’m really afraid.” We then asked, “What are you most afraid of?” Herresponse was, “I’m afraid he’s going to get mad, and he’s going to hit me.” She
didn’t feel permission to say that to him, but she drew it on her map, and she
wanted to share it with him. He was stunned that was actually on her mind. He
had never hit her, but he was able to think about it and respond to it.
Dr. Beardslee: That is a good illustration. The question of confidentiality is really important. What you’re modeling for the family is that different
people can have different experiences and they can choose to share them ornot. If they do choose to share them, it’s probably because they mastered themsomewhat, or they feel safe to share. Very simply, what does it take for a family to be able to have a meaningful conversation that ends well about an eventthat is potentially very difficult or traumatic whether about deployment or
depression.
Dr. Lester: There are things that we do not want the military member
to be talking about with their kids. Part of the parent conversation is making
those decisions in a thoughtful way about what makes sense in their family.
Dr. Cozza: A structural element should be part of this too, in terms ofappropriate boundaries, i.e., what could be talked about, what the roles are
and who takes care of whom.
Dr. Beardslee: In our original work, we would say to parents, it is
not as important what you say as it is that you decide to say the same thing
together. You are sharing with them the idea that parenting involves working
out these differences and then it involves thinking about the child and how topresent it.
Dr. Saltzman: It is a type of boundary making within the family thatis important. From a structural family point of view, we are helping to comprise the parent subsystem so there are certain things that are appropriate to
discuss, and in a way such that they support each other and are clear. Then we
decide together what they bring to the family session.
Dr. Beardslee: One other point. When I started to do this work in thelate 80s in Boston, I thought that families always had meals together, that theytalked about everything, and we were adding in a little bit of a conversation
about depression. Then we found that many families, particularly with adolescents, do not have meals together and do not talk about anything. Whenyou raise the question about permission, it may be that there is no occasion
to talk about any of these things because everybody is busy. It is hard to talkabout certain things. So the occasion arises to have a meeting, and it becomes
an important event.
Dr. Saltzman: All along the way there is homework that is assigned
to try to start building in some of the types of interaction that we think will
be supportive to the family being able to have conversations together. This canbe family assignments, having meals together, or doing certain activities andcertain specifically structured, fun things that we have in our appendix.

66 • Session 2: Practical Application and the Components of Effective Intervention

It is a type of boundary
making within the family
that is important. Froma structural family pointof view, we are helping
to comprise the parent
subsystem so there arecertain things that areappropriate to discuss,and in a way such thatthey support each otherand are clear.

Dr. Richters: Are older adolescents alright with these exercises?
Dr. Lester: We have not had many older adolescents doing it within
the military. We have older adolescents doing it in our clinic around otherkinds of issues. Yes, they will do it, if they choose. Our approach with all theseinterventions is to provide the facilitator, trainer, or counselor, with a variety
of tools they feel comfortable with that fits this family, but that also fulfills thecore principles, and that the family chooses. It is not like everybody has to do
this assignment. I do not think that works very well.
Dr. Cozza: Do you include younger children, under the age of six?
Dr. Lester: When families have brought them and there is nowhere else
for them to go, we have included them and they have done just fine. We givethem some role or activity. They have been part of the conversation in theirown way, but we find we cannot really do a narrative timeline with them inthe same way.
Dr. Cozza: Even just sitting with siblings, even if they do not necessarily participate. For example, if you have a younger sibling, like a five year old
or four year old, with a seven or eight year old.
Dr. Lester: As long as they are not really distracting,
Dr. Saltzman: We have done some of that in which the younger children are witnessing and watching the family have a conversation. That type ofmodeling and interaction of a supportive and appropriate way of talking toeach other is not lost on them.
Dr. Fullerton: Or simply the fact that they are included and not left
out regardless of what they understand.
Dr. Cozza: In relation to the population we are considering, there areso many issues like child care that impact decisions like who gets brought tothe appointments. The other question related in terms of structure is, do you
ever see parents alone?
Dr. Lester: Individually? Yes, because in some families there is only one
parent.
Dr. Cozza: If there are two parents, do you do that?
Dr. Lester: If our assessment reflected that somebody had, for instance,a high level of traumatic stress or severe depression, we would see him or her
alone.
Dr. Cozza: I understand the importance of seeing the parents together
and the strengths that it builds toward developing the parenting relationship.
As we think about the injured, and the availability both cognitively and practically, we think about how to apply these principles to this population.
Dr. Beardslee: That is a very good point. There are the important issues about transparency and confidentiality. They are going to be working
with two parents inside and I am going to see this parent alone. Whether
availability or medical treatment precludes the other, the aim is to include thewhole family. But then you make practical decisions based on what is possible. Where you get into trouble is working with one parent when the otherparent either does not know, or know what it is about. We had some amazing
experiences including younger children. We let parents bring whomever theywanted. We measured kids eight to fifteen, and I do think young children areenormously attentive to feeling tone. They know when people are irritated andthey know when people are trying to communicate well. They can pick up onthat so they can gain a lot. I agree with Tricia. What does not work is having
Workgroup on Intervention with Combat Injured Families — Conference Proceedings • 67

I understand theimportance of seeing theparents together and thestrengths that it builds
toward developing theparenting relationship. As
we think about the injured,and the availability bothcognitively and practically,
we think about how toapply these principles tothis population.

someone (not to be sexist) like a young, hyperactive boy who just cannot sit
still. We just finished a Latino adaptation for our project. One of the families
had an older girl and a very lovely, but very hyperactive, boy. We ended up doing an individual family meeting with the girl and the mother first, and thenincluding the boy, the mother, and the girl second. The communication was
different, but it worked. The second meeting was a little shorter because theboy was about six.
LTC Schneider: Are these weekly?
Dr. Lester: We do them weekly. I think that is best because there is an
opportunity to integrate. When the family can only come a few times, we had
two people. One met with the kids, one met with the parents, and then webring them together.
LTC Schneider: With Steve’s plan of a hospital-based intervention for
injured families, eight weeks for that age group might not be possible.
Dr. Cozza: Yes. The challenge is how to integrate the core principles as
it applies to this population recognizing the logistics of specific populations.
LCDR Kane: How were these military families selected? Do you just do
it for redeployed families?
Dr. Lester: We did this at Camp Pendleton. Either there was a parent
who was in treatment for combat stress or whose wife felt he needed to be intreatment for combat stress, or a pediatrician who was worried about a child’sreactions.
LCDR Kane: Were they clinically flagged?
Dr. Lester: Yes.
Dr. Fullerton: What about alcohol or drug use?
Dr. Lester: We did not exclude people for that. If they had active substance abuse making it made problematic for them to do this work, they would
be referred for treatment. Getting back to the issue of skills, we think families
enjoy the skills. When we use timelines, we introduce them to ‘feeling thermometers’. We introduce children to them. It is a very safe and structured way
for them to talk about their fears, worries, and feelings. As they are building
their timeline, they are actually doing it on some indicator of stress. We teachthem awareness of their emotional and physical reactions. That is one of theways emotional regulation skills are integrated.
LTC Schneider: This does not sound like your typical model of consultation. What you are describing is very problem oriented and skills based,rather than diagnostic using RVUs and CPT codes.
Dr. Lester: This is like our community-based prevention. There is arisk group with whom we do skill building and resiliency building. Certainly
there are people with diagnoses who participated in the intervention, but thatwasn’t our goal. We are going to do this for the Marines and Navy at four Marine installations and three Naval sites. Once we have done that, we will havea better sense of uptake based on referrals. We had very few dropouts. One,
who could not come for one session because of having no gas money, camethe following week. Engagement is the challenge.
Dr. Beardslee: We also had relatively few dropouts. Two things may
account for this. One is that it really is strength-based and not pathologybased. It’s about people acquiring skills and recognizing strengths. Emphatically, for most members of the family, it is preventative. It is prevention forthe children, the spouse and even for the person who is identified as having a

68 • Session 2: Practical Application and the Components of Effective Intervention

When we use timelines, we
introduce them to ‘feelingthermometers’. We introduce
children to them. It is a verysafe and structured way
for them to talk about theirfears, worries, and feelings.
As they are building theirtimeline, they are actually
doing it on some indicatorof stress.

problem. Working with non-dominant cultured families, we have found that a
prevention-orientation and strength-orientation is perceived as more tolerant.
Dr. Saltzman: Once the parents are on board with the family session and the children are prepped, we come into a series of family sessions
in which the centerpiece, especially for the initial couple of sessions, is thesharing of the mutual marriage goals in whatever format they were developed.
This can be a wonderful experience for the family, and this has been Bill’s experience also. There is a sharing of things not shared before, an appreciationof the individual differences and the individual who has been struggling. In
the process, the family is identifying the current issues with which they having
difficulty. Through that, we map out the remaining family sessions in which
we focus on the family skills.
We are doing this throughout, but this is a good opportunity to have thewhole family together, to problem solve, to identify mutual trauma, or loss
reminders. Then there is a list of specific skills on more of a menu basis thatthey can select from and spend a flexible amount of time addressing. That way,
we have some characteristics of an adaptive intervention in that we can mix
and match, and go with what they need.
We have adapted this program for multiple populations. One of the populations we will be working with is the Naval Special Warfare Group, the Navy
Seals in Coronado Beach and in Virginia Beach. Because of their rapid deployment cycling, and their huge training demands, it is unlikely they could
go through all eight sessions. We are looking at these clusters of sessions as
pieces of work that can be done independently.
Dr. Beardslee: In the latest interventions we did with Latino families,
we described the work in modules rather than in sessions. So they could takea couple of sessions to do module one, which was family history and psychoeducation. Module three might be seeing the child. Doing the pieces in different order gave us more flexibility. You might have a family that work with fora couple of months, and then a couple of months after that.
Dr. Saltzman: We have both adapted this approach working with
first responders in the Hurricane Katrina area. Using funding through Robert
Wood Johnson, each of the sessions has to be almost stand-alone or a pieceof work. We were not sure if they could continue. That is how their training
works. As Bill was saying, a module can be delivered that focuses on initial
engagement, assessment and goal setting with psycho-education. Then you
can do just another piece or module and focus on coping skills. If there is time,
you can do a separate piece which is more of the narrative work from boththe parent and child standpoint. It can be flexible, although, the sequence does
have value to it. Some things can be lost, but given the circumstances, it still
can be a good piece of work.
The figure on this slide (see Figure 2.1) is what we call just the timeline.
On the horizontal we have the key events. In this case, we have multiple deployments, plus the time in between in which they rotated. On the vertical dimension is the degree of the intensity of the stress that the event had in termsof their individual reactions to the different events.
Dr. Cozza: When you use the thermometer, do you say, rate your stress,
or what do you?
Dr. Lester: We call it a ‘feeling thermometer’. In this case we ask how
stressful the event was.
Workgroup on Intervention with Combat Injured Families — Conference Proceedings • 69

After this third deployment,
and coming home, the firstthing we see is an up-tickin the distress as reportedby the parents. This was
also accompanied bypronounced marital conflict.
By the time they are coming
to see us, there is also talkabout possible divorce.

Figure 2.1: Timeline of Key Family Events.

Dr. Saltzman: In current versions of the timeline, we actually have athermometer on the left side of it, so they can rate it in terms of low, medium,or high level of stress. So for the first piece, this is a composite of both parents
own narrative. In the initial sessions we get individual narratives from eachparent. The interesting part is to work out the differences between them. We
want them to be able to discuss the differences, and then have a shared understanding and experience of what the multiple deployments were like.
What you are seeing now (see Figure 2.2) is a more simplified versionof the shared experience between the parents. So, pre-deployment with thiscomposite family involved some stress, and some of it was happy stress withthe birth of a new baby. The difficulty was that just two weeks after the baby
was born, the father was called for his first deployment. It was a WESTPAC
training tour, so he was in communication. It was not a huge wartime deployment at that point. He came home, and things were great until a few weeks
later when the war started. He was called up. He came home tearfully saying,“I am going to war in two weeks.”
Dr. Fullerton: So that was at the point where he knew he was going.
What about the anticipation two weeks before leaving?
Dr. Saltzman: Exactly. The stress for the parents was really ramped
up tremendously in the preparation. There was, in fact, a painful goodbye inwhich the part that was most salient to the Dad was when they went to thebus. When they get on the bus, his son, Adam, would not look at him. He justturned away, and he interpreted that as he hates me. So that was what he carried. During the deployment, he was out of touch by and large. Mom watched
the progression of events on CNN, which was stressful for everybody. Mom
told the kids that Daddy had a desk job when in fact he was a Marine on patrol
going outside of the Green Zone.
Coming home, after that wartime deployment, you see a little up-tick interms of the initial stress. That is because he delayed his homecoming. He vol70 • Session 2: Practical Application and the Components of Effective Intervention

In terms of therapeutic
outcomes, sharing these
individual experiences canincrease the appreciationof each person’s challenges,
such as the parents
appreciating what wasstressful for their children.

Figure 2.2: Timeline of Shared Parental Experiences.

unteered to stay longer with his buddies on his unit. Some of them were heldback, so he did not want to leave without them. Preparation for the homecoming is a big deal for the family. To hear that he was delayed in coming home
was quite a hit, especially when he told them that he volunteered. So he stayed
longer. Some other stressors included ramping up to the next deployment.
With this third deployment, there is an overall up-tick in the level of stress,
which was expectable. So, there were some difficulties for that disembarkation as well. Most difficult from the home front was that there were severe
child problems. The children were having behavior and academic problems at
school, and they were struggling. Mom has the two kids, plus the newborn, so
she is really struggling with a lot at that point.
Dr. Fullerton: How long between the deployments?
Dr. Saltzman: For the second deployment, he had almost a year home.
For the first one, he was only there about four or five weeks, but the next one
was about 11 months. So he did have time to get back. He was having trouble
readjusting initially when he got home, but he got into the swing of things
playing with the kids and doing better. But here, after this third deployment,
and coming home, the first thing we see is an up-tick in the distress as reported by the parents. This was also accompanied by pronounced marital conflict.
By the time they are coming to see us, there is also talk about possible divorce.
So it is a highly stressful period for them.
Here is the parents’ timeline. (see Figure 2.3) We worked with the children
individually and together, as they were close enough in age, and they generated their own time lines. Let’s look at the ways in which their narratives weredifferent from their parents. These are the things we want to focus on during
the family sessions. The initial period in which the baby was born was stressful for one of the children. Sara, who is pictured in the chair, is feeling kindof isolated with the new baby. This was not a good time for her, and that wasnews to her parents.
Another difference was the painful goodbye in which Dad thought theWorkgroup on Intervention with Combat Injured Families — Conference Proceedings • 71

If the family together canidentify individual cues,
triggers or reminders thatare difficult for them, andwhich can prompt Dad
being irritable or the kids
having a difficult time, thathelps them to anticipate
these things and to plan
ways they can support
each other appropriately.
Parents work together tomonitor their interactions
and maintain consistentroutines.

Figure 2.3: Timeline of Children’s View of Parental Experiences.

son hated him, which came up in the family session. The son, through his
drawing, was able to show that he was not mad at him, as much as he was really sad and afraid to show his emotions. This was also news, important news
for Dad to hear this coming from his son.
The third difference is when Dad delayed his own homecoming. The kids
actually were worried that Mom was not telling them something that may
have happened to Dad. Is Dad injured? Is he killed? What is going on? The
feeling that the parents were keeping something from them was a difference.
His third departure was very stressful for the family, especially for thechildren. Sara was ten at the time and had a sense of the level of risk that her
Dad was exposed to. In talking to her friends who live on the base, she knew
what could happen. Because she was afraid that she might not be able to see
her Dad again, this was a very difficult goodbye for her.
This was a period when the children were having a lot of trouble at school
and at home. Despite mom having said Dad has a desk job, Adam draws Dad
in a tank, in full warfare, beating the bad guys. They also had a regular pizzanight on Fridays in which they watched movies. This became kind of a sadtime in some ways during which they would recognize the absence of Dad, sothat was difficult.
Dr. Fullerton: Are they asked to draw the family members?
Dr. Saltzman: It is more open-ended. As they are drawing, they are
telling their story, what is important or difficult for them, or what experience
they want to share or what is difficult right now.
Dr. Richters: Look at that sun in the upper left hand corner.
Dr. Saltzman: How would you interpret that?
Dr. Richters: Optimism.
Dr. Saltzman: Yes. In Sara’s drawing, her fears took the form more ofearthquakes. This is a house shaking, being hit by a tree. Fear that there would
be men breaking into the house.
72 • Session 2: Practical Application and the Components of Effective Intervention

We asked one family tomake a family plan. Theysaid, “We don’t plan. We aregoing strawberry picking
this afternoon. We knowthat at any moment he/she may be redeployed, so
we wake up and appreciate
every day.”

Dr. Lester: She was worried that her house could not be safe or truly
protected without her Dad there.
Dr. Saltzman: Those are some of the main differences from the children’s point of view that could be brought into the family sessions. This is not
an exact science, but rather a tool to graphically show the differences for thefamily sessions. This is subjective looking at broad global differences between
their experiences. In terms of therapeutic outcomes, sharing these individual
experiences can increase the appreciation of each person’s challenges, such as
the parents appreciating what was stressful for their children.
This intervention certainly supports more open communication and sharing of worries and fears. For many families, not just military families, there isa culture in which you suck it up and you do not talk about things. Here, wewant to provide a structured and safe way for the family to talk about concerns, worries, and fears with the expectation that it is okay to do that with
their family. If the family together can identify individual cues, triggers or reminders that are difficult for them, and which can prompt Dad being irritableor the kids having a difficult time, that helps them to anticipate these things
and to plan ways they can support each other appropriately. Parents work together to monitor their interactions and maintain consistent routines. Mom
can track Dad when he starts using his voice that upsets the children treatingthem like they are little Marines and coming on too strong. Or, Dad can stop
Mom from leaning too much or confiding too much in the older child, which
was the case here, so she can pull back from doing that. The overall approachis to develop positive coping skills to address challenges and to mobilize thefamily to support each other and to build a team approach to dealing withthese challenges. This is a key part of hardiness and family resilience.
Dr. Richters: Does the photograph at the end depict a victory?
Dr. Lester: They are not throwing up their hands in despair.
Dr. Saltzman: All of our families end up in that same position.
LTC Schneider: Is it mostly Marines that you have worked with sofar?
Dr. Lester: We have done it with military and other families.
LTC Schneider: If it was with Marines, most of whom were young andmale, my guess is that they took to this model pretty readily because it utilizes
the military team building and training focus. That would be very much inculcated into the military culture of a training module and a team building
module. Kind of like, you got your war experience; well, this is my family’s war
experience. We have our own war story.
Dr. Richters: Is that not also true of Army?
LTC Schneider: Yes, but Marines are notorious for pooh-poohing any
kind of treatment based stuff.
Dr. Saltzman: In fact, we decided to call our counselors “trainers.”
Dr. Lester: Our Marine partners felt that we should call them their RTs,
Resiliency Trainers.
LCDR Kane: When you involve the Marines, is it going to be with everybody who is deployed or is it going to be clinically indicated?
Dr. Lester: It is a service program, not a research protocol, so we willtake who they refer to us. But the indication is somebody is having higher
levels of distress.
Ms. Williams: Going back to how to incorporate the younger children,
Workgroup on Intervention with Combat Injured Families — Conference Proceedings • 73

We ask them to reflect on
their child’s experience ofthe deployment cycle or thetraumatic event, which they
can do.

I wonder about the possibility of going through a timeline with the parents to
get the child’s perspective of the events.
Dr. Lester: That is absolutely the way to go with parents of younger
children. Sometimes we do that with parents who are so conflicted and angry
they are not able to reflect on their own experiences in front of each other. We
ask them to reflect on their child’s experience of the deployment cycle or thetraumatic event, which they can do. With Shelly McDermott’s group in Indiana, we have a proposal to do this with the National Guard for couples.
DR. Arata-Maiers: Did you have a group of service members who
were again going to be redeploying, and did you notice if there was any difference in the things that you addressed with that group?
Dr. Lester: Yes. One family stands out. We asked one family to make afamily plan. They said, “We don’t plan. We are going strawberry picking thisafternoon. We know that at any moment he/she may be redeployed, so wewake up and appreciate every day.” In a way, it was a kind of plan. For thoseof us who treat child trauma, what is different now is that we are focused on
recovery. This prevention skill model helps families become better at dealing
with their ongoing challenges.
Dr. Saltzman: It puts in place certain skills that they can really draw
upon to help with readiness. This provides support and is appropriate.
Practical Application and Components of Effective Interventions
Dr. Cozza: We will now address the following questions:■■ How do you take these principles and apply them in the unique injured
population?
■■ What modifications do we need to be thinking about?
■■ How do we address the lack of consistency in terms of family presence?
Refer to the handout, Session Two, Practical Application and Componentsof Effective Interventions.
The conclusions that we have drawn have been based largely on the workwith colleagues at Walter Reed, directly or in collaboration. It is helpful to leverage our developing intervention on much of the family FOCUS work thatwas just discussed recognizing that the injured population is a very uniquepopulation. We feel there are multiple distinct and different problems thatneed to be addressed, and in many ways are more complicated than those thatare addressed as part of the regular deployment cycle. This is a complicateddeployment with profound family effects that are disorganizing and disruptive, and the families need significantly more support to manage their injury
experience. The injury experience itself is unique to the family and varies depending upon the nature of the injury, the structure of the family, the developmental level of the children and the expected outcome, treatment andrehabilitation process.
When we submitted a grant proposal with Bill and Trisha last year, we had
developed an intervention model that was focused upon the similar, sessionbased approach family intervention. We realized that we needed an intervention that is modifiable and allows for an individual and appropriate structure
for the family at any particular time.
The other qualities are that we are constructing the model based on specific sessions that may have varying modules within them, but are more related
to the timing of the intervention as well as the participants of the intervention.

74 • Session 2: Practical Application and the Components of Effective Intervention

The injury experience itself
is unique to the family andvaries depending upon thenature of the injury, thestructure of the family, thedevelopmental level of thechildren and the expected
outcome, treatment andrehabilitation process.

So you will see that we have an engagement and assessment session that is aparent only intervention. We use the Parent Guidance Assessment Inventory(PGAI) as part of that to frame the understanding and to develop the relationship with the family. You have a copy of the PGAI in your packet as well. In
addition to that, there are several other sessions. One is a child mastery session to engage children of the injured service person and others individually.
We need to recognize the fact that many children do not come to the hospital.
When they do come to the hospital, it may be at times when they are not clinically available, such as on weekends or during holiday periods, which makes
it difficult to engage them.
There is also a parent guidance session. The idea is using a session and leveraging much of the family focused activity into parent guidance approaches,
as opposed to necessarily working directly with the children or with the family because they may or may not be available. The other question is within thecontext of the narrative and the use of the narrative: at what time is it appropriate to be considering that? Is it post deployment or between deploymentsthat it is stabilizing in its ability to organize the event? Part of the question
would be, in the midst of the experience and the hospitalization, would it besimilarly organizing or would it be overly anxiety provoking for the family or
for the children? These are the sorts of issues we are struggling with. How topull it together in a way that is effective for this particular population based
upon the problems discussed this morning. Would a family mastery or familytransition session focused on the near discharge timeframe, and then family sustainment sessions, address the specific needs of families in the longer
term? I am particularly interested in how we would apply the principles Billand Tricia described to develop our intervention.
Dr. Saltzman: Our work can also map onto your architecture — yourparent session, child mastery session, and the family mastery.
Dr. Cozza: We do not want to develop so specific a treatment that we
limit it to 20 percent of the population who are there with their children andnot enlist the injured service member parent to participate like the earlier
example of the recently deployed parent. How do you then pull it together in
relation to parent guidance approaches? Let us look at the PGAI to see those
discussions and how they are developed. Much of it is information gathering,but it is also information gathering within the context of the clinical relationship. It gives the clinician the opportunity to help organize the experience forthe spouse of the injured service member.
Dr. Lester: What level person is going to be doing this?
Dr. Cozza: We have had independent clinicians with at least a master’slevel. Child trained independent clinicians have been implementing this.
LTC Schneider: They are social workers in a specific Child and Family
fellowship.
Dr. Arata-Maiers: We are doing it at BAMC. We call it something
different. We are having the pre-doctoral interns do it who are on a child rotation. They may not have an extensive background in child psychology, but wetrain them beforehand and supervise them as well.
Dr. Saltzman: Would you administer this or have your clinician administer it, and what are the next pieces of work?
Dr. Chun: The critical period, the window, is something that applies tothis work. After a few sessions with the parents, I suspect that the family feels
Workgroup on Intervention with Combat Injured Families — Conference Proceedings • 75

The critical period, thewindow, is something thatapplies to this work. Aftera few sessions with theparents, I suspect that thefamily feels comfortable
and safe enough to open
up some of these painful
experiences.

comfortable and safe enough to open up some of these painful experiences.
You have to have a significant amount of therapeutic lines already developed.
When we introduce this assessment, it is not about assessing them. It is for us
to develop skills. They are teaching us about their own experience.
Dr. Cozza: It is not an assessment in the sense of a quantitative measure.
It is aimed at getting a sense of a parent’s sensitivity and the needs of the child.
For example, just simply asking a parent if they have talked with their childabout this injury and what was said can be an important way of understanding, not only the way they integrate the experience for themselves, but how
they organize it and present it to a child. All of this reflects a level and kind ofparenting capacity under stress. That is an example of this assessment.
There is also an opportunity to engage them educationally and guidethem. You have talked with your 12 year old, but you decided not to talk withyour five year old. What were your thoughts? I did not realize that that was
something that they needed to hear. It opens up the opportunity for the clinician to talk with the parent about the needs of the child; what that five year
old may or may not already know and what they’ve picked up on. Are they atthe hospital? What is happening in the family? It is intended to help broachsensitive subjects with a parent in a way that allows them to continue to parent
effectively or to be able to engage that child in an effective way. This helps toopen up conversations around the following questions. Where do you think
this is going? Have you talked with your child about coming into the hospital?
Have you thought about what they might see? Can you insure that they will
be protected in the hospital setting? It is clinically driven, but it has a structure
to it.
Dr. Saltzman: Over multiple sessions, multiple meetings?
Dr. Cozza: It can be.
Dr. Arata-Maiers: In terms of selling this as something we are going
to be doing systematically in the hospital setting, we did not emphasize theassessment aspect of it to the other providers and to the patients. The reason
is that they are being assessed extraordinarily for everything. If it is just another assessment to be filed away somewhere and someone is going to write
a study on it, their investment in getting involved is significantly less, and theinvestment of the various services in letting us do it is less. So even though it
is an assessment, we should present it as a clinical instrument primarily, eventhough it has other dimensions to it.
Dr. Lester: My impression is that when you administer this and hear
the responses, you are integrating guidance for them as well?
Dr. Cozza: Yes. It is not a structured interview from which you cannot
deviate. It is intended to bring up topics that would require some awareness of
how to address them apart from what is listed on these pages.
Dr. Lester: That is the ancillary piece that requires expertise and experience to know how to answer or highlight, so that it can be translated?
Dr. Cozza: Yes. We would start with instructions. They do not fill it out.
It is a guide to the clinician in engaging the family.
Ms. Vineburgh: Knowing that the ultimate goal is to engage the parent/family, and knowing the tremendous anxiety level that families have initially, might there be consideration to creating the PGAI in a way that it becomes a family plan? While we are gathering this information, this is also foryou. That is creates a stepping stone to obtaining resources for the family.

76 • Session 2: Practical Application and the Components of Effective Intervention

We have heard from anumber of people that thisis the first time they have
had a chance to just talkabout what has happened.
Up to then, it has all been
about what happened tohim, as opposed to what
has happened to me andto the family.

Dr. Richters: We have discussed this, and there are some questions atthe very end that specifically ask about what the family needs.
LTC Schneider: Part of the reason this was initially created at Walter
Reed was for us to help the families understand what was going on. Rather
than rushing in and presuming we knew what people needed, we were trying
to go in and understand what people were really experiencing. That way, we
could tailor what they needed to what was actually going on. But we foundthere are interventions that go on in the process of doing this.
Dr. Cozza: One of the most interesting findings is that it really does
serve as a way for the spouse to organize the experience for himself/ herself.
We have heard from a number of people that this is the first time they have
had a chance to just talk about what has happened. Up to then, it has all been
about what happened to him, as opposed to what has happened to me and to
the family. I like the idea of thinking about how you can translate administering the PGAI, both as an observation and respect for the experience, intosome sort of skill building opportunity for the spouse.
Dr. Newby: Often when you see families of injured soldiers and you aretrying to engage them, they are under so much stress and anxiety they do nothear a great deal of what is being said. Therefore it would be helpful if there
were some kind of a take away from this. If it is summarized in some way thenthey could have a chance to read through it and reacquaint themselves withwhat may have taken place during the course of the interview that you had
with them.
Ms. Vineburgh: Or that it becomes the first stage for them to consider
their own plan. The interviewee becomes a partner. This is your plan, as well.
We can build this together.
Dr. Cozza: Family goal development is part of the goal setting.
Dr. Beardslee: Two things. The way you described it, it is very important that it is done in a window of opportunity, very sensitively in the context
of a relationship with a lot of support. If any of the questions stump or upset
the person, you stop and deal with that. That is exactly as it should be. It is awonderful instrument for that. The observation that many of these parents
have not had the chance to have a conversation about themselves and theirchildren because it has been about the wounded warrior is a very important
observation. Just giving people a chance to speak and talk about what they
have been through often is very therapeutic.
People who have depression do not have good memories. They do notremember things very well, particularly positive things. We found ourselves
being the historians for the families, i.e. we would have elicited somethingaround how excited they were when the child was born or something that thechild did, and could bring that back. You could do the same thing here. You
could pick out positive parts of the story and highlight them.
In our latest iteration of our mandate for this Latino version, one question we did find useful at the beginning of each session was asking the family,“How are you doing right now; what’s on your mind right now?” It is like acheck in. “Is there anything you want help with right now, anything you’re very
concerned about?’ It is another variant of being a partner with the family. Youmight think about a question somewhere in here, along the lines of, “Do you
need help with something right now? What is your concern?”
My next comment is about a different developmental process. How do
Workgroup on Intervention with Combat Injured Families — Conference Proceedings • 77

The observation thatmany of these parents
have not had the chance
to have a conversation
about themselves and theirchildren because it has
been about the wounded
warrior is a very important
observation. Just giving
people a chance to speak
and talk about what they
have been through often isvery therapeutic.

you go about finding an intervention that works? And you do it exactly thisway, by starting on the ground with families. What is their experience? And
then, if you went ahead and did a parent guidance session, that would be about
psycho-education or the basic knowledge we have about how to guide parents
through this experience. It would be like the first and second sessions of either
what Bill and Tricia presented or what we do initially. You would be thinking
about that as both reflecting the best of the best practices wisdom about how
to guide parents, and then fitting it to their individual circumstances, such as
their needs, the ages of the children, the circumstance of the spouse, and thetime that you have, and whether somebody was leaving soon or not.
One of the things we found very valuable was to have two interventionsof different intensity. We have a two-session intervention and a six or sevensession intervention. In the two-session intervention, we just do groups ofparents. Oftentimes you are not going to have time to do a six or eight sessionintervention with families, but there are going to be concerns about getting ahistory, recognizing strengths, and doing guidance.
Dr. Saltzman: That is interesting. You said groups with the parents,
getting multiple families together?
Dr. Beardslee: Yes. In our randomized trial, the comparison condition, which was an active condition, was two sessions with groups of parents
doing basic teaching about what is depression, what is resilience, how do families cope with it, and asking and answering questions? We showed sustained
effects from that intervention, as well. What I am saying is you try to get atwhat the family’s experience is and how you can join with it in multiple ways.
That is what you are doing by framing these sessions.
Dr. McCarroll: It is really important to give people something totake away. This would be a marker where they were at that time, which people
are not going to remember later. If somebody asks,” What did you tell the doc,”
they would say, “Well I do not remember,” so being able to have something totake away is important.
Dr. Chun: It is also important to ask what they are concerned aboutright now, and something that possibly happened this week.
Dr. Beardslee: I agree, but I think there are actually some positive
questions in here. We found the question that was the easiest and that people
responded to the most positively was, “Tell me something good about yourchild. What are some of your child’s strengths?” We have also found in working with a depressed parent, nobody asked them what was going on with theirchildren. They can often rally and see some strength in a child when they cannot see any strength in themselves and certainly no strength in their spouse.
Dr. Saltzman: Is the PGAI administered just to one spouse? Have you
ever administered it to the service person?
Dr. Cozza: Ryo-Sook, have you ever used the PGAI with the injured
service person?
Dr. Chun: I have done it when they both are present.
Dr. Beardslee: Good, so they are both sharing in the experience.
Dr. Arata-Maiers: We experienced that as well. The service member
had seizures and the spouse was the non-medical attendant. We could notadminister it unless the service person was present. What we found is thatthey started talking about their experience similar to what your narrative did.
They started talking about how their experiences were different on certain78 • Session 2: Practical Application and the Components of Effective Intervention

It is really important togive people something totake away. This would bea marker where they wereat that time, which people
are not going to remember
later. If somebody asks,”
What did you tell the doc,”
they would say, “Well I do
not remember,” so being
able to have something totake away is important.

parts of it. Comparing the experience of the service member and the spouse
was therapeutic.
Dr. Saltzman: So you would be able to compare notes in the session
and find they have very different experiences in some cases, different views.
Dr. Arata-Maiers: Yes. There was a sense of, “Oh, that is what you
were going through,” and, “Oh, that is what was happening with you,” sort ofthing.
Dr. Beardslee: When we started developing this I thought everybody
had family meetings or meals together; however they do not. We were amazedthat couples would have gone through these very powerful experiences suchas hospitalization and never have talked about it, never have talked about what
they shared in common and what was different. We cannot make the assumption that people have conversations about these things that are very much in
the foreground, that separated them for months at a time, that people often
do not talk about as a couple. It is very important and therapeutic to provide
a context to do that safely.
Dr. McCarroll: They probably do not because talking about trauma
is difficult. The soldier does not want to expose the spouse to what they havegone through. Sometimes the spouses do not want to hear it. It is a very difficult ordeal.
Dr. Beardslee: I would agree with that. On the other hand, raisingchildren together puts them in a situation where they do need to talk to eachother.
Dr. McCarroll: All I am saying is it is a very difficult barrier to overcome, particularly in trauma. There is the issue of protection and people who
do not want to be exposed to it. So you have to break that down.
Dr. Beardslee: Right. I think the lane in here is what degree of conversations about these experiences is going to help the children? The lane in is
not all about my experience, but rather what part of my experience and whatpart of our shared experiences might help?
Dr. Saltzman: That is an important boundary: that you do not fall
into the deep well of marital therapy, because you will never get out of it. It isa constant reframing about what you are doing. This is for the children. We are
not here to solve their relationship issues. Then to keep framing it: how does
this impact the kids? What do you think is important for them?
Dr. McCarroll: They still have to feel that you are doing something.
The spouse has to feel that you are doing something for them too. You cannot
just put it on the service member or the child or the spouse. Everybody has toget something out of it.
Dr. Saltzman: Yes, and they do. That process of just sharing theirexperience is a win/win because they are experiencing being heard by theirspouse. That is huge. But then, they might want to start talking about all thethings that they are really angry about, and it can evolve or deteriorate.
Dr. Cozza: At some point, the injured are typically available to participate, although it may take some time. What becomes complicated with the
injured is the issue about the timing of the intervention, especially aroundprotective issues related to parent guidance about child decisions. If both parents are not available to participate and the spouse is available to talk about
the child independently, and then have a conjoint discussion.
Another challenge is the non-injured spouse who does not want to share
Workgroup on Intervention with Combat Injured Families — Conference Proceedings • 79

Another challenge is the
non-injured spouse whodoes not want to sharethings because of theamount of difficulty, pain,
or medical problems of theirspouse. A spouse may be
extremely reluctant to comein and start talking about
the degree of pain they
have and the worry theirfamily has while dealing
with major illness or injuries,
such as amputations, TBI.

things because of the amount of difficulty, pain, or medical problems of theirspouse. A spouse may be extremely reluctant to come in and start talking
about the degree of pain they have and the worry their family has while dealing with major illness or injuries, such as amputations, TBI. The non-injured
spouse is concerned about overwhelming the other spouse with the information, rightly or wrongly. I think there is another issue: not just, I’m worried
that I’m going to upset him, but a need to be in charge. How can we be helpful
with all of this?
Dr. Beardslee: Also, the non-injured spouse may need both a forum
to talk and guidance about what to do with the children before the injured
spouse can participate. You all are very sensitive to the experiences of thesefamilies. The fact that you are aware of these areas that are difficult to talkabout is a very important clinical skill to reflect on as you construct an intervention. If you begin to feel that there are taboos or things people are notready to talk about, the thing to do is not talk about it in front of your kids.
Rather, it is to step back and ask what is going on here and where can there
be an activity that engages these parents in coming together around helping
the child.
Dr. Cozza: Correct. Parent guidance through an engagement or assessment session with the non-injured spouse is appropriate throughout the
injury experience, focused on the health of the spouse. It can include couples
mastery or a parent mastery session in which the injured service member is
at a point to participate in the discussion. It can address their independent
experiences by focusing on what part would be helpful in terms of helping
their children.
Dr. Richters: And the family.
Dr. Cozza: Does it make sense to include family mastery or child components given the limited amount of time there?
Dr. Chun: It is very seasonal. During a holiday period, there are morechildren around, so we get to see those children at least a couple times during
the hospitalization.
Dr. Richters: In what proportion of families are children present
when the spouse first visits?
Dr. Chun: That depends on the seriousness of the injury. If it is a serious
injury, some parents bring the children.
Dr. Richters: During the school season roughly what proportion arepresent — 10 or 20 percent?
Dr. Chun: I believe it is higher. At least half or 50 percent of the children
come and see their parents briefly, one or two days.
Dr. Richters: With the non-injured spouse for the initial visit?
Dr. Chun: Right.
Dr. Richters: As many as half?
Dr. Cozza: Not necessarily for the initial visit. Did you say 50 percent
for the initial visit?
Dr. Chun: When they first arrive, they are allowed to have at least three
traveling together — one non-injured spouse and a couple of children get
to come. Many children do come for a weekend or a couple days, and that is
usually the missed opportunity for us because we do not get to see them. The
children come back for subsequent visits like holidays or extended weekends.
The decision parents make to bring the children or not, really depends on

80 • Session 2: Practical Application and the Components of Effective Intervention

A poignant comment madeby a spouse in response to
the question, “What is thebest thing you did during
this period,” was, “The best
decision was to leave thechildren behind.” Then, I
asked, “What is the mostdifficult decision you had to
make?” Her response was,“Leave the children home.”

their resources and the backing of the community. They can even leave theirchildren with friends, but not many people do that. If they have extended family available, they leave the children with their in-laws and their own parents.
Other than that, they tend to bring the children, often out of necessity.
Dr. Richters: The military will cover expenses to bring children here,
but not to cover childcare back home?
Dr. Chun: Exactly. A poignant comment made by a spouse in responseto the question, “What is the best thing you did during this period,” was, “Thebest decision was to leave the children behind.” Then, I asked, “What is themost difficult decision you had to make?” Her response was, “Leave the children home.”
LTC Schneider: That highlights how complicated and conflicted a lotof these decisions are, like your example of the soldier who decided to staylonger in Iraq. There are a lot of conflict-based decisions that military families
have to make routinely.
Dr. Arata-Maiers: There is a great deal of guilt and anger. In terms of
who comes, our situation at BAMC is a little different because we have outpatient services — the CFI and the burn outpatient services. We may have a lot
more families there for longer periods of time. Often, the children come later
during a semester spring break, or over the summer. They actually move to
San Antonio and Fort Sam, which has its own attendant, disruptive problems.
As clinicians, we may have a larger group to work with because the length oftime that most of those people stay in San Antonio is several years.
LCDR Kane: The same is true for San Diego. If they are going to San
Diego, it is because their family is there, so a family oriented intervention does
make more sense.
LTC Peterson: It is the same for Madigan.
Dr. Cozza: And this is true for Walter Reed. The major medical centers
for the seriously wounded will be where they congregate.
Dr. Chun: Right. Parents usually will get a call about the injury. The
next stop is Germany. When the soldier arrives in Germany, they have an ideaof when they are going to come to Walter Reed. Walter Reed is usually the
first stop in the States, so the parents come here. Some bring their extended
families and grandparents. They arrive, and then quickly they return. Because
there is only one room assigned to one family, they have to share a room withchildren and extended family.
Ms. Vineburgh: Where is the room?
LTC Schneider: Some are on the post and some are off post in hotels
up the street. It is interesting how they organize themselves. Many of thesefamilies come with extended family members. If there is a child, they mightorganize the childcare into shifts and sleep in this one hotel room. It is likebeing on a Navy ship. You can spend time from 8:00 a.m. to 4:00 p.m.; I havefrom midnight to whatever. They incorporate childcare and attending to thewounded service member into a schedule that is very well orchestrated. It isamazing what some of them do.
Ms. Williams: Sometimes there are even babies born there.
Dr. Chun: These families are so resilient and strong. It really touches
all of us. They do talk beforehand about the possibility of getting injured orgetting killed. They have to because they have SGLI, and they have a power ofattorney. So they do talk, but, perhaps not in a medical way.
Workgroup on Intervention with Combat Injured Families — Conference Proceedings • 81

Each of these families has
some very complex issues.
What holds it together is theintegrity of the intervention:
its focus on the family andthe health of the family;
its focus on the support ofthe parent and supporting
parental efficacy so they cantake care of their children;
and, understanding where
the children are comingfrom through this very
difficult time.

Dr. Cozza: Developing an intervention with all of these moving variables is what this is about. In a manualized treatment, it can be difficult toaddress every possible scenario. Our charge is to think about a model and aschedule of preventive intervention that focuses on the family’s experiencethrough the treatment and recovery period, and to have a family mastery session with certain goals around the experience at particular times by incorporating the availability of those children when they come while not knowing
what the particular issues for that family will be at that time. It requires atremendous amount of flexibility in how it is done and with clinical acumen.
A non-trained person trying to do this kind of training or intervention wouldfind themselves lost very quickly because of the sensitivity and the complexityof the problem.
Each of these families has some very complex issues. What holds it together is the integrity of the intervention: its focus on the family and the healthof the family; its focus on the support of the parent and supporting parental
efficacy so they can take care of their children; and, understanding where thechildren are coming from through this very difficult time. That is how I would
summarize it.
There are specific kinds of interactions that would be appropriate. These
include skill building, speaking to strengths, and addressing problems as theychange over time realizing that the family is going to be moving. Examples
are the parent is leaving the military, a TBI that is not going to get better, or
return to their community. Part of the reason there is an interest in sustaining the involvement is recognizing that many of the families do better in thehospital setting than when they return to their communities. The longevity of
involvement is what we want to integrate into these principles and their use.
John and I are going to work on the timing — what parts of the intervention
are appropriate at what particular times and what decisions determine when
they are eligible to participate in a particular component of the session.
Dr. Saltzman: The way you are mapping this out for a flexible approach makes sense. When you talk about being extended throughout the recovery period, are you talking about beyond the transition to home? There area great deal of emotional issues that come once you leave the hospital, perhaps
even in the hospital. It is like trying to hit a moving target.
Dr. Cozza: Yes, that is why we are setting up these sessions.
Dr. Saltzman: The follow-up work that was done with the injured
soldiers four and seven months after was based upon the fact that they knew
the person they were talking to on the other end of the phone. It was not justa cold call from someone they had never heard of before. It was an opportunity to re-engage them, to talk with them about the transition, to talk about
how their health care needs were going, to talk with them their sleeping, theiralcohol use and the nature of relationships in their family. It provided an opportunity to understand what the problems would be and to direct them toresources in the community. It was not necessarily an intervention that attempted to solve those problems, but to think with them about how to gain
resources for themselves so that they could solve the problems they were experiencing. They can use the skills they have acquired for new types of challenges they will encounter.
Dr. Cozza: That is why one component needs to address the concept
around transition including self-advocacy, the capacity to pull resources into

82 • Session 2: Practical Application and the Components of Effective Intervention

That is why one component
needs to address theconcept around transition
including self-advocacy,
the capacity to pull
resources into themselves
and to self-identify andseek out assistance. This
would allow them to gethelp in the future andto ask for help at theinstitution where they camefrom if they were having
difficulties.

themselves and to self-identify and seek out assistance. This would allow themto get help in the future and to ask for help at the institution where they camefrom if they were having difficulties.
Dr. Lester: Could you make this something that people other thanhighly skilled, highly trained people would use? Considering shortages of childproviders and child psychiatrists, there might be a way to put some of this intoa manual that would enable Master’s level people to do it if enough decision
making points and skills were integrated and the structure were simple. There
are a lot of highly skilled Masters level clinicians who can administer trauma
focused CBT dealing with really difficult family and child issues.
Dr. Cozza: Yes. We accept that Master’s level clinical social workers will
be able to do this, just not lay people.
Dr. Lester: The challenge is making the rules of your intervention andyour session explicit and deciding the key skills people need. Once they havelearned it in one context, they can face new things that cannot be anticipated.
Another question is how to train both a parent and the child on comparable
skills and strategies so they can support each other. It sounds hokey, but ourchildren and parents will sit and talk about, ”What is your feeling thermometer, Mom? You need to take a time out before we can talk. You need to be at a
30 before we can do that.”
Dr. Cozza: Do you have exclusion criteria for distressed families?
Dr. Lester: For our intervention codes, we have very few exclusion criteria. One is active psychosis.
Dr. Cozza: Can people who feel depressed and are falling apart or
struggling in interpersonal relationship problems use these tools?
Dr. Lester: We would refer most of the people you are talking about
to individual treatment, but then hope that they might still be able to use it.
Sometimes you have somebody who is so distressed that they cannot.
Ms. Kaul: Did you say that active substance abuse might be an excuse
why the project would fail?
Dr. Lester: It might be. Another is family violence.
Dr. Saltzman: Yes. On a family based approach, especially. We use different approaches in non-military situations. We have done parts of the modelin which domestic violence is present. We are usually working just with themom and the kids. It is a different scenario, but also has value.
LTC Schneider: If you referred someone for individual treatment,
would you do your portion concurrently?
Dr. Lester: Yes, we would as would Bill.
Dr. Beardslee: In our situation, we often had someone treating theparent’s depression. We would not work with the family unless we had permission to talk to that person and make sure that we were going to work together
and support one another. We had three big exclusion criteria — active psychoses, fulminant substance abuse, and legal actions for divorce.
Dr. Saltzman: Fulminant substance abuse?
Dr. Beardslee: In other words, really abusing substances and denying
it. They are coming in under the influence. The other requirement we had isthat if we were going to work with a family, everybody had to consent to be
involved. And we had lots of families where that would not happen initiallyand we would never say no. We would say, “Let us work with you until we understand why your adolescent will not come or why your husband will not.”Workgroup on Intervention with Combat Injured Families — Conference Proceedings • 83

Sometimes families willtell you, “I cannot go any
faster or I am not ready.” I
have two larger questions.
What is the normal
developmental course ofthat kind of adjustment(having a combat injury)
within the individual andwithin the family?

We also worked with a lot of families with the same number of sessions, but
over a longer interval. For example, there were families who said they could
come only once a month. It was a long time ago in the 80’s, but we were very
careful to be very respectful of the families and say what we were going to do.
This is a six or seven session intervention; we are going to get a history, weare going to do some teaching, we are going to see your children, and we aregoing to meet with you and talk about having a meeting. Each time we could,
we would orient the family to that contract guidance agreement we had madeand place them on that. They found that very helpful.
Dr. Saltzman: Did you feel like something was lost though, when you
stretched it out that much?
Dr. Beardslee: It depended upon the reasons for stretching it out. If
there were good reasons in the family such as their coming from far away orsomebody was recovering from an illness, it was okay. Obviously, we would try
to do things once a week or once every other week and move it along. Sometimes families will tell you, “I cannot go any faster or I am not ready.” I have
two larger questions. What is the normal developmental course of that kindof adjustment (having a combat injury) within the individual and within thefamily? And then, how do you position your intervention to try to maximize
the likelihood of that for all families? The kinds of things you were observing about the remarkable resilience of these families. In intervention development, what you want to do is find some families that you can do the intervention with. Most people would say you select people that are seriously enoughill that they really need it, but are strong enough that they can actually do it
within a time frame that you could do it with them and learn from it. Having
done that, you then mix-match and strategize about the situations. So you
would consider someone who would only be at Walter Reed for six weeks oreight weeks before returning to the community. You might choose them to dosome parent guidance as well as a session with the couple together, and thenat some later point, you may wish to do this in the family.
Dr. Cozza: Using the parent as a means to develop the skills in thechild, or is that a little too difficult in terms of stretching?
Dr. Beardslee: The issue is whether the parent could both be the parent and the coach for developing skills in the child. I wrote a book for parents
about how to formulate difficult matters, saying the kinds of things that are
helpful based upon your own experience, what you have been through, what
you have been through together, and what you think are the concerns of yourchild. Now you have wonderful narratives where the girl is afraid there is going to be an earthquake and the tree is going to fall over. You have these examples where people have experienced the same powerful thing, but they had
different experiences. And they come together. We want to create the climate
where that can be respectfully discussed.
There are certain basic principles that people endorse, like ‘do not try totalk in the midst of a crisis’, ‘be able to listen’, ‘plan to talk more than once’, and‘try to have the experience end on a positive note for everybody’. The parents
often say they could never do that, that it is too much. My response would be,“You don’t have to. Wait and see what part of that you can do.”When I visited Walter Reed, there was a group following up with people
after they left Walter Reed. That was very powerful in their report. After ourinterventions with families, we did an outreach every six to nine months, for

84 • Session 2: Practical Application and the Components of Effective Intervention

The simple fact that in a
preventive intervention
someone is going to callin six to nine months andnot say what is wrong, butinstead say. ‘How are you
doing? How are you using
the skills you learned?
What are the issues now?
This is where you were lasttime.’ This follow up wasenormously helpful because
it let people know there
was both a resource anda chance to practice theirskills and have follow up.

several years. We called them. Sometimes they would come back in. Sometimes we would do it over the phone. The simple fact that in a preventive
intervention someone is going to call in six to nine months and not say whatis wrong, but instead say. ‘How are you doing? How are you using the skills
you learned? What are the issues now? This is where you were last time.’ This
follow up was enormously helpful because it let people know there was both aresource and a chance to practice their skills and have follow up.
Dr. Lester: There is some evidence to show that at least some effectsof our intervention wear off after two years. That suggests you need some“boosters” or “refreshers.” We invite people back in quarterly. Most people do
not take you up on it, but they appreciate the contact. Some people come inevery chance they can get.
Dr. Fullerton: Can they reach out to you?
Dr. Lester: Yes, of course.
Dr. Beardslee: Absolutely. We have a 24-hour, seven-day hotline, andwe provide additional support as part of our intervention.
LTC Peterson: What was the context of the guidance provided, andwere there limits?
Dr. Beardslee: That is a good question. Let me give you the model. I
was working with a strength-based model, but also with a common disease
management model. The illness most like chronic depression is rheumatoid
arthritis. Because there are flare-ups and because it is chronic, people get various kinds of preventative strategies. When you have a long term relationshipwith your rheumatologist, you are going to go in for regular visits and in crises. Because this intervention is for families, we will do a burst of intervention,
be available for anything that comes up, but obviously we will make referrals
or route things. Strikingly, we did not have a great deal of abuses of this availability. People were very respectful when they called. They called because they
were worried that their kids had become depressed, which is a big issue as kids
go through adolescence. They wanted to figure that out and we were able tohelp them with that. The other reason they called was they might want to haveanother family meeting because a crisis had come up. I think the limits wereclear. This was not open-ended therapy. This was not couples therapy. We weregoing to work with families for six to eight sessions around a piece of work
about shared responsibility for children and the conversations with them.
Dr. Lester: What is important is making it clear what this is and is not,and setting the parameters at the outset.
Dr. Beardslee: There is also an issue around available resources. We
believe that people with chronic depression need a regular physician to deal
with it, so there was somebody who had that assignment. The issue about notgetting overwhelmed is very clear… that this is a limited piece of work.
LTC Peterson: When you stumbled into a marital issue or something
more, did you limit yourself?
Dr. Beardslee: We approach it several ways. If I was working witha couple and thought they were about to get divorced, I would stop the intervention and say, “I wonder if what you need to do is some work on yourmarriage before we go on with this?” They would often then say ‘yes’ or ‘no’.
When you start working with depressed people, they often go into an episode.
We also did the intervention with people who were bipolar, and they would
go into episodes more rapidly. Part of our work was teaching families how to
Workgroup on Intervention with Combat Injured Families — Conference Proceedings • 85

The hardest part about thispopulation is they represent
a family in transition where
bigger problems are likely
to come later. How do you
build the skills in there toprepare them to address
this at a later date?

recognize that and how to help one another. If our team was working withsomeone they thought was getting acutely depressed, we would tell them thatand make a referral for them. So we were modeling not only that there werelimits to what we would do, but there were other resources that they could
access.
Dr. Cozza: That is helpful. It might indicate our ending with a transition session rather than a sustainment session. We might consider a check-up
phone call or a follow-up phone call. The hardest part about this population isthey represent a family in transition where bigger problems are likely to comelater. How do you build the skills in there to prepare them to address this at alater date?
I like the idea of doing a parent guidance that focuses on a parenting role
including availability — to let them know that they can talk with their childand to make them aware that the child is likely experiencing something similar. A parent guidance to educate them about the way children may express
that, not through words, but through misbehavior or whatever, so the parent
can identify it. Some of it is hearing, making good decisions, building skills,
but some of it is watching yourself and watching how you do, over time. It
would be interesting to know what is a good disease model for that, in termsof identifying when you are about to get into trouble?
Dr. Saltzman: You know enough to help them anticipate the challenges and difficulties they might have after they transition out. To have an
early warning system so they can see when they are getting in trouble. What
are some of the red flags that can be built into your intervention around identifying and when to seek out help?
Ms. Vineburgh: This is one of the greatest challenges this intervention
might encounter. In Bill’s intervention there was a baseline, namely you know
when the family is experiencing an absence of depression because it was built
around ‘breaking the silence’, getting the family communicating, making surethe health of the family was defined as the absence of depression, the management of depression, and the prevention of depression in children.
What is the baseline and goal of this intervention? How would you define what you would ultimately want that family to be experiencing once theyleave such that the family knows what to put their hands around in terms ofknowing they are functioning in a healthy way?
LCDR Kane: I remember meeting at least one family on the ward who
was functioning really well. I was impressed with how they adapted. We knowthat not necessarily one size fits all treatment. Something else to think about isthat there might be some families where you want to emphasize progress andfor others there are different kinds of emphasis. You do want to know the goal
you are headed for is something that can be achieved in this level.
Ms. Williams: According to whose perception, yours or the families?
LCDR Kane: Yes, this is definitely something that you want to know.
Dr. Saltzman: You have to build in the possibility that the parents cancheck in together or the family can check in together to see how their progress
is going. You are right.
Ms. Vineburgh: Should criteria be set that they can check on?
Dr. Saltzman: Right. And not just for one as it could be unique foreach family, and how they define a good level of functioning for them. That
comes out of the initial engagement and goal setting and assessment period.

86 • Session 2: Practical Application and the Components of Effective Intervention

The biggest finding of ourwork was that families canbe remarkably resilient in
the face of very difficult
stresses. If you take astrength-based, positive,
but fairly prescriptive
approach that gives
structure and a narrative
to someone, they can finda lot of strengths withinthemselves.

What do they see as a good level of functioning and what are the concrete
markers of that level of functioning?
Dr. Beardslee: In our experience, with replications in European
countries and in this Latino situation, it is important to redefine terms with
their culture in mind. What is depression? What is resilience and what is goodparenting? When you find a family that is coping well, they can teach us all agreat deal about how people deal with this naturally — how they are resilient.
I think it is very important to characterize that. If you could do this intervention, five or six sessions, with a number of families, in which you had the time
to do it and they could consent and say yes, it would teach you a lot about what
the eventual doses or levels of intensity you would do.
The biggest finding of our work was that families can be remarkably resilient in the face of very difficult stresses. If you take a strength-based, positive, but fairly prescriptive approach that gives structure and a narrative tosomeone, they can find a lot of strengths within themselves. You need to think
about how to describe the resiliency, but I am sure it is there.
Dr. Cozza: There is a unique part that is a bit different than some of the
FOCUS model. For the most part, we are talking about transition, especiallyfor families where there is injury the consequences of which are not going togo away. There is integration and a transition that is required. How do you get
a family to a point of re-equilibrium and acceptance that is healthy? There
are probably families that struggle with this indefinitely. We are dealing withpeople who have experienced an almost life ending event or what appeared to
be a minor injury, but now they are completely different than before.
Ms. Vineburgh: The concept of equilibrium and balance might besome of the criteria that a family would be able to think about.
Ms. Kaul: That is unique to each family.
Dr. Saltzman: When we developed this kind of goal setting technique
working with the Navy Seals, we had certain domains and family functionthat we think are important such as communication, cohesion, time together,
these sort of things. The family identified key goal areas that are importantto them and then identified specific behaviors that are either on target or off
target. These are your warning signs that mark you are achieving and moving
towards your goal. Then they rate themselves on a progressive basis. For thesustainment period, that can be helpful because they already have a map ofwhat does it mean to be moving towards our goals and when are we moving
away from our goals.
Dr. Lester: I am not sure our bull’s-eye is going to be a traumatic reminder. The Seals are into peak performance, which is the origin of this metaphor. But it is actually kind of a feeling.
Dr. Cozza: Instead of making it a silhouette, just make it a bulls-eye.
Dr. Arata-Maiers: One of the important issues we hear with thispopulation is their difficulty defining equilibrium, given all the changes intheir lives. They do not have a reference point because the past is no longer
possible. Part of the therapeutic intervention is about defining that for themnow, in their new circumstances, so they are not going to revert.
Dr. Cozza: What are reasonable expectations given the injury that has
been sustained?
Dr. Fullerton: They might not know that.
Dr. Arata-Maiers: Right, and that is part of the issue.
Workgroup on Intervention with Combat Injured Families — Conference Proceedings • 87

One of the important
issues we hear with thispopulation is their difficulty
defining equilibrium, given
all the changes in theirlives. They do not have areference point because thepast is no longer possible.
Part of the therapeuticintervention is about
defining that for them now,in their new circumstances,
so they are not going torevert.

Dr. Cozza: And part of the intervention.
LCDR Kane: In some of families I met with, the service member wasbound and determined for full recovery. Any effort that was not aimed at thatwas wasted effort including adapting the parenting style around his limitations because his view was those limitations will not be there in seven months.
With any intervention, you need to understand where the family is before you
structure how you are going to change them. Yes, it is a dose response. For example, there is the service member who is cognitively impaired and the extent
of his recovery unknown.
Dr. Richters: You have a point. We need to respect there could besome families that are very self-rising and very resilient naturally and we do
not want to disturb that.
Dr. Cozza: How do you balance optimism with reality especially early
on in the injury recovery? We have not talked about the fact that Pat Martinez
and John Richters are new to our team, which we are building to assess theseissues, help develop the core principles and refine the intervention with the input of the work group. We plan to develop a work group product that provides
a unified response to this challenge. We will be meeting this afternoon andpreparing our agenda for tomorrow, based upon today’s discussion.
Summary and Reflection: Day One
Dr. Cozza: Before we end, I would like to go around the room again
and get people’s last minute or end of day thoughts. Tell us what you thinkwould help in summarizing our experience today. We have moved from principles to general strategies to very specific intervention foci, which was ourintention. I am impressed by the challenges that we face in doing this and how
helpful it has been.
Dr. Saltzman: We also came full circle. We are back to principles.
Dr. Cozza: Yes. Scott, would you start.
LCDR Kane: I liked how we started out very broadly and tried to think
about as many principles and things as possible. In the afternoon, we talked
about how to define the FOCUS and how that intervention will help with theclinical problems we discussed. My suspicion is there are a lot of clinical problems not addressed that are important with the family intervention we are
discussing. We talked about financial resources as an example, and how you
address those particular needs. How would this intervention address that?
There are many clinical problems families might need to address.
Dr. Cozza: We have a good sense of the core principles and need torefine them. Our Center’s job will be to digest it and then get it back to you
all for comment. The other part we are struggling with and need to figure out
is to define the specific intervention in a narrow way that could become agold standard model using general strategies for families that are less specificthan using a feeling thermometer or the family narrative. What are the best
ways of approaching strategies in the clinical sense while thinking about thecore principles? We may want to be more specific about parent guidance approaches, i.e. protecting children in these environments and assisting parents
in developing skills for themselves and their families around identifying problems in the future. Those kinds of strategies can be used independent of anintervention. We may want to spend some time focusing on those tomorrow.

88 • Session 2: Practical Application and the Components of Effective Intervention

I am quite excited about
the fact that what we havebeen doing conceptually andalso structurally could be
replicated in another placeand could be broader. While
we are considered a research
field, our struggle is to takethe power from some otherplaces to do what we havebeen doing.

LCDR Kane: What do we do when our resources are narrow? Can we bevery specific as to what we can do? When I came here, Captain Clem wanted
to know if I could hire somebody who may not be at the full child psychiatry
level to make some of these implementations. The other part is doing an assessment to see where the family is at, so the importance of an initial assessment as compared to a one size fits all.
Dr. Chun: While I am a bit overwhelmed and near having reached asaturation point, I am quite excited about the fact that what we have been
doing conceptually and also structurally could be replicated in another placeand could be broader. While we are considered a research field, our struggle
is to take the power from some other places to do what we have been doing.
The other struggle is when patients leave Walter Reed I know we kind of lose
them, which is another kind of dilemma. But that is where the families usually
struggle most. So how are we going to extend our mission of service?
I very much like the idea of using the parent guide assessment as thatstarting point. The lessons learned provide the family with a plan. Although
we kept that in mind, we have not used it in any more of a specific way. If we
could just focus that a little bit more, it would be more helpful.
Dr. Fullerton: The core principles that we have talked about are invaluable. We were able to build upon a few things, get those down and now
they are there to build upon. Regarding the assessment of outcome, as a researcher I have been thinking about some of the outcomes that you are notlooking at. There have been some comments about not making this seem like
another set of forms to fill out. The way I have worked with Bob Ursano is
gaining entrée. Whether it is a plane crash, a disaster situation, Katrina, working with the Tsunami, the CDC, we try not to embed ourselves, but in a way
yes, so there is a face there for them. We have been up in Mortuary Affairs in
Dover and they know us. When we say to an adolescent, “You can help us,”
they love this. We did an MVA study of adolescents and engaged them withthe approach; “Only you can help us better understand this so people in the
future can deal with this.” If you design something for people who have been
through what you’ve been through, what would you do, that type of thing?
While I have not read his book, I loved the way Dr. Beardslee used theterm developmental as in the developmental tasks of the spouse, the developmental tasks of the injured soldier, the developmental tasks of the children.
Being a developmental psychologist, you were using those terms in a different
way, which represented action and movement.
Dr. Saltzman: I have enjoyed being here today. I have learned a lot
about staging an intervention of this kind, and I appreciate the thoughtfulness
that has gone into preparing these materials and selecting people and pulling this together. The next steps though will get harder and harder in termsof specificity. Although the research is not solid, you have a lot of knowledge,
intuition, and wisdom about what types of intervention components are mostuseful for different types of people at different stages of this recovery and sustainment process.
Collin’s article has a great template for thinking about not only thosecomponents but discerning those tailoring variables and how would you pickwhich to apply in different types of dosages. I assume you selected that because you like the model. There are some real challenges, but we are happy towork with you on this.
Workgroup on Intervention with Combat Injured Families — Conference Proceedings • 89

With this particular
population we have agreat deal of expertise andexperience in working withthese families. In identifying
the problems, we are
dealing with people who
were actually working withindividuals who have done
this. It is not just theoretical.

Dr. Arata-Maiers: With this particular population we have a great
deal of expertise and experience in working with these families. In identifying the problems, we are dealing with people who were actually working withindividuals who have done this. It is not just theoretical. We are also looking at
the differences in characteristics between your setting and our setting, which
impacts what we are going to be able to do in terms of interventions. It has
also been helpful to look at the core principles because those are what we aregoing to implement and operationalize it. And there will be other things we dobased upon our settings, our types of injures, how long the people are there,
etc. The briefing on FOCUS was also helpful to get us thinking how we makethis practical. I come away wanting to read this memo — this literature about
the TOG project.
I would like to flesh out, not only the topics that we started today, but also
the methods of engaging the family. Whether we are looking at the need forthis to be primarily psycho-educational or to have a clinical activity associatedwith it, we need to determine the structure.
Dr. Richters: I am struck by, in Brett’s words, the importance of deploying resources when and where they are needed and what types are needed. This is kind of the central theme of discussion. Also valuable is the emphasis Bill and everyone has articulated regarding the importance of capacity
building, resilience building, rather than a problem focused intervention. The
principles we have discussed and some of the front line observations about
the realities involved all ring true and will be indispensable in ironing out thedetails.
I was thinking about that old New Yorker cartoon of a scientist in frontof a blackboard where on the left side is this complex set of formulas andalgorithms, and on the right side is the solution. In between them it says,“Something magic happens here.” It feels qualitatively different to be in aroom full of people who are on the front lines and know the phenomena
well, as opposed to a traditional meeting of scientists and colleagues. Thereis a story about a ferocious game hunter who goes on a safari and is unable
to shoot anything for the two weeks he is there. On his way back to basecamp at the edge of the woods he spots a ferocious lion 50 yards away, whospots him at the same time. The hunter instinctively pulls up his rifle andshoots, and it misfires. He drops to his knees, bows his head in prayer, but
nothing happens. In about five seconds, he looks up and the lion is next tohim. He said, “My God, my prayers have been answered. The lion has joined
me in prayer.” And the lion looked up and said, “I don’t know about you, but
I’m saying grace.” Things are not always what they appear from a distance.
I bow to all of us. I took more notes today than I typically take in a week ofmeetings. Thank you, all.
LTC Schneider: The experience here has the opportunity to have somesynergistic outcomes. I am excited that we are creating something that can begeneralized and has a good chance of actually getting buy-in by families, clinicians, and command. Our challenge now as a group is to allow ourselves totrust Steve to carry this forth. We have to focus specifically on what he wants,
which is this particular module for a particular group of people. To have thatmanual does not necessarily meet the needs of everybody who came here. The
connections and the thoughts generated here have the capacity to be morethan just the outcome of the meeting.

90 • Session 2: Practical Application and the Components of Effective Intervention

The experience here has
the opportunity to havesome synergistic outcomes.
I am excited that we are
creating something thatcan be generalized and has
a good chance of actually
getting buy-in by families,
clinicians, and command.

Dr. Cozza: Our outcomes are broader than that. There is a development and a consensus, core principles.
LTC Schneider: We did that today.
Dr. Cozza: Having these core principles that will drive this intervention is important as well as having it available to a group of professionals who
can bring it back to institutions. It is also vital to have broader strategies thatcan be implemented regardless of the setting and to be able to evaluate its effectiveness in a particular context.
LTC Schneider: Yes. What we give you we get back by having data that
supports everything we all want to do, ultimately.
Dr. Beardslee: This day has been a very exciting day for me. I have
had the privilege of developing interventions with many groups and learning
a great deal from Tricia and Bill in the development of Project FOCUS. There
are several points I would like to make. One, this notion of developmental
challenge and resiliency is important. What does it look like in a family thatcomes through this okay? Where do they find it? They can teach us a greatdeal. Second, I think the question of specificity of intervention versus orderconstructs go hand in hand. You put yourself on the line when you say I know
enough to do an intervention with families that six other people are going toin the same way and we are going to see what we find out. It is not an intervention that answers all the questions. It is an exercise in trying to think about
how you will eventually answer the questions by asking, “What could we do
now that looks like other things?” Off of the top of my head, I would probably
think about two interventions: the one you described in which some of you
would find families and do five or six sessions and a briefer intervention when
you only had two weeks.
Dr. Richters: We just had the interview session.
Dr. Beardslee: Yes, when you had only the assessment session andcould give some guidance, for example ‘take care of yourself ’, ‘reach out for
help’, ‘think about your children’s experience’, ‘think about how you and your
spouse can find common ground’, etc. When we were able to follow these 100
families, many of them for as long as 10 years, we found there were longer term
processes of healing and coming to grips with things. Many of these families
have been alienated from church because of their illnesses. As they recoveredfrom their depression, they found their way back into the mainstream of theculture. I think that window is important because you do not want to say wehave to get it all done in six weeks or eight weeks or whatever. With Project
FOCUS, the idea is to give people skills that they can use over years.
No one should view this exercise as trying to do far more than they can
possibly do or go way beyond resources. It is exactly the other way around.
With resource constraints, one must ask what might be something worth doing whatever it would be.
We did not talk about changing systems to make them more family
friendly. What if the core principles became part of the care process? Whether
someone was cared for at Walter Reed or at another facility, there would beconcern about the family as essential for the soldier’s recovery and the experience of the children and parents coming together around parenting. Thatis a systems change issue. We have worked at trying to get systems to track
families and what has happened to them. Medical records do not do this. It isa different level and order for which there is a lot of interest. I will not be with
Workgroup on Intervention with Combat Injured Families — Conference Proceedings • 91

We did not talk aboutchanging systems to makethem more family friendly.
What if the core principles
became part of the care
process? Whether someone
was cared for at Walter Reedor at another facility, there
would be concern about thefamily as essential for thesoldier’s recovery and theexperience of the children
and parents coming
together around parenting.
That is a systems change
issue.

you tomorrow because the Institute of Medicine is starting a committee on
which I am part of to study parental depression, my area of interest.
Whatever you develop and disseminate, it must be evidence-based andclear. There is always the possibility people misunderstand what you do. It
is important to have, as do I, a conviction that people who are parents want
help with parenting regardless of whether they are depressed or regardless ofwhether they are in the military. Public education is a different kind of intervention, but it helps you think about the core principles.
Ms. Vineburgh: I have some copies of the brochure. I would just like to
add that “public relations”, a term not readily endorsed in academic settings,
is an important part of public education and communication. Bill may recall
that Children’s Hospital had only endorsed public education materials at the
department level, but that was such a powerful piece that Children’s Hospitalendorsed it at the institutional level. Talking about promoting systems change,
public education is a level at which you can do something here.
Dr. Lester: This has been informative, and we have appreciated thiscollaboration and your time. There are still many pieces to be resolved. It is
like a five dimensional puzzle. The assessment piece is very important because
we talked a lot about families’ assessments of where they are, but it would be
helpful to come up with a model diagram of what we think is our assessment.
What would it look like if our intervention is working? Is it less distress? It isbetter functional outcomes? Are there other indices of resiliency? And thenbacktrack, What do we think the family components are that are going to get
us there, and what are the risk factors that may come up that we would haveto address? This would help us shape what components and what topics wechoose. One module might deal with medical problems and the education
around that. What are the core skills needed around dealing with pain andrecovery? I am feeling in need of diagrams, but maybe that is where we are.
Dr. Cozza: As long as some of them have overlapping skills.
Dr. Lester: We have made great progress. I share your feeling that there
are at least two clear pieces here: a short-term guidance phase with educational intervention, even if it consisted of one session; the other would be amore intensive skill building intervention.
Dr. Cozza: So feeling good about that PGAI and its use in a single session?
Dr. Lester: Yes for providing the backside of the decision-making processes and the guidance woven into it.
Dr. Cozza: Skills in goal setting?
Dr. Chun: Your comment validates what we are doing, so it makes us
feel good. Not every family we see could do six full sessions.
Ltc Schneider: Right. Even if we had the resources, sometimes thefamilies just are not ready for this or they leave before an intervention can bedone.
Dr. Beardslee: Regarding a previous comment made by Carol, we ask
people all the time, and it is very powerful, “What would you advise us if wewere developing a program for other families?” Oftentimes people disclose
their needs by talking about what other families need because they do nothave to personalize it. That is another question we included as part of ourregular session and it also builds a nice relationship with the family.
Dr. Lester: We will probably be taking some of these pieces and run-92 • Session 2: Practical Application and the Components of Effective Intervention

Oftentimes people disclose
their needs by talking
about what other families
need because they do nothave to personalize it.
That is another question
we included as part of ourregular session and it alsobuilds a nice relationshipwith the family.

ning them with some families. It may give us a good feel for how it might fit
together and how to get it down on paper in order to make someone else beable to use it.
LTC Peterson: Among the positive things I will take away was notlooking to pathologize as much as looking at the normal developmental process and looking to elicit help from family members regarding the next generation of people. Then in taking this paradigm and shifting it to a system ofbeing family friendly, the intervention becomes a recruitment tool in its mostfundamental form or a deployment enhancer. One of the top two things soldiers say bother them when they are deployed is the family back at home. We
are looking at deployment enhancement and recruitment retention. To temper some of the optimism that I feel is that magical thing. What happens in
between the problem and the solution is resourcing. It is important when thisis rolled out is to emphasize it is in modules and is flexible and can be tailored
for the patients and the staff. Saying this up front inoculates the providers
from saying here is yet another program. Also, we can take it back to the command and say this is what I need to be able to do if we want such a program.
Dr. Cozza: Yes, this is what we want. We can focus on a specific intervention, but the purpose of this is to infiltrate the system with knowledge andinformation that will shift the way we think about these injured families. To
assume that there is only one kind of narrow way of addressing them is inappropriate. We want to provide information in a way that is usable and very
flexible. It helps people understand these families have certain experiencesthat need to be addressed in some way, that those issues are valid, and that thisis not the only thing that will work for what we do.
Ltc Peterson: That has to happen to be able to be useful.
Ms. Kaul: From our perspective at SAMHSA, the collaborative cooperative focus of this meeting and also the approach going forward, will increase capacity particularly if one expands as mentioned. Collaboration andcooperation go beyond disciplines. Going to peer professionals and using thefamilies as resources extends capacity, which we are going to be struggling
with for a long time. Knowing that these principles can be generalized and areportable is exciting. Once we start nailing down what the interventions are,how they work, and showing some evidence or efficacy, we can start generalizing that. I have always been interested in strength-based approaches. If themodel could be tailored in which every session could almost be a stand-alonethat also could be useful. So if this is the last time the patient sees you, they
still got something out of it.
Ms. Williams: I am excited about the possibility of taking these very
core concepts, tools, and strategies and engaging the civilian community more.
We could be supporting our families once they leave these settings. I think it iscritical we cast that safety net widely.
Ms. Vineburgh: Everybody in the room, in addition to their specificrole, is an educator. This is a great opportunity. This topic is desperately in needof being addressed. As the intervention develops, you are educating someone
and it has been my experience that people love to learn. I am referring notjust to the patient or the patient’s children, but also to other institutions andsettings.

Workgroup on Intervention with Combat Injured Families — Conference Proceedings • 93

94 • Session 2: Practical Application and the Components of Effective Intervention

SESSION THREE:

Integration and Programmatic Intervention
The goal is to develop
a more comprehensive
intervention modelthat would include anumber of different
session modules to be
used in a variety of ways,
depending upon theneeds of the family.

Summary of Proceedings
Dr. Cozza: I would like to introduce Bob Ursano, our Department
Chair of Psychiatry at the Uniformed Services University and Director of theCenter for the Study of Traumatic Stress. I appreciate the opportunity of yourbeing here today, Bob.
We are going to summarize the work from yesterday. Today I want tore-frame this as we move forward. Our group met yesterday afternoon before dinner to think about how our Workgroup might best use our time. We
developed a list of our core principles of intervention with families yesterday.
Our job at the Center is to digest those and to flush them out a little bit. We
will then provide a document to the Workgroup members in a draft format
to get input. Then we will finalize a list of core principles — consensus principles — that the Workgroup agrees upon in terms of addressing the needs ofchildren and families of injured service members. This list will be useful in a
number of ways for professionals who are trying to manage clinical programs
and may need information that would support interventions, as well as underlying principles of the interaction with the families. It would also be useful inthinking about where we go forward with strategies and future intervention
models.
The second thing our small group did was to talk at great length about theintervention. We heard from Trisha Lester, Bill Saltzman and Bill Beardslee
about the FOCUS model and the family-focused intervention that has beendeveloped. The work that has been done has a tremendous amount of applicability to what we are doing. But we really need to be thinking more specifically, especially in the sensitive population that we have, about how pieces andparts of that can be put into place. We discussed the importance of developing
an intervention that is flexible and modifiable for a number of different reasons; largely though, to address the changing needs of the family and also thechanging presence of family members. Bill Beardslee’s recommendation that
we consider a brief intervention model as well as a more flushed out intervention model is a good one. We are going to take a look at the PGAI and think
about how we can modify that in ways that speak to family strength, which
was another suggestion, skill development and also using the instrument as away for families to develop their own survival skills. These would include how
they move forward into the future and be equipped to advocate for themselves, especially if we are only able to interact with the family on a single ocWorkgroup on Intervention with Combat Injured Families — Conference Proceedings • 95

When the war ends, thequestion will not only be,“Can we help the soldiers?”
but “Have we helped thenation?” The work thatyou all are doing has theopportunity for both of those.

casion. The goal is to develop a more comprehensive intervention model thatwould include a number of different session modules to be used in a variety
of ways, depending upon the needs of the family. The model would include
the initial engagement and assessment, similar to this brief model, but thenwould also include a parent-mastery session. How do we support parent skillsin the work with the families? We would use a parent-mastery and potentiallya child-mastery model. We want to develop a number of different pieces that
could be used based upon both the skill and interest of the clinician.
We also developed a comprehensive list of family challenges rather thanfamily problems, reconsidering the verbiage to indicate that we are shifting
this to a strength model as opposed to a pathology model. Today, we would
like to look through these again and begin thinking about goals and strategies
that the Workgroup would develop and guidelines for intervention aroundthese models that can begin to inform clinical interventions that are being
used at the clinical centers represented here. I would now like to ask Dr. Ursano for his thoughts and comments.
Dr. Ursano: I heard from Steve and Dr. McCarroll about the marvelous work that was done yesterday. One of the pieces that I wanted to underline for the group is that the goal of such work is also to test it. As Harry
Holloway would say, “Ideas are free; they are everywhere.” Ideas are free but
are not the same as accomplishing something. What accomplishes somethingis when you can test it, show that it works, and then test it and refine it again.
The work of this group, which is so very important, has to move into phase
two and phase three evaluation because evaluation and assessment allows
one to produce a product that is actually useful and shown useful, and thatyou can be sure is not doing more harm than good. There is a tremendous
amount of work happening and very much more to come. The route to followthat has already been done is that of Psychological First Aid. Phase two looms
as well for this group to tackle to be sure that its work does not go off into
the vapor, but in fact becomes a solid contribution that can be used not only
in our military populations, but also in other trauma exposed populations.
The issue is that trauma centers around the nation do not always have waysof helping children of those who are in those trauma centers. When the war
ends, the question will not only be, “Can we help the soldiers?” but “Have wehelped the nation?” The work that you all are doing has the opportunity forboth of those.
Programmatic Application and Future Study
Dr. Cozza: I would like to pass out a reformatted list of family challenges that we had looked at. If you remember the packet that you all had yesterday, there was a column on the right-hand side that had a number of different interventions along with, parenthetically, models that we would be using
to inform those interventions. Based upon the discussion we had yesterday,
it would be useful now to shift to a goal-oriented approach to who we would
address and what would the goals of any sort of interaction or intervention
with these families be without getting into the weeds of specifically what exactly we would do. What are the goals that we want to see in these children andfamilies if we address the challenge areas that we had identified from the family’s
perspective? What would we want the family or the child, based on those challenges, to accomplish?

96 • Session 3: Integration and Programmatic Intervention

We are talking about family
and parental approaches.
We want the parent toacknowledge a child’s
distress. There may be someclinician or health caresystem acknowledgmentof the child’s distress, but
we also want the parent toserve that role.

In our first area is ‘acute parent and child response to injury’. We discussed
a number of those being anxiety, distress and child distress. What would wewant to see in the family?
LTC Peterson: The counterpart of it would be the reduction in stress.
Dr. Cozza: It is important to first acknowledge the family anxiety andstress.
Dr. Richters: It is not just reducing anxiety, but helping channel it
because a certain amount of anxiety is called for, which is consistent with thisidea of normalization. Assuming they are within normal range in their functioning, we want to help them channel that and through that channeling andthe actions they can take, reduce their anxiety through their own efforts.
LCDR Kane: You start with acknowledgement and then you help themwith toleration. In the last step, you help them to put it in some perspective,
meaning, ‘Yes, there is a lot going on.’ Acknowledge it and the whole perspective is, ‘what he is going through is difficult and hard but that the family, in theinterval, will heal at some time.’ During the acute stage, it is not necessary to
do all of the healing, but to see that the healing process has begun.
Dr. Cozza: We are talking about family and parental approaches. We
want the parent to acknowledge a child’s distress. There may be some clinician
or health care system acknowledgment of the child’s distress, but we also want
the parent to serve that role.
Ms. Williams: There is recognition from the parent’s perspective perhaps about how that distress appears in terms of behavior, etc.
Dr. Cozza: Also, think about the developmental differences and theparents’ understanding of different children’s presentation of anxiety.
Dr. Richters: With a normal range of presentation and developmental
differences.
Dr. Cozza: What came out of the discussion yesterday is the need todevelop some clear goals. What do we want to have happen in these families
if we are going to be successful with an intervention? What are the strategies
for doing that?
Dr. Arata-Maiers: We also want to look at the child’s developmentally appropriate understanding of their anxiety in the course of responding
to the acute stress.
Dr. Cozza: To develop an age-appropriate understanding of one’s own
stress?
Dr. Arata-Maiers: Perhaps this needs to be a separate one about how
it is not just the developmental processes of the child but is also the developmental process of the response. There is a developmental progression ofa response to trauma. Understanding this can help them get the type of perspective that Dr. Kane was talking about.
Dr. Richters: It is the parent’s understanding of the normal rangeof anxiety and reactions to these kinds of stressors and sensitizing them tosigns of their own manifestations of stress that they haven’t recognized as being normal and the development differences in the way these things play out
within any given child or parent. There is a development trajectory across thecourse of the parents’ injury, recovery, and transition home.
LCDR Kane: One thing about this particular problem is the acute parentchild response to injury. Some of our goals are a little bit theoretical, whereas
in this particular group, we might get very practical like Psychological First
Workgroup on Intervention with Combat Injured Families — Conference Proceedings • 97

A parent’s capacity totolerate children’s expressionof anxiety may be a goodoutcome. They are notyelling at their children, they
are not overly disciplining
them, etc. They are able totolerate reasonable levels ofanxiety.

Aid. The goal here is to try to establish safety amongst the family. Are the kidsin school? Can we address the disruption issues? In my opinion, this category
is primarily ‘Psychological First Aid’.
Dr. Richters: We have been talking about establishing the alliancewith the parent and getting a sense of where they think things are.
LCDR Kane: I meant practical things such as, ‘Do you have a hotel
room?’ ‘Are the kids in school?’ ‘Do you have money for food while you arehere in the hospital?’ These are routine things, thinking of Psychological FirstAid first. Before we ask ‘How is your level of stress?’ we ask, ‘Do your kids havea place to sleep tonight?’
Dr. Cozza: We want the parents to re-establish their role as supporters
and comforters of their children.
Dr. Chun: We want to provide a safe environment for children and family in a time of crisis. A safe environment can mean a lot of different things.
Dr. Richters: Immediate needs in a triage sense, or as Maslow said,‘First things first.’
Dr. Cozza: Parents will establish or re-establish themselves as comforters and supporters of children.
Ms. Vineburgh: This may be the spot where you want to identify any
risks that may not be associated with the injury? For example, what if somebody has a parent who is dying? What if the parent has a mother who is dying? What about the identification of risk in a child that may have exceptional
needs? Consider the identification of other risk factors.
Dr. Cozza: We definitely want to do that. I am trying to remember
where we had included those at previous risk somewhere else. The idea is that
we have disruption and it has an impact on children’s lives. There may be someoverlap with these as we think about them. This is the acute nature of stress
reactions in the parent and child. It is the need to identify and provide treatment and to refer to clinical resources when needed.
Dr. Chun: Providing families and children with accurate and developmentally appropriate information about the immediate medical situation isimportant.
Dr. Cozza: We want to be careful about the difference between goals
and strategies. We want a reality-based understanding of the nature of injury
considering all family members.
Dr. Lester: It might be helpful to add a column of outcomes after goals
and strategies. Thinking about this measurement evaluation piece, we have a
lot of goals for what might be a single session. We may have to choose what weare going to focus on. It might help if we knew which outcomes we were driving at. Sometimes it helps me to think about what the end point is and then to
back it up from there. In the first session, we may want to focus on increasing
people’s knowledge and understanding of developmental issues and impactof the injury. They may not get a lot of emotional regulation and skills in thatone session.
Dr. Cozza: How would a goal be different than an outcome?
Dr. Lester: The module appears to focus on mental health. Reducing
emotional distress might be the main objective. There is a focus on decreasing
behavioral disturbance and there is also a knowledge aspect, too.
LCDR Kane: We are not quite at the point where this is like module one,but because this is the acute initial issue it is likely the first thing we will do.

98 • Session 3: Integration and Programmatic Intervention

The ultimate hope is forbetter emotional regulation
and better understanding.
They also have decreased
distress and anxiety. In
many ways, these are
strategies to reach positive
adjustment.

Dr. Lester: If you had broken it apart this would just be the first one or
two sessions.
Dr. Richters: For some families, there will be pre-existing problems
not related to the injury that will trump other things that might otherwise be
addressed in that initial meeting. It requires stabilizing them. That is an issue
of intervention, flexibility, etc.
Dr. Cozza: We may find that knowledge and understanding should be
its own problem area. We may shuffle areas around.
A parent’s capacity to tolerate children’s expression of anxiety may be agood outcome. They are not yelling at their children, they are not overly disciplining them, etc. They are able to tolerate reasonable levels of anxiety.
LCDR Kane: Another outcome might be parents’ establishment of asafety plan or a safe environment for the family. They should have a plan for
how they are going to get their family to a safe environment.
Dr. Cozza: The idea is for the parents to develop and communicate asafe plan regarding children.
Dr. Lester: These may be goals. Outcomes should be measurable. Could
we develop an ‘understanding’ or a ‘knowledge’ outcome? Bill Beardslee has aninterview that measures kids’ understanding of parental illness.
Dr. Richters: A goal might be to assess and recognize the normal
range of child responses. We might reflect on how to recognize and cope withthem. We want the parents to be tolerant of the child’s varying responses. A
knowledge goal could be used to convey information in ways to inform theparent and arm them with the capacity to tolerate. It would be the knowledge
goal. We would design it in ways that facilitate their acceptance of this.
Dr. Ursano: Pat, do you have major categories that you would put
there, such as knowledge, symptoms, behaviors, cognitions. Do you have someframe that you are operating under?
Dr. Lester: It is usually reduced to something less sophisticated thanthe conversation here. It is social, emotional, behavioral adjustment, andsometimes, another indicator of positive adjustment in both the parent andthe child. Knowledge and understanding are important when you have a primarily psycho-educational intervention.
Dr. Richters: This may be time to discuss the parent’s capacity foradvising and clarifying information for their children and outlining what the
implications may or may not be. The child’s possible cognitive distortions
should be implicitly addressed at this time.
Dr. Lester: The ultimate hope is for better emotional regulation andbetter understanding. They also have decreased distress and anxiety. In many
ways, these are strategies to reach positive adjustment.
Dr. Richters: Minimally, we want to make sure that the information
gets through to them. That is measurable enough.
Dr. Cozza: What would be an outcome measure for safety in a family?
Dr. Lester: Ask them if they have a safety plan. However, you cannot
see change on a yes/no outcome.
Dr. Richters: At the beginning of the session, they should have adequate answers for questions such as, ‘Where are the kids? Who is taking careof them? Do any of them have special needs that need to be addressed? Are
these needs being addressed?’ If they did not have answers, initially, we would
help them think those things through.
Workgroup on Intervention with Combat Injured Families — Conference Proceedings • 99

In the initial meeting, weare attempting to assess
the capacity of the family
to mobilize and their own
ability to manage thesethings. Do they just need alittle nudge, are they doing
it on their own, or are they
unable to do it and need a
lot of help?

Dr. Cozza: It is an interesting question. How do you measure principles
of first aid?
Dr. Arata-Maiers: It may be stability of housing, schooling, and other family routines. For instance, at BAMC, they are going to have a room but
the question is going to be, where is it? Are they going to be moved quickly
from place to place? There may be issues related to that setting to cause themto feel unstable.
Dr. Cozza: I like the idea of using categories. We have social, emotional,
and behavioral, and cognitive, to include knowledge and understanding.
LCDR Kane: Many of the ideas around safety and the parent securing asafe place for the family to reside falls under the social category.
Dr. Richters: The children may be left behind at their residence orthey may come to the hospital. Some children may stay with a caretaker. Are
the children out of school? Considering all of these things, is there a plan? Do
we intend to get them back to school to help normalize their lives as much as
possible?
LCDR Kane: In the outcomes, it is not necessary to state every possible
contingency. We will recognize it when we see it.
Dr. Cozza: If we throw some of these out on the table, it will help us
conceptualize it. What are the most important ones?
Dr. Lester: Is the creation of a safety plan an intermediate outcome ora mediating outcome? In other words, is it a primary outcome or is it a vehicle
to reduce child and parent distress? Is there a primary outcome to improveparent and child functioning and adjustment?
LTC Schneider: The development of a safety plan is a strategy with an
outcome of re-stabilizing the family.
Dr. Lester: You could frame it that way. It anchors you and it allows you
to choose what your measures are going to be and think about it as a model.
Dr. Ursano: The making of a family plan becomes a strategy.
Dr. Lester: The outcome becomes decreased child distress. They feel safe.
Dr. Richters: We should consider the literal conditions of their daily
life, for example, children being in school versus being with a caretaker. At
some point you are going to test these interventions and compare them tofamilies who are not getting an intervention. Presumably, you would see differences in those basic kinds of things and that is crucial to our foundation.
LTC Schneider: In the initial meeting, we are attempting to assess
the capacity of the family to mobilize and their own ability to manage thesethings. Do they just need a little nudge, are they doing it on their own, or are
they unable to do it and need a lot of help? An outcome might be the family’s
capacity to mobilize. Can they show that they know how to engage the system
and meet the needs of the family plan? It could be as simple as that.
Dr. Cozza: That is part of a family assessment.
LTC Schneider: Part of our job would be to assess whether the family
is able to meet these goals and if they have done so.
Dr. Richters: You may learn through that initial intake interview, forexample a PGAI-type interview, that they have adequately thought throughthese things, made necessary arrangements and are thinking forward.
LTC Schneider: In a strength-based model, I would assess their capacity to actually do so.
Dr. Cozza: That is overarching for all of these. Are they able to employ

100 • Session 3: Integration and Programmatic Intervention

Our purpose is strengthbased. It is to not pullaway the parenting roleand to engage children
independently unless they
are really struggling. The
purpose here is to help theparent reassume that role ifthey have lost the capacity
to do that.

these strategies? Are they able to reassure their children? The ability to develop a family plan would be an indication of their capacity to address thischallenge.
LTC Schneider: We are just priming the pump that exists, not building
the engine from scratch.
Dr. Chun: We often say that parents do not recognize the level of distrust of children or they deny or avoid it. The process of acknowledgment
should be accomplished in the beginning.
LTC Schneider: Once you bring it up to them, can they incorporate it
into how they look at things? That is the capacity part. We can to bring it into
their awareness.
Dr. Cozza: We may want to do this for each of the challenge areas andlook at whether the family can independently demonstrate the capacity to
do this prior to our discussing it with them. Some families may be available
or interested but were disorganized by the experience, and when prompted
are readily able to do it. Some families are interested and understand but,
based upon the disorganization, have difficulty implementing it. Lastly, somefamilies are completely disorganized. Think of it as an organizational level,in terms of the family’s organizational and emotional capacity. I like the ideaof including that as an assessment for how the family manages the different
challenge areas.
LTC Peterson: Conceptually, would we assess the outcomes for eachfamily member? You might have somebody in the family (e.g. a parent) who
is successful in negotiating these goals and getting outcomes, but a child or anadolescent might fail miserably. Would an assessment be done for each member of the family or would we look at the family collectively?
Dr. Cozza: Conceptually, we are talking about this as a family intervention. It is the family’s capacity to do these things. If an individual is having
extreme difficulty, we want a mechanism to be able to notate that and address
it in some way. Approaching the family as a unit is the idea.
Our purpose is strength-based. It is to not pull away the parenting roleand to engage children independently unless they are really struggling. The
purpose here is to help the parent reassume that role if they have lost the capacity to do that. If they are distressed, we assist them with their distress. They
calm their own children and help manage and develop a sense of safety in thehouse. That is the purpose of it and then we measure the family’s capacity andthe parent’s capacity to do that. That hangs together well, conceptually, in mymind. What would be an indication of a parent’s capacity to effectively communicate and to relieve the anxiety of the children?
Dr. Ursano: Reading a bedtime story.
Dr. Chun: Set a routine like reading at bedtime or calling about thesame time every day when the kids are away. Some parents say that their kids
will not talk to them on the phone and so the parents stop calling. They do nothave to say that. You could encourage them. That kind of encouragement may
help them to maintain that routine and structure.
Dr. Ursano: The things you are collecting will eventually cluster into parental nighttime behaviors. This involves teaching them about these behaviors.
Ms. Vineburgh: One area of importance at this stage is hope.
Dr. Cozza: Instilling hope is Psychological First Aid.
Dr. Lester: There are a number of hope measures.
Workgroup on Intervention with Combat Injured Families — Conference Proceedings • 101

The outcome is thefamily’s capacity to
manage challenges andtheir success at a numberof levels. The family
challenge assessment
gives you a sense of
the family’s capacity
to manage challenges
independently, the family’s
capacity to manage
challenges with some
instruction, or the family’s
inability to manage
challenges due a level offamily disorganizationthat makes them unable
to participate, despite
being willing.

Ms. Vineburgh: Hope is something that has to be communicated. It issomething that a parent can communicate to a child.
Dr. Ursano: I think the goal would be phrased as feeling hopeful andhaving realistic hope. Then, the questions would be how you get there andwhat the outcome measure may be.
Dr. Chun: The strategy for instilling hope might be having fun with thekids or by having the injured service member get out of their bed to take a fiveminute walk outside.
Dr. Lester: We might look at goals for the entire family that are unrelated to the injury.
Dr. Richters: We should move forward on various fronts to gain selfefficacy.
Dr. Cozza: It is about not allowing the injury to get in the way of normal
activity and maintaining development. This is an example of a problem area.
Dr. Arata-Maiers: The structured parental engagement sounds like itapplies to young, school-aged children. I do not know many adolescents whowant you to play with them. We need to figure out if there is something different for the adolescent age group.
Dr. Lester: The general category might be maintaining or building
family routines. Routines might be different based on developmental age.
Dr. Arata-Maiers: Reading a bedtime story would be developmentally appropriate for younger children.
Dr. Ursano: The shorthand of your categories is the problem, the goal(is) the intervention, and the outcome. That might be an operational way toapproach this. What is the problem? What is the goal? What is the intervention you will use? Finally, what is the outcome you will measure?
Dr. Lester: These outcomes might be for your long intervention or the
combined intervention.
Dr. Cozza: The outcome is the family’s capacity to manage challenges
and their success at a number of levels. The family challenge assessment gives
you a sense of the family’s capacity to manage challenges independently, thefamily’s capacity to manage challenges with some instruction, or the family’s
inability to manage challenges due a level of family disorganization that makes
them unable to participate, despite being willing.
LTC Schneider: This does not necessarily fit under 1.1, Acute Response. To measure resiliency and how effectively people have responded toa challenge, you can look at the lack of negative outcomes. Was the familyreferred to ASAP? If the answer is no, they may not have been at risk for that.
It is a positive outcome that this family was not referred to FAP (Family Advocacy Program), ASAP (Alcohol and Substance Abuse Program), etc. Thisshows that this particular family had some form of resiliency. A lack of negative outcomes, which is measurable, is an indicator of a positive outcome.
Dr. Richters: Ultimately, that is the kind of outcome the system will
care most about.
LTC Schneider: When you talk about a prevention program, you arepreventing negative outcomes. You cannot necessarily correlate one-to-one,
but as a group these people are experiencing less stress. That would be an indicator that some kind of intervention might be helping.
Dr. Ursano: In the family assessments, the corollary to that would befamily strengths. We treat and assess the strengths. There is an organization

102 • Session 3: Integration and Programmatic Intervention

From a family systems
perspective, one is looking
for the avenue for alteringfamily function and therecovery environment. In
working with the family,
you may choose to target
the adolescent child as away to change the family
because that is the one
with the most strength,
the most activity.

here which is almost in each category of child-parent-family. Underneath,think of the outcome section in particular, you have child outcomes, parent
outcomes, family outcomes, even though one’s intervention is family directedor parent directed. Similarly, in the problem area we would have child problems, parent problems, family problems, even though one’s intervention may
be parent directed and family directed. The issue of the evaluation and theintervention are really separate concepts. When you are thinking about the
problems, the goals, the interventions, and the outcomes, there may be child/parent/family levels to think through. Eventually, some of those may collapse
in terms of the measurements they use.
LTC Schneider: There is some ambiguity regarding who we are targeting and for which particular thing. There should be more clarity about what to
do when a certain person is or is not there.
Dr. Ursano: One of the unique things is the focus on the question ofparental and family function as the intervention and to not remove the childfor treatment. It fits our system level issues and what is practical and possible.
You are trying to alter the family function. That does not mean one is assessing at different levels and measuring at different levels.
Dr. Cozza: The problem may be a child problem, but the intervention
is a parent solution. The strategies may be more parent-directed.
Dr. Lester: The theory behind this is that we are driving the intervention through the family system. It is by targeting the parent-child relationshipand conflict that we are going to get improved outcomes for the family, theparent, and the child. The same theory drives the intervention no matter who
shows up to participate.
Dr. Cozza: We want to build an intervention in families where we may
not see the child and still be effective in the way we do it.
LCDR Kane: We also have families where the injured soldier’s parents
are the family. It is the reverse. We have another group where it is the siblings
that are part of the family intervention. Today’s framework is the traditional
one but it would be nice to throw in an asterisk to explain that the intervention could be modified to deal with atypical family arrangements.
Dr. Cozza: The challenge is that the roles and responsibilities of siblings
or adult parents of adult children are different. The question is, how much canit be adapted and in what ways?
Family Systems Perspective
Dr. Ursano: What you are driving here is a family systems perspective.
From a family systems perspective, one is looking for the avenue for alteringfamily function and the recovery environment. In working with the family,
you may choose to target the adolescent child as a way to change the family
because that is the one with the most strength, the most activity. Most of the
discussions will be targeted towards them or the parent. It might also be theparent outside.
If I were thinking about how to invite corollary to it, it would be adapting a family systems program for Marines whose parents are not in the service. How can one develop a care giving response and environment for them?
There would be a way of working through that. This fits with a family systemorientation and creating a caring recovery environment for the entire family,
not just for the injured soldier.
Workgroup on Intervention with Combat Injured Families — Conference Proceedings • 103

This calls for a broader
definition of family.
We are locked into
the traditional family
definition with the mom,dad, two kids, and a dog.
We do not look at in-laws,
older parents, girlfriends,
etc. We are in thecontext of the reality ofrelationships today rather
than what would beconsidered a traditionalfamily.

LCDR Kane: It is alright to go with the traditional model and talk about
ways that it can be shaped for those other types of family situations.
LTC Schneider: That fits with Dr. Beardslee’s discussion yesterday
about the developmental challenges of being injured and the developmental
challenges of being a parent who comes in to deal with their injured adultchild. The process of development is always unfolding.
Dr. Ursano: That is an important outgrowth of what you are doing.
Given all this discussion, how can I apply it in different settings and leave theother spin-offs?
Dr. Chun: We have seen many younger siblings. For example, a fiveyear-old sister joins her injured older brother and their mother must take careof both children. The five-year-old child may have regressive symptoms. In
other instances, we see a teenaged younger brother who is feeling devastated.
When we visit patients, we see the whole family. We do not say ‘you are notqualified’ or ‘you are not amicable.’ We face the whole system.
Dr. Newby: This calls for a broader definition of family. We are locked
into the traditional family definition with the mom, dad, two kids, and a dog.
We do not look at in-laws, older parents, girlfriends, etc. We are in the context
of the reality of relationships today rather than what would be considered a
traditional family.
Dr. Chun: Lately, the military has been relying on those extended families for non-medical attending. They need someone else besides medical staff
to care for these people for 24 hours. They allow these family members to carefor the injured service member and provide financial support and travel arrangements to ensure that it takes place. It is just that they are not included inthis family concept.
Dr. Cozza: They can be included. It can be challenging to meet theneeds of different family members individually. What becomes more difficult is doing it in a family context if some members are not there. How do
we develop family strength or implement family-focused intervention ina situation where the sister of the injured service member comes in fromout of town and the parents are away in California? We need to modify it.
It has to be developed in a way that is respectful of those non-traditionalfamilies.
Dr. Arata-Maiers: One of the issues, no matter what type of family constellation you have, is helping to define the roles within the family. If
you have an adult parent of an adult injured person, that role is going to bedifferent than parents of a younger child. If you have a grandparent who isfunctioning as the parent of the children who are there, then they are goingto have more of the parental role in the family. What is the role of a younger
sibling who comes to visit? What is an appropriate role for them to take on
within that capacity and what is not appropriate? That is part of our job. We
are helping the families to define roles for themselves because these roles shift
as they come into the hospital environment.
Dr. Cozza: Have you applied FOCUS to families where the service
member is the child as opposed to the parent?
Dr. Lester: We have not. It would require a lot of adaptation because
our model is really focused on the impact of trauma on parenting. Most of theconversations we have had here have been about the developmental impact,
child reactions, etc.

104 • Session 3: Integration and Programmatic Intervention

One strategy may
be teaching how tocommunicate via e-mail.
What is the appropriate
parent-child, child-parent
communication, including
with the injured parent?
Should the injured parent
be telling the 12-year-oldthat the pain is bad on aparticular day?

It is one thing if you are using the principles and making clinical adaptations where needed, but it is another thing if you are trying to evaluate it. Youmight have to say that it is an intervention that requires a child under 18 tobe part of it.
Dr. Ursano: That is why we have an inclusion and exclusion criteria forthe evaluation phase.
Dr. Lester: It does not have to be a traditional family; you could include
other caretaking adults. It seems that the intervention is a child intervention
to improve their functioning.
Family Communication and Connectivity
Dr. Cozza: Today is not so much about solving the problem; it is amatter of understanding what needs to go into the solving of the problem.
Recognizing the fact that we cannot get through all of these challenges, weshould pick two. Two useful areas to address are family communications andconnectivity, and parental efficacy, availability, awareness, and style. We canlook at the identified challenges and also think about goals, strategies, andmeasurable outcomes.
Dr. McCarroll: Almost everybody depends on some kind of electronic communication medium. It ties people together no matter where they
are, present or not. The amount of this material that is suitable for some kindof electronic communication or distribution might be a really important issue
to work with. This would be a strategy.
Ms. Martinez: The strategy may be ways of transmitting material andcommunicating.
Dr. Cozza: We want to maintain connectivity.
LTC Schneider: On the topic of connectivity, when you are in Iraq,
most use the phone, e-mail, or web cameras. I did that every day. I had a routine with my kids. I used a web camera and saw them as a group when theycame home from school. I wonder how many injured service members areable to re-establish that connectivity if their kids are not there or if there are
too many barriers and they do not think of it or do not know how to do it.
Dr. Chun: The hospital actively supports that. The problem is that very
few get to use web cameras. Security issues may be a problem. Most of theservice members have a laptop. They are donated by a company so they dohave access to a laptop.
Dr. Arata-Maiers: Some of the injured are given a BlackBerry. The
idea is that it helps them to keep up with their appointments. It may become
the means of communicating with the children.
LTC Schneider: I do not know if the Fisher Houses have access to freewireless internet, but all should.
Dr. Ursano: One strategy may be teaching how to communicate via
e-mail. What is the appropriate parent-child, child-parent communication,
including with the injured parent? Should the injured parent be telling the
12-year-old that the pain is bad on a particular day? If he or she does say that,what should be the follow-on to it? He or she may say, “But I’m taking mymedication to help.” What is the protocol? What is e-mail protocol that may
facilitate family strengthening and what are those principles? Communication offers opportunities for problem solving. In couples where the communication breaks down, I tell them to start sending e-mails. It can be a way tosolve family conflict.
Workgroup on Intervention with Combat Injured Families — Conference Proceedings • 105

What is the role ofcommunication
connection in the family
and what is the typeof communication?
What are the roles andthe effectiveness ofcommunication? Howmuch is enough? Howmuch is too much? What
information should beshared, in what kinds ofways, and with whom?

Dr. Cozza: There is this issue of communication and also connectivity
across family separations. How do you keep people connected and together?
I have often told parents that it is helpful to take pictures of a hospital and email them to the children so they can see where they are at and what that islike.
Ms. Vineburgh: When we were in Baltimore at the International
Traumatic Stress Society Meeting, there were many military presentations.
The Veteran’s Administration is doing quite a bit of interventions through videoconferencing technology. There may be possibilities to deliver this beyond
the face to face contact. This is something to think about in terms of the communication component.
Dr. Ursano: It also deals with the resources available. There is the issue of teaching about where the resources are. There may be three that you
want to include in the package and teach people how to find information to
help them. Examples may be the National Child Traumatic Stress Network(NCTSN), the Veteran’s Administration (VA), etc.
LTC Schneider: We are still not all that great at our capacity to getthings across appropriately face-to-face, much less think of the impact of themedia on connectedness.
Dr. Cozza: What is the role of communication connection in the family and what is the type of communication? What are the roles and the effectiveness of communication? How much is enough? How much is too much?
What information should be shared, in what kinds of ways, and with whom?
Dr. Ursano: Specific to the picture of your intervention, is there going
to be a website for families to access that answers specific problems, so that
there will be a sequenced course of information. It might be organized aroundfrequently asked questions. For example, “three-year-old children do such andsuch during this time”. It becomes an avenue for delivery of information subsequent to their leaving the hospital.
Dr. Arata-Maiers: There is a website that is being developed involving at least the Air Force and the Army and we may want to find out more
about it. It concerns deployment with injury being a part of it.
Dr. Ursano: It is a database but it becomes an avenue. Will there bethings to send out? Is there a form of e-education to go out to the family? Will
the target be by child’s age or the particular challenges? There is a whole sequence of things to think through in the area of communication to the families and between the family members.
Dr. Cozza: A goal would be to support appropriate communication
within the family.
Dr. Lester: We talked about the need for the parents to reflect on theirown experience prior to communication with the child.
Dr. Cozza: This is similar to the first two sessions of FOCUS with theidea of encouraging the parents to get their act together. There is an expectationthat the parents should be capable of pulling it together in order to be the parent, and figure out what they are going to share or not share with that child.
LCDR Kane: The next step is making sure that they have a mutual respect and understanding. It is important that they have a unified presentation
to the kids. They are a parental unit leading their children.
LCDR Kane: Marital counseling becomes important. If there is a total
breakdown between the parents and they are battling each other for some106 • Session 3: Integration and Programmatic Intervention

It is important to figureout how parent surrogatesin the community should
communicate withthe children. This may
include either passing on
information or directing
them in terms of how
much information theyshould or should notshare. There are multiple
caregivers.

reason, it is hard to move forward with other things. I recommend a goal forthe parents to come together in agreement about how their parental styles will
be shared to help them move forward together.
Dr. Cozza: This is where there is a separation between the marriage andthe parenting. I will tell parents to agree upon two ground rules and not to talk.
If they talk, the kids may suffer. We are not there to solve marital problems atthat time. We are there to help them be good parents. This is important because
sometimes you can get dragged into these marital situations. If you can at least
get them to recognize that the purpose of any interaction with us, above andbeyond having a nice conversation together, is to get the parents to figure out
how to take good care of their kids. If, in trying to fork out the rest of the problems, it makes things worse for them, then you should not do it at all.
Dr. Ursano: This is really one of your strategies of intervention, whichmight include appropriate neglect of couples’ problems and focusing on theparenting task as distinct from the marital problems.
Ms. Kaul: We are focusing a lot on the interaction between the parents,
so a strategy could be to help them determine what the key kind of anxiety orsources of anxiety are for their children. Sometimes they miss that. They do
not understand that the worry is really ‘x’ and they are assuming it is ‘y’.
Ms. Williams: It is also important to be mindful in these particularsituations of strategies when another caregiver is involved, i.e. a child is being
watched by a relative. We want the communication of messages to be unified
and consistent with what the primary caregiver communicates and how heor she does it. We need to problem solve around that. You know, how do we
address that?
Dr. Cozza: It is important to figure out how parent surrogates in thecommunity should communicate with the children. This may include either
passing on information or directing them in terms of how much information
they should or should not share. There are multiple caregivers. You get grandparents, aunts, and uncles involved too. There are multiple ways that information can be communicated that may be overwhelming to a child.
Dr. Ursano: Your primary outcome measures are improved parenting;everything else is secondary. The example where couple interaction may beunsatisfactory is a good one. The parents may be diagnosable and in treatment, but the child still has symptoms. The target is to change the parenting
function, goals, and tasks with the picture that over time you will have a sustained impact on the child. In thinking about the evaluation of this type ofintervention, the sustained impact on the child is the one thing you are goingto evaluate. Everything else becomes a secondary hypothesis. Your primary
question is going to be how they are able to make parental decisions. Yourevaluation might include scenarios that assess parental decision-making. Do
the parents talk with each other about a particular problem? Is there a change
from beginning to end where initially, they do not talk to one another but inthe end the two parents are talking? In the end, they may not be able to talkabout anything else, but they are able to talk about this particular problem fortheir child.
LTC Schneider: It is the demonstrated capacity to do these things together as good parents.
Ms. Williams: Regarding connectivity, the person that you bring into
the fold (i.e. a parent surrogate) should maintain that connectivity as well.
Workgroup on Intervention with Combat Injured Families — Conference Proceedings • 107

Sometimes, the injured
service member feels that
he is a second option to hischildren at home. Whenthe children are home and
Mom is out, they call Mom
on her cell phone insteadof asking Dad about daily
things. The injured service
member father then feels
left out. What does thatdo? There are multiple
layers getting involved.

Dr. Ursano: You cannot measure everything that exists. You are goingto have to choose something that is important and it does not mean that you
do not care about the other things.
Dr. Cozza: How do you measure communication? You could do thatfrom the parent’s side or ask if the child knows enough information, too muchinformation, etc. That is an indication of communication.
Dr. Ursano: Does the child know how to make use of available parenting? Does the child feel he/she could go to both parents instead of just one?
There are many indices one could use for those kinds of changes in the systemthat will be present over time. That is the primary focus and it does not mean
the others are not important or secondary outcomes.
Dr. Lester: The other piece is parent-child communication. In ourfindings, this issue of parent-child conflict is critical in terms of child outcomes and is something that a parent’s traumatic stress symptoms seems toinfluence. We think a lot about teaching parents and children how to resolve
conflict and how to communicate more effectively about their emotional life.
Several skills are involved with that.
Dr. Ursano: We need to make sure not to confuse interventions withoutcomes. Interventions can be very broad and outcomes can be very narrow.
They are not one-to-one.
Dr. Cozza: The capacity for conflict resolution or the capacity for conflict avoidance might be domains of an outcome. It is the idea that parents
need to know that this may not be the best time to scream at their kids overthe phone in Arkansas because they are not unloading the dishwasher. Whatis a good measure of that? It is a sense of connectivity and it is the amount of
information and quality of information that gets passed.
Dr. Arata-Maiers: We should not focus only on the parental side. We
need something in here from the child’s side.
The younger the child is, the more often they need to be encouraged toverbalize when they get to be older.
Dr. Cozza: It would be nice to structure a strategy around daily checkins between parents and child. It reminds me of a discussion with Trisha aboutchildren diagnosed with HIV and helping them find ways to ask the questions
that they need to ask. How could the parent or the parent surrogate encouragethat in a child? The child may need to write it down or need help asking thequestion.
Dr. Lester: The activity creates a structured and safe way for children
to communicate. Children can engage in the activity because it is an activity
outside of them. We are not just asking them to talk about their feelings. They
are actually describing what worked, what did not, what was hard, and they
are doing it in this very active way.
Dr. Cozza: That is an intervention strategy. If you are putting out information, how do you help parents help their children to ask some of thequestions that they need to ask?
Dr. Lester: There is a great deal of information about helping children
label feelings, talk about their feelings, etc. There is psycho-education for parents. It is important to give them ways to do it that lifts it off the paper.
Dr. Chun: Often children in this situation do not want to burden theparent. Even younger children do not want to call Mom or Dad to talk about
how upset he or she feels when they are away from home. We need to look108 • Session 3: Integration and Programmatic Intervention

The concept ofcommunication can belooked at as a strength
model. The family canbuild a story around what
has happened to them, astory that they understandas a family and one thatincorporates everyone’s
understanding. Then, they
can communicate that toother people.

at ways to encourage that kind of a communication. Sometimes, the injured
service member feels that he is a second option to his children at home.
When the children are home and Mom is out, they call Mom on her cell
phone instead of asking Dad about daily things. The injured service member
father then feels left out. What does that do? There are multiple layers getting
involved.
Dr. Lester: There might be different strategies for a family to choose
from that can work individually for them.
Dr. Cozza: There is communication with a parent and then there are
the unique challenges of communication with the injured service member.
And we may want to just talk about that for a second, too.
Ms. Vineburgh: We are in the domain of communication and thepoint about having a protocol for talking to your children is an importantone. Bill Beardslee’s intervention helps the family build a story. The concept
of communication can be looked at as a strength model. The family can build
a story around what has happened to them, a story that they understand asa family and one that incorporates everyone’s understanding. Then, they cancommunicate that to other people.
Family Meaning and Connectivity
Dr. Lester: This is at the heart of Dr. Beardslee’s intervention. Our adaptation is to create a shared sense of family meaning and experience around a
stressful or difficult event in the family’s life by first regarding the individual andthen bringing the family together.
Dr. McCarroll: How do you help a family to have a meaningful conversation? At a practical and concrete level with measures, you may see if they
can identify problems. Can they set goals? Can they meet a goal? How many
did they do? How many are short-term? How many are long-term? How
many concern the children? How many have to do with relationships? You
can measure many things that go into the elements of making up a meaningful conversation. The key word is meaningful if the goal is a task outcome andyou set it in terms of task as opposed to processes. You may ask, ‘what tasks
do you feel that your family has to accomplish or what problems do you haveto deal with your child?’ You can set those up to have a measurable quantitythat is oriented toward the task and not necessarily toward the relationships.
Although, you would expect the relationship to improve as a result of working
on tasks together.
Dr. Cozza: The measurement could be the successful completion of
establishing of family goals. The idea is communication to facilitate connectivity. The purpose of the communication is to connect people by way of
meaningful conversation, i.e., a family story, narrative, etc. The communication between the injured service member and the child is still an important
challenge for families that we need to reflect on in our discussion. At CSTS,
we have had discussions about goals for military children and having some
capacity to engage the parent and also a connection with the parent. It is thecapacity to recognize and accept the changes in the parent and still realize thatthey are their parent.
Dr. Arata-Maiers: It is important for them to be able to converse
about developmentally appropriate topics beyond the injury.
Dr. Chun: Moving beyond the injury is the core of what we are trying
Workgroup on Intervention with Combat Injured Families — Conference Proceedings • 109

Along with fear, somechildren feel blame; they
feel that they caused
it. This is so unique forthe young children. For
example, there may be alittle boy who says that
because he misbehavedor he did not say ‘Daddy,
be careful’, he caused the
explosion.

to do here. We want to help the injured service member who feels shattered
get back to the role of parenting that is still intact. We hope that this role isstill intact.
Dr. Ursano: What are the four or five topics that you are thinking
about? For example, we have a soldier with a missing leg and a five year-old
child. What should be the communication? What are the barriers? We havethe same soldier with a 14 year-old. In one example, the child is a girl and in
the other, the child is a boy. What is it that we think is impaired and what do
we think should happen?
Dr. Cozza: We can give examples and distill out the core elements. This
was the whole issue with the Sesame Street project. The child’s feelings about
the injury should be validated. For example, Rosita’s father is in a wheelchair
and the character’s response is anger. The producers came up to me and asked
if I thought she was too angry. I said no because that is what you really want
to see because she is angry. It was powerful. A child can feel any way they needto feel about the injury and the parent needs to understand that. Then, thechild needs to be able to resolve it. This gets into the idea of free associations.
It reminds me of Judy Cohen’s balloon exercise. When a parent dies, the childwrites those things that they no longer have and things that you can continue
to have, and then they let those things go with the balloon. Concretely, it is
the ability to give up those things that you no longer have, recognize realistically what you can continue to be able to do, and then be able to integratethat change and move on. The challenge to the child is integrating the parent’s
serious injury.
Dr. Ursano: The case may be that the child was not able to express
their anger during the initial meeting. You see the child at a lighter range ofaffect expression. Afterwards, the parent is able to tolerate and assist. We arelooking for something measurable but also how it looks from the outside perspective.
Dr. Arata-Maiers: Eventually, another aspect may be emotional
modulation when there are extremes of emotions expressed by the child. Another thing we see with the younger children is fear, which keeps them fromapproaching the parent. The child needs to be able to approach the parent. You
want the child to be able to modulate as time goes on so that they can continue
to be in that relationship.
Dr. Chun: Along with fear, some children feel blame; they feel that theycaused it. This is so unique for the young children. For example, there may be
a little boy who says that because he misbehaved or he did not say ‘Daddy, be
careful’, he caused the explosion. There is a lot of self-blame and also, the anger
toward the enemy or the ‘bad guys.’
Dr. Lester: Are there certain pieces of information that the injured parent needs to communicate to the child? Some information could come froman outside person or a therapist and some could come from the other parent.
Are there important aspects that are unique and should come from the person
who has the injury?
Dr. Richters: There may also be anger towards the parent for redeploying. In the case of the very young child and, arguably older ones too, some
explicit acknowledgment of the fact that the children are not to blame for the
injury is necessary. Let them know that there was nothing they could havedone to stop it. If the injured parent is capable and cognitively intact, he or she

110 • Session 3: Integration and Programmatic Intervention

Some children blame
the parent for getting
injured and some blame
the Army or the President.
I know a seven-year-old
who wanted to write
President Bush in every
session and had a strong
opinion. Everything thatwas being said on CNN,
the seven-year-old wassaying in his language.

is the best source for hearing that information. Otherwise, the spouse should
relay that message to the child.
Dr. Ursano: One of the goals could be for the parent to be able to develop an injury narrative to tell their child as a way of opening the discussion.
It is the parent that is going to open this discussion, and therefore the parent
has to develop some ability, skill, facility, comfort, self-esteem, etc. in order tosay, ‘Yes, I lost my leg…and sometimes kids feel…’
Dr. Cozza: That gets back to the idea of ‘getting it together’ as a parent
and doing some self-reflection.
Dr. Lester: Is this something that would happen in your brief intervention? Would this need to develop a clear narrative and make decisions about
what to share with the child occur early on in the process?
Dr. Cozza: This would not occur in a single session but it would occur
early on in the process. If there was a parent mastery session, it would be helpful for that to happen with both parents. There should be a capacity to talkwith the child. It allows the spouse and the injured to share the experience
together in a narrative and then decide the appropriate way to share it with thechildren. It requires a certain amount of thinking and processing.
Dr. Ursano: Talking about the injury with children is an entire module for an intervention. You would develop it for different aged children. Thatwould be a core component of the parental intervention.
Dr. Cozza: The goal may be to come up with two or three things thatare important for this child to hear. Communication to the child should be
distilled and processed. The parents need to decide what the child needs tohear from them.
Dr. McCarroll: You need to know what the child wants to hear, as
well as what the child might be afraid to hear and what their concerns are.
There is going to be a domain including what you know how communicate
and a domain of things you may not know how to communicate.
Dr. Ursano: This should be a dialogue, not just a one-way narrative.
Dr. Arata-Maiers: Some children blame the parent for getting injured and some blame the Army or the President. I know a seven-year-old
who wanted to write President Bush in every session and had a strong opinion. Everything that was being said on CNN, the seven-year-old was saying in
his language.
Dr. Lester: There should be a list of topics for the child that is separate
from the parents, otherwise, you are going to run into the things that the childis too afraid to say.
Dr. Cozza: There may be a problem if the child is not present. How can
you direct the parents and their discussions with the children regarding how
much information needs to be shared? Does that need to be determined by aclinician?
Dr. Richters: You may not need to know what the child is feeling or
thinking to make an absolute statement about, for example, the case of blame
or guilt that the child may experience. You should state this in whichever format that is comfortable for them. Feeling guilty and somehow responsible
for the injury can be a normal reaction for a lot of children. It is not always
obvious when the child feels guilty because it can show up in different ways,
or possibly not at all.
There are certain absolutes. The form of the dialogue is different for differWorkgroup on Intervention with Combat Injured Families — Conference Proceedings • 111

The focus of yourintervention is on injury
communication andparenting function. The
list of challenges can be
categorized under these
two areas. Which of these
problems have to do with
impaired parenting andwhich have to do withdifficulties related to injury
communication?

ent children and the child’s family would know the best way to communicate
to the child.
Dr. Lester: If the child is not present, you could ask the parents to reflect on what they feel their child’s experience has been. That is a step towards
that reflection.
Dr. Arata-Maiers: The parents can look at the child’s current behaviors as well as what has been already said to figure out what is going on. Sometimes the child is unable to verbalize what their experience is because they are
so involved in the acting out the behaviors.
Parenting Function and Injury Communication
Dr. Ursano: The focus of your intervention is on injury communication and parenting function. The list of challenges can be categorized underthese two areas. Which of these problems have to do with impaired parenting and which have to do with difficulties related to injury communication?
Problems occurring over time could be their depression, a new medication’sside effects, their inability to throw the ball with their son, etc. You have injury
communication and parenting function with particular sets of problems andstrategies directed towards them.
Dr. Richters: To address parent functioning effectively, they need to
be stabilized and their distress levels need to be controlled.
Dr. Ursano: What creates a very strong focus here is the idea of neglecting certain problems. There is a whole area in brief psychodynamic psychotherapy that has to do with maintaining the focus. How does one focus?
There is a reasonably well-known article that talks about benign neglect inorder to maintain one’s targeted focus on what is your goal. Your goal is parent functioning and injury-related communication. What causes problems inthese areas and which strategies can alter these?
Dr. Arata-Maiers: Many challenges fall under injury communication between the service member who has been injured and the child. We
should also consider issues around the child communicating with individuals
outside of the family including their teachers, peers and friends.
Dr. Richters: We discussed preparing the child on how to react whenpeople ask about their injured parent.
Dr. McCarroll: You could construct a number of 2 x 2 tables. One
axis lists what the injured service member wants the child to know and what
he or she does not want the child to know. The other axis lists what the childwants to know and what the child is afraid to know. In each of the four boxes,
you would have targets that would be fairly easy to talk about. An easy one
would be information that the service member wants the child to know andthat the child wants to know.
It can become more complex though. Does what the service member does
not want the child to know conflict with what the child wants to know and if
so, how do you resolve that problem? This could join injury communicationand some aspect of parent functioning because if you do not address the elephant under the table, as they say, you are going to have an issue that is goingto go unresolved and may impede some aspect of functioning.
Dr. Ursano: During a parent assessment, you would be able to ask theparent what things they want to tell their children and what things they are
too frightened to tell them. What are the things that they probably want to112 • Session 3: Integration and Programmatic Intervention

We would like the parents
to acknowledge thata difficult thing has
happened and that they
may be worried or sad but
as a family, they will get
through it and will be okay.
It takes some work on theparent’s part to get to thatpoint.

know? What are the things they are frightened to know? That would create aninteresting grid between parent and child for a targeted focus.
Dr. Cozza: The intervention is reworking the boundaries because
sometimes the child wants to know information that a parent may be afraid
to talk about. The parents need to be reassured that this could be informationthat the child should know. They may need to switch to a different box whenboth the parent and the child can handle it.
Dr. Chun: We are getting quite a few injuries that are not only accidental but also self-inflicted. Some feel that a parent cannot tell a child about what
happened and some parents want to maintain a certain image of their father
being hero even when it is not a heroic battle injury.
Dr. Lester: There may be child-driven reasons for not sharing a lot of
information. We think secrets are bad and that it is better for families to talkbut on the topic of HIV disclosure, studies showed children actually did worsein the initial year after being told about their parent’s HIV illness. Children
who knew their own HIV diagnosis were not necessarily doing better thanthose who had that information withheld. When we are providing guidance,
we have to consider how parents make these complex decisions based on theircommunity, their cognitive styles, their child’s impulsivity, etc. There may betimes when the children are told too much.
Dr. Cozza: Parents may even have the child look at the amputated leg
in order to accept the reality of the injury. We have seen parents who have told
their children nothing and brought them to the hospital to introduce themto the injury without words. This could be a parental anxiety response. The
parent is unclear about how to inform the child. The parents need to digest
it and go through the important process of reflection first. We expect parents
to organize the experience in some capacity for the children and model thatorganization. We would like the parents to acknowledge that a difficult thing
has happened and that they may be worried or sad but as a family, they will
get through it and will be okay. It takes some work on the parent’s part to getto that point.
Dr. Lester: This is the beginning and the initial meetings will hopefullylaunch the family towards a series of conversations.
Ms. Kaul: A statement of the intervention should assess the communication norms and keep with the core principles of the family culture. The
norms may be to talk less about very unpleasant things or to be more protective. We need to assess what they do in a normal situation and see how that fitswith the current issue. How do we really help them without taking them so far
away from their norms?
LCDR Kane: I would use the words values in that case.
Dr. Cozza: If the family’s culture is not to talk about anything, we want
to respect that as their norm but we also want to help them to recognize that
under difficult circumstances, it may put them at greater risk. You have to understand where the family is coming from and where they are.
Ms. Kaul: You may pace your intervention accordingly. We should ask
about their communication norms in the beginning.
Dr. Ursano: We have to organize the information into baseline versus
change. We might measure present family communication and then see how
it changes afterwards, both in content, process and competencies.
Dr. Cozza: To switch gears, the parental reflection idea relates to theWorkgroup on Intervention with Combat Injured Families — Conference Proceedings • 113

A major goal here is thecapacity for self-advocacy.
We expect that this is a
population whose needs
will continue in a larger
sense than the averagefamily. It is the idea ofrecognizing the importanceof being able to engage thecommunity in appropriate
and effective help-seeking
and self-advocacy.

intervention of the PGAI. It is about having the parents think about what
has happened. What has the child’s experience been? How do you understand it? What has it been like for you? How do you figure out what to say
to your child about this? It is an attempt to help the parent organize theexperience in preparation for effective parenting. The parent should also besensitive to the child’s cues. This involves the idea of injury communication
as a method of thinking and developing principles of injury communication
as we consider what parents should or should not share. It is a nice integration of issues. For the extended intervention, we shift towards the protocol
for when the child comes in. We now have the opportunity to develop an
injury narrative.
Dr. Arata-Maiers: Families come to us at different points in the recovery process. They may have already gone through some of these initialaspects. We have to assess where they are and may want to move immediately
into the development of the narrative.
Dr. Cozza: It would be helpful to look at transition and long-term impact. We are now talking about longer term goals when the children, parents,
and the family return to their communities post-hospitalization. One goal is
to maintain the connection to resources and support.
LTC Schneider: Another goal may be for the family to feel competentin their ability to deal with injury communication and parenting challenges
as they change during the post-hospitalization phase. Can they demonstrate
the capacity to utilize the set of communication skills learned while in thehospitalization phase of the injury? In the hospital, the parents practice how
to talk to their three-year-old about the fact that his father lost his leg butwhen they return home, depression may get in the way of that. The parent
may ask the question, ‘how do I communicate with my child about impact
of my depression and how do I continue to parent effectively?’ If we can help
them to continue to communicate effectively post-hospitalization, then we
have succeeded.
Dr. Cozza: The goal is to continue to effectively communicate withchildren and relay adequate amounts of information.
Dr. Newby: There is a systems response providing a continuity of careto ensure family functioning over a long period of time or after the familytransitions, for example from active duty status to civilian status. That seems
to be incorporated in the elements here.
Dr. Cozza: A major goal here is the capacity for self-advocacy. We expect that this is a population whose needs will continue in a larger sense than
the average family. It is the idea of recognizing the importance of being able
to engage the community in appropriate and effective help-seeking and selfadvocacy.
Dr. Arata-Maiers: The process at BAMC can take years actually. They
are in the hospital for anywhere from a couple of weeks to a year or more, andafter that they may remain on post and go to the hospital nearly every day for
another period of time. After moving out to the wider community, they still
visit the hospital to get their medication. Then, they may be VA or go back toactive duty. This can be a very long process and there are going to be different
needs of varying intensities over that time. Self-efficacy is important but there
is also specificity to it.
Dr. McCarroll: They carry those principles of self-efficacy with them

114 • Session 3: Integration and Programmatic Intervention

The fact is that most of theamputees demonstrate
war resilience. Most of
the amputees at Walter
Reed, when they can,choose to wear shorts. It
is a badge of courage. It
demonstrates the ability
to overcome the injury.

and they are sort of independent of the conditions.
Dr. Arata-Maiers: As time passes, their issues become more related
to the larger community versus the family. Part of the self-efficacy needs to bearound negotiating and interacting with the community.
Dr. Lester: Are there interventions for injured service members without children, which would help support those long-term rehabilitation goals?
There are goals for everybody who has been physically injured and transitioning back to the community. Case management becomes important in helping
ease the transition.
Dr. Arata-Maiers: There are people who negotiate those pieces forthe service members, for example case management personnel or Defense
and Veterans Brain Injury Center.
Dr. Cozza: There is system interest in maintaining continuity of careand we should also look at the family aspect of that. Relapse prevention activities are of importance to the family. This may move towards another goal.
This may not be part of the formal intervention because it does not move into
the sustainment phase but the development of a narrative is something for VA
colleagues to think about. A sense of family continuity pre- and post-injury
is very important. It may be helpful to describe experiences before the injury
or deployment. What has happened and where are they now? Are there waysof identifying threads of continuity that give the family a sense of integrity?
That is a concern.
LTC Schneider: That is a great idea for a Department of Defense-Veterans Administration grant.
Community Reintegration
Dr. Arata-Maiers: When the injured service member re-integrates
into the community, the community reacts positively or negatively to seeing
the injured person and the family is aware of those reactions. If the father goes
into the school setting, the child may experience concern about him meeting
his/her friends. There needs to be communication and a consideration of thedevelopmental aspects. How does the family navigate through the community
system and when the community responds, how does the family handle theresponse?
Dr. Ursano: We discussed the hospital discharge and the concern
about caring for the injured soldier and the anxiety over the caregiver burden.
It is important to consider the transitions of care giving that fall on both theadult and the children. The child indirectly experiences the care giving of the
injured parent and may possibly participate at times. How can we effectively
manage this burden?
LTC Schneider: The fact is that most of the amputees demonstrate
war resilience. Most of the amputees at Walter Reed, when they can, choose towear shorts. It is a badge of courage. It demonstrates the ability to overcome
the injury.
LCDR Kane: We could include this injury situation in the developmental roles of the parent and children and look at how the family accommodates
for the physical limitation of the injured member. The long-term goal is being
able to adapt and accommodate with this new injury and accept that it has
become part of the family: we can make it a visible part; we can look at it; we
can talk about it.
Workgroup on Intervention with Combat Injured Families — Conference Proceedings • 115

An individual with adisfiguring injury is going tohave to deal with the shock
people may experience andcommunicate throughout
their life. Whereas theamputee may put on apair of pants and a lot of
people may never realize
the extent of the injury. TBI
involves primarily the family
who must deal with the
injured parent’s potentiallyinappropriate behaviors
in public. These are all very
different types of challenges
specific to the injury of theservice member.

Dr. Newby: It has to be incorporated into the community and reflectedin the services that the community provides. With a lot of soldiers comingfrom rural communities and communities that don’t have a lot of services, it
is really important that we consider that.
Dr. Arata-Maiers: It is not just an issue of adjusting to the limitations; it is the changes. It is not just what they cannot do; it is the fact thatthey look so different than other children’s parents, or the parent they used tobe. Parents who have burns that you cannot see have different issues within
their families than those who have visible burns. Sometimes it is easier thatthey are visible. There are a lot of issues around the change and not just thelimitations.
Dr. Chun: It may apply to TBI, too, because it is often unseen.
Dr. Cozza: Remember this thinking is from the health care system perspective and not the community at large. What are the issues either just predischarge or within the receiving health care organization that would assist
with some of the challenges faced by the family? What would be the strategies
to facilitate a sense of comfort and belonging in the community and to manage family care giving burdens?
Dr. Chun: We could stay on the theme of injury communication.
LTC Schneider: If a service member has a disfiguring injury and theirfamily comes together, their story becomes an example of how you can deal
with this experience. An individual with a disfiguring injury is going to haveto deal with the shock people may experience and communicate throughout
their life. Whereas the amputee may put on a pair of pants and a lot of people
may never realize the extent of the injury. TBI involves primarily the family
who must deal with the injured parent’s potentially inappropriate behaviors
in public. These are all very different types of challenges specific to the injury
of the service member.
Dr. Ursano: The challenges in the transition show up in the categories
of parenting function and injury communication. What is Johnny going to tellhis best friend next door about his parent’s injury, and how has the parent noticed that or addressed that? What are the child’s challenges that the parenting
function should be dealing with at that time?
Dr. Richters: It is helpful to have the two bearings of parenting function and injury communication because they tell us when we are venturing
beyond reasonable intervention goals. In order to help them in this transition
phase, we would give them a layout of the land and show them the kind ofthings they will be facing in some form or another including the potential
reactions of other people. The child deals with the reactions of their friends
after seeing them for the first time since their parent has returned home. Beyond that, the injured parent is exposed to the public and people’s reactions.
We need to forewarn them about the things they will be going through. Helpthem to think about the types of things they are going to experience in advance and guide them through some strategies.
Dr. Cozza: There is this idea of self-efficacy within the injured population. The strategy would be getting parents to ask for help based upon the
injury’s effect on the family who may have been completely self-sufficient in
the past and pre-injury.
Dr. Arata-Maiers: One of the major things you see happen to TBI
and burn patients is social isolation due to exhausting care giving responsi-

116 • Session 3: Integration and Programmatic Intervention

Remaining culturally
minded, military families
often pride themselves on
their self-sufficiency. They do
not necessarily like seeking
out or demanding things.
It is important to develop
or shift the model fromone of dependency to selfsufficiency or self-care.

bilities and fear over how the TBI or PTSD patient is going to behave. Whereas
for the burn patient, it would be fears about how the community will respond.
Part of the focus needs to be to help the family avoid social isolation.
Dr. Cozza: Some of this is psycho-educational. It is identifying familysocial isolation.
Dr. Lester: It is reactivity to reminders and relapse risk as they are engaged in health care systems. We do a lot with our medically ill moms about
assertive communication skills with providers and systems of care and accessing support. There may not be room or time to do that, but they seem to geta lot out of it.
Dr. Arata-Maiers: With this review, you might want to add communication with schools and other institutions about parenting and child issues
related to the injury.
Dr. Cozza: Remaining culturally minded, military families often pride
themselves on their self-sufficiency. They do not necessarily like seeking out
or demanding things. It is important to develop or shift the model from oneof dependency to self-sufficiency or self-care.
Dr. Arata-Maiers: One woman that we worked with said people havebeen asking her for months if they could help and by the time she realized sheneeded help and was ready to accept help, they stopped asking.
LTC Schneider: For most injuries, it is going to be about overcoming
and adapting to the injury. In the case of severe and moderate to severe TBI
patients, we have to focus more on the other parent’s management of the injured service member.
LCDR Kane: We have not discussed when a parent dies. There is grief
and a great loss. Our group is focused on injuries that are recoverable and allow the injured individual to regain parenting roles. For example, you talked
about an earlier goal that the child will recognize the parent and see this rolein them. Much of that has to do with clear cognitive abilities. When you talkabout the impact of TBI, the service member is not who he used to be. It isdifferent and you might think of it in the area of grief and loss as opposed tothe service member being able to return to the developmental pathway that
had been there before the injury.
Dr. Arata-Maiers: Grief is a large part of the whole process. Unlessthey are regaining full functioning, they are losing certain abilities that may
impact the parent functioning. Some abilities may never be regained, whether
it is cognitive or physical, so there must be an adjustment to those losses.
Dr. Ursano: Sometimes also, the issue about not focusing on the child’s
symptoms. A child’s depression might be a very appropriate outcome. By focusing on the child’s symptoms or targeting attempts to change the child’s
symptoms, you may miss the fact about whether or not they are being appropriately managed and parented. Depression would be very appropriate forthat study.
Dr. Chun: When the parents allow their children to do socially anddevelopmentally appropriate things like sleep over at a friend’s house or havefriends over to their house, they are maintaining social and developmental
norms as a family.
Dr. Cozza: It is that continuity and shows that not everything haschanged. There are still some things that they have that they had in the pastand those can be sustaining. This is also related to marking holidays. Holiday
Workgroup on Intervention with Combat Injured Families — Conference Proceedings • 117

What about the adolescentwith a parent who lost a leg
who goes home and their
response is to drive fast or
to drink as a way to ensure
their own sense of integrity
and their sense of strengthand power?

traditions, celebrating birthdays are things that are a normal part of their family life and they are not giving those up. Those are deployment based issues. It
is the idea of regularity to life that is reassuring.
Dr. Ursano: Taking that to the picture and next stage of adolescence,
the idea of anticipating problems comes up. What about the adolescent witha parent who lost a leg who goes home and their response is to drive fastor to drink as a way to ensure their own sense of integrity and their senseof strength and power? The goals should include this picture. We should be
anticipating both the challenges and the times when help may be needed sothat there is knowledge about future child developmental responses. What isgoing to be measured that indicates the intervention itself had done what it
said it was going to do; not that it cured all of life, but that it carried this one
issue through?
Dr. Cozza: The way I am viewing this is to inform our thinking earlier
on. This could turn out to be important information for families. It may not be
part of an intervention, per se.
Dr. Ursano: You could track how often the parents access your email
information system afterwards. This could be a way to see whether or not theytune in every six weeks and whether or not they respond to your communications to them with boosters.
Dr. Richters: At this phase, we are not giving them a fish dinner; weare teaching them how to fish. All bets are off once they leave the hospital.
We can follow-up and make contact, but this is our last certain chance to arm
them with certain proactive skills.
Outcome Measures
Dr. Ursano: Brainstorming about possible measurements will keep us
targeted, so what would you measure six months later? As John said, life goeson. There are many things that will happen in the next six months that you did
not anticipate, plan for, and that were not involved in your intervention, butwhat piece do you think might be sustained six months from now? It is notgoing to be symptoms, it is not going to be ‘life is great,’ and it is not going tothat finances are good. What might it be? It might be parental communication
about child problems. It might be that they have a new way to talk about what
the present injury problem is.
Dr. Cozza: It could be the development of discharge goals. Threemonths later, you might call them to check in.
Dr. Ursano: Ask how the first PTA meeting went.
LCDR Kane: Ask if they are still talking at dinner each night.
Ms. Vineburgh: The family story concept gives the family a sense of
self-efficacy with the knowledge that they can construct their own story. The
categories of injury communication and parenting function are defined in alanguage that can be shared. They both provide a metaphor for a family but
they give some structure to their own measurement. Are they communicating
well? Is the communication meaningful to the injury? The idea of the parenting function is a self-alerting mechanism and is an ideal. We have createdsome language that could be very adaptable to public education.
Dr. Ursano: An assessment can include general items and family specific items. There would be an injury communication score with seven generic
items and three items developed for the specific family and their unique chal-

118 • Session 3: Integration and Programmatic Intervention

It is not the narrative itself.
The narrative is merely anindicator that a process
has gone through. If you
are going to measuresomething, you have got
to measure that piece,
not the narrative. The factthat the family developed
the narrative is not theoutcome.

lenges. Similarly for parenting function, there would be a total of ten items.
Seven are generic, defining the usual problems, and three are very specificto what you have learned about this family. Then, they score themselves onthat. It becomes both a booster shot, as well as an assessment as to how are
they doing in these areas that again is focused to the intervention. Are they
remembering this particular area, which is unique to their family as an injury
communication problem? Are they remembering this particular issue of parenting function that their particular family has problems with, and how dothey score themselves on a scale of 1-5, on each one of those?
LTC Schneider: It would be good to have a module that includes anarrative with the whole family, and in one session you could look at the outcomes and see whether the family came together to share the narrative. It is
important to have the whole family share in the development of the narrative.
It helps to overcome the isolation that the service member feels about the
injury; being something that he went through while his family was not there
and therefore they cannot understand it. It could be seen as a copout to say,‘you were not there so you cannot understand it.’ It is important to encourage
people to develop their own story as a family unit.
Dr. Ursano: It is an operational outcome. I am a little concerned about
too much focus on the narrative itself because there are many studies thathave looked at that. Many adult studies have looked at whether an individual
is able to develop a cohesive picture of their illness, their disease and theirlife, and if that predicts better outcomes. The answer is, it does not. As a psychoanalyst, I have a big investment in that process, but it is not the goal nor
the mechanism nor the outcome. That happens to be one of the sidebars. The
outcome may be that there is a decreased avoidance that has occurred. It is not
the narrative itself. The narrative is merely an indicator that a process has gone
through. If you are going to measure something, you have got to measure thatpiece, not the narrative. The fact that the family developed the narrative is not
the outcome.
Dr. Cozza: We are seeing the narrative more as a strategy.
Dr. Ursano: It is an integrated way of pulling together your interventions.
LTC Schneider: Does that strategy facilitate improvement in that particular outcome goal of reducing avoidance?
Dr. Lester: The narrative allows you to hang on to some of the skills
that would appear to be irrelevant to a family unless they are revealed as connected to their issues. It is a strategy. If you are going to teach emotional regulation skills, which reduce stress, it is better to do it in a way that appears
relevant to the family.
Dr. Cozza: Returning to the categories of Parent Function and Injury
Communication, have we identified a third one around the idea of self-advocacy? It goes beyond parent function. It is a family function and the expectation that the families should be able to care for themselves in the future inspite of the injury. It is a matter of the child asking the parent for help appropriately when needed. It is the parents who recognize when they are running
into trouble, and seeking out health services appropriately, rather than engaging in risk behaviors such as alcohol misuse. Again, it is a family function andfamily self-efficacy within the community and not just within the medical
environment.
Workgroup on Intervention with Combat Injured Families — Conference Proceedings • 119

We should arm themwith skills that encouragethem to anticipate andapproach future challenges
in ways that are healthyand successful as opposed
to breaking down into
substance abuse, repression,
denial, family conflict, etc.

Dr. Ursano: The family function might fit with the idea related to theway the family is operating.
Dr. McCarroll: How about the idea of self-surveillance or self-monitoring as tools? Would you construct a method that most individuals could
use to monitor themselves and their functioning? You could probably extend
that to the family, as well.
Dr. Ursano: Nearly all family measures are means of asking the child,asking the parents, and then adding it all together. The only place where that
may not be true nor possible is where you actually videotape the interactionsof the family.
Dr. Richters: We have done some diagnostic work with young children and the discrepancies between parent and child reports. They are notorious for their disagreements, but it turns out that a lot of them are not reallydisagreements. We interviewed some of the kids independently in a room fora section of the DISK (Diagnostic Interview Schedule for Kids), and simultaneously one of the parents in the other room was going through the samequestions about the kid. Then there was a debriefing session, and often thechild would say that she did not have symptoms, and the parent would say
she has a great deal of symptoms. Although they actually agreed during thesession, they disagreed in their individual reports. You had to know what wasgoing on. There appeared to be a lot of disagreement, which is probably whysome people have gone to these composite measures that are psychometrically more reliable even though they do not tell you anything. For the kinds ofthings that an intervention has to confine itself to, the only outcomes that we
could reasonably rely on would be much more objective.
Dr. Cozza: Maybe it is family problem solving instead of family efficacy. It is an important idea to include because our biggest concern for thesefamilies is what happens to them when they leave the health care setting. We
should arm them with skills that encourage them to anticipate and approach
future challenges in ways that are healthy and successful as opposed to breaking down into substance abuse, repression, denial, family conflict, etc.
Dr. Ursano: The type of measurement that comes to mind is to ask
the family to solve a medical-related problem. You could videotape the interactions and derive scores based on certain questions. Did the family communicate emotions about the event? Did the family communicate negative
emotions about the adventure? Did the family problem solve about the event?
Were they able to express varying emotions about different topics? You would
try to also get a sense for the flow of the session. Then you would somehow
score the family on their responses. That brings up the measurement issue.
Measurements for this do not exist.
Dr. Cozza: It could be done in a way to determine whether they followed up with their health care provider three months later. What type ofproblems with continuity of care and compliance did they have? What werethe challenges related to community reintegration? They may look at a list ofcommunity reintegration challenges and tell whether they occurred in theirown experience, and how and in what way they managed those specific challenges. We want to get a sense for how they tackled the real problems.
Dr. Ursano: You could certainly look at what they accomplished, what
the tasks and problems were, and how they did it. Did they do it through family function? Did they do it through one parent who was shown to be capable

120 • Session 3: Integration and Programmatic Intervention

One of our roles could be
to assess their risk before
they leave the hospital.…
This assessment would bebased on our evaluation of
how they went through thehospital stay, their progress
throughout, and finally, anevaluation of how well wethought they were going to
do upon leaving.

of handling it? Did they do it through a child who took on that role?
LTC Schneider: Your outcomes are not one-to-one with your families.
Dr. Chun: You can measure the absence of negative outcomes.
LTC Schneider: One of our roles could be to assess their risk before
they leave the hospital. We assessed one family as not being at high risk and we
assessed another family as a minimal concern based on our interaction. This
assessment would be based on our evaluation of how they went through thehospital stay, their progress throughout, and finally, an evaluation of how well
we thought they were going to do upon leaving.
Dr. Richters: Would you then have done a study of clinical judgment?
Dr. Newby: Are there measures of family problem solving?
Dr. Lester: The McMaster Family Assessment Device (FAD) has aproblem-solving scale. There are also reasonable measures of family conflict.
LCDR Kane: We are starting to get into lofty goals and long-term goals
in family function. We are perhaps getting ahead of ourselves. We have a threemonth window, for instance, where a family is going through a very uniquely
challenge experience and we would like to provide the family with resources
and help to get through so that when they look back, they can see that the
military helped them to get through the ordeal. That is a very measurable
outcome. The families can look back at the process and see that they were
included, sending the message that the family is important to the military. In
terms of the outcome goals, we will do better if we focus first on the shortterm things that we are doing here. The long-term will evolve over time. We
are struggling over the measures of our long-term goal because we are looking
ahead, but there are still areas, 1-4, where we have very reasonable, focused,outcome goals that are more applicable to what we are going to get out of this
topic.
Dr. Cozza: The transition out of the hospital is important and is a factor
in the experience that looms large. The question is whether in the short-term,
there is a way to build in certain information to the families in an intervention
that may be useful as they transition. Whether we eventually measure it usefulor not, and regardless of how difficult it is to organize, it is important to prepare the families. We know these families are going to meet multiple challenges upon their transition out of the hospital. It is important to include a method
for preparing the families even if it is a 15 minute conversation or connecting
them with resources that will be useful in the future to address reasonableproblems. Then we can measure the impact of our preparing them.
Dr. Ursano: Is the family self-efficacy a process that you are trying tochange, or is this an intuitive process that you think leads to an end result?
Let us think of the perfect study only because it highlights your question. The
perfect study is to have families randomized so you know they are exactly thesame. You do not have to worry about other pre-variables. They are randomized to different interventions. They have your intervention and they haveanother intervention. One of your outcome measures might be the number oftimes they contact the hospital after they leave. You would expect that people
from your group might have made more contact because they are more effective and they are capable of problem solving, etc. You might decide that wasdue to family self-efficacy. That would be your construct for explaining thisWorkgroup on Intervention with Combat Injured Families — Conference Proceedings • 121

Family self-efficacy might
be the broad construct
and the two areas of
impaired family selfefficacy in this set offamilies are parenting
function and injury
communication.

outcome. The outcome you are measuring is whether they made more followup contacts. Did they make more visits? Were they happier with the outcomeof care? The group with your intervention would be higher than the othergroup. The family managed the problems better, but you would not necessarily measure family self-efficacy. You would be saying that efficacy was the
explanatory construct by which you understood how the parental function
and the injury communication were resulting in a better functioning family
and, therefore, this was your outcome. In contrast, if you want to change family self-efficacy, then you have to be able to measure it during this study. You
have to be able to show that it was there initially and that it changed in the end
after the family was exposed to your intervention.
Dr. Richters: You should be able to show that it was not a measurement of some other component. e.g. parenting function or injury communication, but it was its own measurement.
Dr. Lester: It is hard to know because you would probably do fivethings at once, for example, the education piece, the narrative piece, the skill
piece, etc.
Dr. Richters: If you have a sample size that is large enough and you
have these components organized, you can keep track of all of it if you measure each piece.
Dr. Ursano: Family self-efficacy might be the broad construct and thetwo areas of impaired family self-efficacy in this set of families are parenting function and injury communication. The family self-efficacy may haveanother 10 or 12 components to it. You are targeting these two dimensions offamily self-efficacy as areas that become impaired in this set of families, andtherefore, your intervention is targeted to these. But construct-wise, you arealways thinking of family self-efficacy.
Dr. Cozza: Family self-efficacy may be too broad. It may be more of
the idea of effective problem solving. It is not an injury-communication issue.
You could describe it as a parent function issue but it is not just the parents. It
is the family’s capacity to problem solve. We expect that they are going to facemultiple problems in the transition that are related to the child, the injury, andthe family function, which also impacts the child.
Dr. Ursano: I would be cautious. Remember that you are now launching these people off into the world. There are a thousand variables you cannot control, for example, how many providers there are and where they are.
The idea that the family will be able to solve all the problems that are out
there assumes that the system is functional and consistent no matter where
they go. If you say they are going to solve all of the problems related to theinjury and seeking health care, you are assuming that the system out there isvery good, and the same everywhere. Are they able to solve a problem aroundinjury communication or parenting? Problem solving within parenting function may include how the parents decide how much allowance to give theirchildren or how to decide whether to let them get a car.
Dr. Richters: There is another level of complexity. Suppose you decided to look at ultimate outcomes of how many and what kind of health services
the families seek out. How do you interpret that? Do you use that as index
of how a family is doing because they need to seek psychiatric care or they
may have a child hospitalized? In other words, are those positive outcomesof family communication because they are dealing with problems they might

122 • Session 3: Integration and Programmatic Intervention

It is the idea of preparing
individuals for uncertain
times. It is not just a
matter of telling the family
that they are going toexperience this or thatproblem. We want to help
the family figure out how
to recognize when they
are in trouble and how toapproach those issues.

otherwise not have? They become complex issues and the worst thing to do isto think we can approach them simply.
Dr. Cozza: It may be difficult to study but if we are going to engage inany kind of intervention, there is an obligation to help these families prepare
for what they are going to face. There is an obligation to do this in a way that isevidence-based. How do you construct it and how do you study and measure
it?
Dr. Richters: Those things are easier to think about than what you use
as outcomes. It is a lot easier to get consensus on what components ought tobe in there.
Dr. Arata-Maiers: When the family comes to the point where they
are being discharged and going out into the community, there are three things
that seem to be very important. The first one is that they should have a senseof what is going to happen next in the recovery process. Often, the doctors
focus on the medical things and what is happening right now, and they do notprepare them for afterwards. The parents, who often experience issues lateron, feel like they were never prepared for the other things that occur during
the long-term recovery process. Anticipating what the future is going to be
like is important for them so that they are prepared. The other part is problem
identification. It is helping them to identify problems within the family, knowing that the two-year-old who starts to say ‘no’ all of the time is not related tothe injury, but rather should be identified as a developmental problem. The
adolescent who starts getting angry may be a developmental problem or it
may be something beyond that. We should help the parents identify when thisbehavior is developmentally appropriate and when is the point in time where
they need to seek additional help for that child. Another example might behelping to identify when the father’s drinking becomes a problem to address.
It is the ability to identify the problems as well as figuring out how to masterthem. That is the first step in problem solving. That may be something that you
can do, at least in a psycho-educational way, with families before they leave thehospital. The third part is identifying challenges they might face in the larger
community. How do they interact with the community and what are theirconcerns with this interaction, around the issue of the injury?
Dr. Richters: Given our interests, I cannot imagine a coherent intervention without this component of preparing them for what they are going to
be face in the future.
Dr. Cozza: We need to see if there is a way to consider the model alittle tighter. It is the idea of preparing individuals for uncertain times. It is notjust a matter of telling the family that they are going to experience this or thatproblem. We want to help the family figure out how to recognize when they
are in trouble and how to approach those issues. It might not be a matter ofsolving the problems as much as it is identifying and addressing each of them. I
have two question marks next to that.
Dr. Newby: We might consider fostering resilience to achieve that, in
addition to the notion around problem solving.
Dr. Cozza: We should all agree on the definition of resilience.
Dr. Ursano: Resilience is defined as good parenting and ability to communicate many of the problems.
Dr. Lester: It might be the ability to anticipate and problem solve.

Workgroup on Intervention with Combat Injured Families — Conference Proceedings • 123

As a result of this meeting,the group agrees that there
is a core set of principles
that should guide theintervention with injured
families. We need to be
thinking about family
communication, the healthof the family and its impact
on the injured service
member, etc.

Closing Comments
Dr. Cozza: For those who have survived and stayed the course, yourcontributions are appreciated. A great deal of information has been exchanged,
and it will be tremendously helpful to us. Our plan is to organize this information to clarify core principles with feedback, and to distribute them as acomprehensive list of consensus core principles. Understanding how we willdevelop the intervention around guideline-specific strategies will be an iterative process. We need to understand guidelines in a construct that generally
informs the population, and in a way that helps us to define a specific intervention that can be studied and evaluated using measurements.
Now there is an opportunity for final statements.
LCDR Kane: Is the PGAI, which we are using at Walter Reed, ready to
be rolled out? Is that something that a clinician might use to be able to do a
one-time assessment to inform what is going on? We will look forward to the
FOCUS-oriented module program that will be piloted at some point. I also
look forward to presenting the ideas here to Captain Klam outlining the sortof things we could do for a one-time intervention and then a modularizedintervention. He will want to know what level person to hire to do these typesof things if we’re going to implement these ideas, which can be stratified beginning with a one-time intervention. So, how do we operationalize all of this?
How do I help the Navy to start incorporating our ideas?
Dr. Ursano: There is nothing to implement yet. There are some principles of guidance on how to provide care and that is what one can communicate. There is nothing here that says what to do or how to do it. There is nothing here that says this works or this does not work. One can communicate
about this wonderful discussion, which indicated core principles that we need
to be sure are present in our ongoing programs. In talking to Dr. Klam, one
might want to ask if parenting function and injury communication challenges
are being addressed. The Workgroup is working on formalizing techniques toaddress and measure these challenges to be sure that interventions and programs can help. Those are important issues and they ought to be at the core of
our thinking about our providing care. We should look at our present treatment programs to see whether or not we are addressing parenting and injury
communication.
Dr. Cozza: As a result of this meeting, the group agrees that there is acore set of principles that should guide the intervention with injured families.
We need to be thinking about family communication, the health of the family
and its impact on the injured service member, etc. There is a challenge for the
person on the ground in terms of using that information. That is a strategic issue. There can be some leveraging at the medical center level to see how otherpeople are using the information. It is a tool for the executive at the health carefacility site to be able to organize a response.
Dr. Ursano: “Tool” is being used metaphorically. It is a concept.
LTC Schneider: It is similar to the level of the DSM. It is an organized
way for us to be communicating in the same way about the issues and asking thesame kind of questions. The PGAI offers some guidelines and it is a tool in thatway. It helps us all to be looking at the same issues and thinking about it withthe same focus in mind but it is not an intervention with outcomes.
Dr. Ursano: The other thing to ask your colleagues is whether there arethings that our focused ideas of parenting and injury communication do not

124 • Session 3: Integration and Programmatic Intervention

You have taken aknowledge base andincorporated it into childclinical thinking. It does
not represent all of theclinical thinking, and it is
not meant to be the only
thing collected.

address and if there are dangers in this. What do you think has been forgotten?
Dr. Cozza: Returning to the PGAI, there is an interest in incorporating
concepts about strength, and developing core skills in families. We also wantto predict family challenges. The instrument may be modified as we develop abetter understanding of the problems.
Dr. Lester: Do we feel comfortable with somebody using it without
training for how to respond to a family? It is a detailed, structured interview
that seems to elicit a comprehensive summary.
Dr. Richters: Currently it is an information-eliciting interview, which
has no built-in guidance even though it is used clinically.
Dr. Lester: There is guidance woven into it. The question is whether
you would hand it to somebody and feel comfortable that they would be able
to use it effectively without information about how to respond and give feedback to the family.
Dr. Ursano: Training is an important part of implementing the program.
Dr. Arata-Maiers: Is utilizing this instrument in and of itself a program? At Brooke Army Medical Center, we are working with clinicians who
have a certain level of clinical skills and a knowledge base. We are orienting
them to the instrument and preparing them to respond to the potential tangents from the interview. These are clinical trainees under supervision so they
always report back to supervisors. We are setting up an organized context inwhich they use it.
LTC Schneider: We have the ability to collaborate with the other institutions and utilize what is available now. Most people who have used the
PGAI have seen some value. The PGAI is not yet developed at a level where
it will provide certain outcomes or a sense of security in knowing what will
come from it, but that does not mean it is not useful.
Dr. Ursano: Someone may come back one year from now to say that
we instituted and supported the development of a program that in fact totallyneglected Z and we now know that Z was the most important component ofintervention for injured soldiers. We should be careful about that even if it isbenign neglect. You have organized concepts that a group of thoughtful clinicians have indicated as important to review programs for. Each group needs
to have its own thoughtful clinicians to think about where the instrument
works, where it does not work, where its holes might be, etc. because it is not acomplete tool. We need to be cautious.
Dr. Cozza: This came up in our discussion yesterday as an encouragement of the use of this, or a similar approach within the context of development to understand how effective it was.
Dr. Ursano: You have taken a knowledge base and incorporated it into
child clinical thinking. It does not represent all of the clinical thinking, and
it is not meant to be the only thing collected. It supplements the usual assessments done on this population. You are advising clinicians to think about
these things and that is different than instituting a program.
Dr. Cozza: It is just a way of organizing thoughts in a useful way whentalking with the spouse. We might make the PGAI available for a clinician at aparticular site, and within the context of their clinical programs, they can decide what is helpful and how it could be integrated into the way they do theirWorkgroup on Intervention with Combat Injured Families — Conference Proceedings • 125

The reason why someinterventions, which
are shown to beeffective in testing, nolonger work is because
there are importantcomponents that enable
the intervention to workin one setting but not in
another.

work. They can decide what is reasonable. There is agreement that this is going
to be an iterative process and there may be changes. It is not an evaluated instrument. In terms of clinical experience, we found that spouses find it helpful
to be given the opportunity to speak about their experience. It is a way for theclinician to organize their approach with spouses so that they cover important
areas related to child preparation, child education, psycho-education, etc. The
next step is to address any pieces that are missing from the instrument.
Dr. Chun: We have to use qualifiers because this is an interview guide.
Dr. Ursano: When the PGAI reaches Camp Lejeune, and it is administered by the Sergeant who just came back from Iraq, to the wife of an injured
soldier, will it collect reliable information and lead to appropriate interventions? When it reaches Fort Stewart and is administered by the 91-G in theoutpatient clinic to the soldier who is there in medical care, and his spouse,
will it generate accurate information and lead to accurate interventions? Thisis the way a program needs to be and that has to do with training and who isqualified to do it.
LTC Schneider: The SCID (Structured Clinical Interview for the DSM)
had important study components to it, but was it good for everybody in every
situation, and can you roll it out and have everybody do it? You cannot.
Dr. Ursano: The SCID actually had an advantage over the PGAI. The
proposal of the PGAI implementation requires high-level skills in the assessment.
Dr. Lester: I train child psychiatrists, and given that they do not haveexperience with this, I would be worried handing that interview to trainees.
They may not know what to say or what to do with the information. Do they
have the developmental knowledge, though, to respond to parents about someof the developmental issues?
LCDR Kane: It requires somebody who has this knowledge to supervise
them.
Dr. Arata-Maiers: These are very legitimate concerns and we need toaddress them, but there is a danger that these concerns stagnate and prevent
us from responding clinically to the patients we have. Some families will end
up gathering information from outside of the healthcare and military community, perhaps from individuals who have even less experience dealing withthe family challenges. Their health needs may not be addressed adequately
because help is not coming from knowledge or evidence-based interventions.
We currently have patients coming in and we have to respond to them clinically. How do we do so in an informed fashion until we move this intervention further along? One possible answer is to make sure that our principles
correlate with our developing interventions. I do not want to lose sight of thereality that we will continue to treat combat injured families and we need to
improve our response to them.
Dr. Ursano: We should remember that what is being built is something that will require resources and support from the environment aroundit in order to function. If you were to take what you have designed and you
moved it to Fort Huachuca, Arizona, the presence of additional support services for injured people changes dramatically compared to what exists at Walter Reed Army Medical Center, Brooke Army Medical Center, and Bethesda
Naval Medical Center. Would you expect the same outcomes? The resources
provided by the surrounding community relates to whether or not an out-

126 • Session 3: Integration and Programmatic Intervention

This needs empirical
study to define when,
under what conditions,
how given and in whatways can interventions
on parenting and injury
communication help,
or in some cases impair,
restoration of family
function. The system
requires a definition
around which thisparticular set of lenses or
flashlights may be helpful.

come is possible. We were talking about the question of looking at long-term
outcomes in one of the interviewing variables and whether or not this type ofintervention will have any impact on certain other variables. What happens
when you put a person in a setting in which they have no access to care, no car,and nobody is available to help them with it, and by the way, many in the community are not sympathetic to anyway? The reason why some interventions,which are shown to be effective in testing, no longer work is because there areimportant components that enable the intervention to work in one setting but
not in another. Not only do you jump over evaluation, you jump over the stepto generalization. You have yet to show its effectiveness when you generalize
it to other places. You have to show that it works somewhere before you caneven assume that it might work everywhere.
LTC Schneider: The PGAI is really just like a flashlight. It allows us
to shed a little light on the situation and see where we are going. Now we aremoving on to the next phase of trying to figure out what we saw in the dark,
and bring some clarity to that without stepping in the trap.
Dr. Ursano: It is a generic issue, but it also has some specificity. If wehone to it, there are some important pearls to be found. The pearls are theimportance of injury communication and parenting function. The opportunity with the PGAI is to focus on the importance of injury communicationand parenting function. If there is already support for family problem solving
within the family and within the community, then these two issues become
central to family resilience and function. If family problem solving is not present because of family deficit and/or lack of assistance, then injury communication and parenting may be minor contributors to outcome, swamped by thelarger problem solving needs.
Regarding problem solving and family resilience, there is a great dealof help in the system directed towards problem solving in general. So, better defining how assistance in injury communication and parenting can assist
is important. This needs empirical study to define when, under what conditions, how given and in what ways can interventions on parenting and injury
communication help, or in some cases impair, restoration of family function.
The system requires a definition around which this particular set of lenses or
flashlights may be helpful.

Workgroup on Intervention with Combat Injured Families — Conference Proceedings • 127

128 • Session 3: Integration and Programmatic Intervention

Bibliography
American Psychiatric Association. (1994). Diagnostic and statistical manual ofmental disorders, 4th ed. Washington DC: American Psychiatric Press.
Anthony, E. J. (1970). The mutative impact of serious mental and physical illness of a parent on family life. In E. J. Anthony & C. Koupemik, (Eds.), The
child in his family (pp. 131–63). New York: kWiley-Interscience.
Armistead L., Klein K., & Forehand R. (1995). Parental physical illness andchild functioning. Clinical Psychology Review, 15,409–22.
Baker, S. P., O’Neill, B., Haddon, W., & Long, W. B. (1974). The injury severity
score: A method for describing patients with multiple injuries and evaluating emergency care. The Journal of Trauma, 14, 187–196.
Beardslee, W. R. (1984). Familial influences in childhood depression. Pediatric
Annals, 13(1), 32–6.
Beardslee, W. R., & Wheelock, I. (1994). Children of Parents with affective disorders: Empirical findings and clinical implications. In W. R. Reynolds& H. F. Johnston (Eds.), Handbook of depression in children. New York:
Plenum Publishers.
Beardslee, W. R., Tracy, R. G., Gladstone, E. J., et al., (2003). A family–based
approach to the prevention of depressive symptoms in children at risk:
evidence of Parental and child change. Pediatrics, 112, e119–e1310.
Beardslee, W. R., Versage, E., Gladstone, T. R. G. (1998). Children of affectively
ill parents: A review of the past ten years. Journal of the American Academy of Children and Adolescent Psychiatry, 37(11), 1134–1141.
Berkman LF, Syme SL (1979) Social networks, host resistance and mortality: A
nine-year follow-up study of Alameda County residents. Am J Epidemiol,
109, 186–204.
Black, W.G. (1993) Military induced family separation: A stress reduction intervention. Social Work, 38(3), 273–280
Bonnie, R. J., Fulco, C. E., & Liverman, C. T. (1999). Reducing the burden of
injury: Advancing prevention, and treatment. Washington, DC: National
Academy Press.
Bourdon KH, Goodman R, Rae DS, Simpson G, Koretz DS. (2005). The
Strengths and Difficulties Questionnaire: U.S. normative data and psychometric properties. J Am Acad Child Adolesc Psychiatry, 44, 557–64.
Breton, J. J., Valla, J. P., Lambert, J. (1993). Industrial disaster and mental healthof children and their Parents. Journal of the American Academy of Childand Child Psychiatry, 32(2), 438–45.
Briere, J. (1992). Medical symptoms, health risk, and history of childhood sexual abuse. Mayo Clinic Proceedings, 67(6), 603–4.
Workgroup on Intervention with Combat Injured Families — Conference Proceedings • 129

Briere, J. (1996). Trauma Symptom Checklist for Children (TSCC) Professional
Manual. Odessa, FL: Psychological Assessment Resources.
Butera-Prinzi, F. & Perlesz, A. (2004). Through children’s eyes: Children’s experience of living with a parent with an acquired brain injury. Brain Injury,
18,83–101.
Chesnut, R. M” Carney, N., Maynard, H., Patterson, P., Mann, N. C., & Helfand, M. (1999). Rehabilitation for traumatic brain injury. Rockville, MD:
Agency for Health Care Policy and Research.
Christ, G., Siegel, K., Sperber, D. (1994). Impact of Parental terminal cancer onchildren. The American Journal of Orthopsychiatry, 64(4), 604–13.
Cohen, J. A, Mannarino, A P., Gibson, L. E., Cozza, S. J., Brymer, M. J., & Murray, L. (2006). Intervention for children and adolescents following disasters.
In E. C. Ritchie, P. J. Watson, & M. J. Friedman (Eds.), Interventions Following Mass Violence and Disasters (pp. 227–56). New York, Guildford.
Coie, J.D.; Watt, N.F.; West, S.G.; Hawkins, D.; Asarow, J.R., Markman, H.J.;
Ramey, S.L.; Shure, M.B., and Long, B. (1993) The science of prevention.
A conceptual framework and some directions for a national research program. American Psychologist. 101–1022
Compas, B., (1987). Coping with Stress during childhood and adolescence.
Psychological Bulletin, 101, 393–403.
Compas, B., Phares, V., & Ledoux, N. (1989). Stress and coping preventive interventions for children and adolescents: Primary prevention and promotion in the schools. Primary prevention of Psychopathology, 12, 319–340.
Conte, J. R., Schuerman, J. R. (1987). Factors associated with an increased impact of child sexual abuse. Child Abuse & Neglect, 11(2), 201–11.
Coyne, J. C., Downey, G. (1991). Social factors and psychopathology: stress,social support, and coping processes. Annual Review of Psychology, 42,
401–25.
Cozza, S. J, Chun, R. S., & Miller, C. (in press). Children and families of combat injured service members. In War Psychiatry. Washington, DC: Borden
Institute.
Cozza, S. J., Chun, R. S., & Polo, J. A (2005). Military families and children during operation Iraqi Freedom
Derogatis LR: BSI-18: Administration, Scoring and Procedures Manual. Minneapolis, MN, National Computer Systems, 2000.
Derogatis LR: The Brief Symptom Inventory (BSI): Administration, Scoring
and Procedures Manual, 3rd Edition. Minneapolis, MN, National Computer Systems, 1993.
Dhalla, S., & Kopec, J. A. (2007). The CAGE questionnaire for alcohol misuse:a review of reliability and validity studies. Clin Invest Med., 30, 33–41.
Dohrenwend, B. S., Dohrenwend, B. P. (1981). Stressful life events and theircontents. Reseda, CA: Watson.
Everson, M. D., Hunter, W. M., Runyon, D. K., et al. (1989). Maternal support
following disclosure of incest. The American Journal of Orthopsychiatry,
59(2), 197–207.
Finney, 1. W., & Miller, K. M. (1998). Children of parents with medical illness.
In W. K. Silverman & T.H. Ollendick (Eds.), Developmental issues in theclinical treatment of children (pp. 433–442). Needham Heights, MA: Allynand Bacon

130 • Bibliography

Folkman, S., & Lazarus, R. S. (1980). An analysis of coping in a middle-aged
community sample. Journal of Health and Social Behavior, 21, 219–239.
Frick, P. J. (1991). The Alabama Parenting Questionnaire. Unpublished instrument, University of Alabama.
Friedrich, W. N., Beilke, R. L., & Urquiza, A. J. (1987). Children from sexuallyabusive families: A behavioral comparison. Journal of Interpersonal Violence, 2, 391–402.
Gibbs, D.A.; Martin, S.L.; Kupper, L.L., & Johnson, R.E. (2007) Child maltreatment in enlisted soldiers families during combat-related deployment.
Journal of the American Medical Association, 298(5). 528–535
Glyshaw, K., Cohen, L.H., & Towbes, L.C. (1989). Coping strategies and psychological distress: Prospective analyses of early and middle adolescents.
American Journal of Community Psychology, 17, 607–623.
Gonzales, S., Steinglass, P., & Reiss, D. (1989). Putting the illness in its place:
Discussion groups for families with chronic medical illnesses. Family
Progress, 28, 69–87.
Goodman R (1997) The Strengths and Difficulties Questionnaire: A Research
Note. Journal of Child Psychology and Psychiatry, 38, 581–586.
Green, B. L., Korol, M., Grace, M. C., et al. (1991). Children and disaster: age,gender, and Parental effects on PTSD symptoms. Journal of the American
Academy of Child and Child Psychiatry, 30(6), 945–51.
Grieger, T. A, Cozza, S. J., Ursano, R. 1., Hoge, C., Martinez, P. E., & Engel, C.
C. (2006). Posttraumatic stress disorder and depression in battle-injured
soldiers. American Journal of Psychiatry, 163, 1777–83.
Herrenkohl, E. C., Herrenkohl, R. C, Egolf, B. (1994). Resilient early schoolage children from maltreating homes: outcomes in late adolescence. The
American Journal of Orthopsychiatry, 64(2), 301–9.
Herrenkohl, E. C., Herrenkohl, R. C., Rupert, L. J., et al. (1995). Risk factors forbehavioral dysfunction: the relative impact of maltreatment, SES, physical health problems, cognitive ability, and quality of Parent-child interaction. Child Abuse & Neglect. 19(2), 191–203.
Johnston, C., & Mash, E. J., (1989). A measure of parenting satisfaction andefficacy. Journal of Clinical Child Psychology, 18, 176–175.
Katon, W., Rutter, C., Ludman, E. J., Von Korff, M., Lin, E. & Simon, G. (2001a).
A randomized trial of relapse prevention of depression in primary care.
Archives of General Psychiatry, 58, 241–7.
Katon, W., Van Korff, M., Lin, E., & Simon, G. (2001b). Rethinking practitioner
roles in chronic illness: The specialist, primary care physician, and thepractice nurse. General Hospital Psychiatry, 23, 138
Katon, W., Von Korff, M., Lin, E., Simon, G., Walker, E., & Unutzer, 1. (1999).
Stepped collaborative care for primary care patients with persistent depression: A randomized trial. Archives of General Psychiatry, 56, 1109–
15.
Kelley, S. D. & Sikka, A. (1997). A review of research on parental disability:
Implications for Research and counseling practice. Rehabilitation Counseling Bulletin, 41, 105–121
Kinzie, J. D. (1986). Children in Cambodian concentration camps. Journal of
the American Academy of Child Psychiatry, 25, 370–376.
Koren, D., Norman, D., Cohen, A., Berman, J., & Klein, E. M. (2005). Increased
PTSD Risk With Combat-Related Injury: A Matched Comparison Study
Workgroup on Intervention with Combat Injured Families — Conference Proceedings • 131

of Injured and Uninjured Soldiers Experiencing the Same Combat Events.
Am J Psychiatry, 162, 276–82.
Korneluk, Y. G. & Lee, C. M. (1998). Children’s adjustment to parental physicalillness. Clinical Child and Family Psychology Review, 1, 179–93.
Kotchick, B. A, Summers, P., Forehand, R., & Steele, R. G. (1997). The role of parental and extra familial social support in the psychosocial adjustment ofchildren with a chronically ill father. Behavior Modification, 21,409–32.
Laor, N., Wolmer, L., Mayes, L. C., et al. (1996). Israeli preschoolers under Scudmissile attacks. A developmental perspective on risk-modifying factors.
Archives of General Psychiatry, 53(5), 416–23.
Layne, C. M., Saltzman, W. R., & Pynoos, R. S. (1999). School-based psychosocial program for war-affected children. Bosnia & Herzegovina: UNICEF(250 pp.).
Layne, C. M., Saltzman, W. R., Arslanagic, B., et al. (2001). Trauma/Grief-Focused Group Treatment for war-exposed Bosnian children: Preliminary
results from a school-based post-war program. Group Dynamics: Theory,
Research, and Practice, 5(4), 277–290.
Layne, C. M., Warren, J. S., Saltzman, W. S., et al. (in press). Contextual influences on posttraumatic adjustment: Retraumatization and the roles ofrevictimization, posttraumatic adversities, and distressing reminders. In
Schein, L. A., Spitz, H. I., Burlingame, G. M., & Muskin, P. R., (Eds.), Group
Approaches for the Psychological Effects of Terrorist Disasters. New York:
Haworth.
Lazarus, R. (1991). Emotion and adaptation. New York: Oxford University
Press.Lee, M. B.
LeClere, F. B. & Kowalewski, B. M. (1994). Disability in the family: The effects
on children’s well-being. Journal of Marriage and Family, 56, 457–68.
Lester, P., Stein, J., Bursch, B. (2003). Developmental Predictors of Somatization in Adolescents of Parents with HIV: A 12-Month Follow-up. Journalof Developmental and Behavioral Pediatrics.
Lincoln, A.; Swift, E., and Shorteno-Fraser, M. (2008) Psychological adjustment and treatment of children and families with parents deployed inmilitary combat. Journal of Clinical Psychology, 64(8), 984–992
Lonigan, C. J., Shannon, M. P., finch, A. J. et al. (1991). Children’s reactions toa natural disaster: Symptom severity and degree of exposure. Advances in
Behaviour Research and Therapy, 13, 135–154.
Mannarino, A. P., Cohen, J. A., Berman, S. R. (1994). The relationship between
preabuse factors and psychological symptomatology in sexually abused
girls. Child Abuse & Neglect, 18(1), 63–71.
Mayfield D, McLeod G, Hall P. The CAGE Questionnaire: Validation of a New
Alcoholism Screening Instrument. Am J Psychiatry 1974;131:1121–3.
McCaig, L.F. (1992). National Hospital Ambulatory Medical Care Survey:
1992 Emergency department summary. Advance data from Vital Health
Statistics, vol. 245. Hyattsville, MD: National Center for Health Statistics,
1994
McFarlane, A. C. (1987). Posttraumatic phenomena in a longitudinal study ofchildren following a natural disaster. Journal of the American Academy ofChild and Child Psychiatry, 26(5), 764–9.
McFarlane, W. R., Stastny, P., Deakins, S. (1992). Family-aided assertive community treatment: A comprehensive rehabilitation and intensive case132 • Bibliographymanagement approach for persons with schizophrenic disorders. In:
Robert Paul Liberman, Ed. Effective psychiatric rehabilitation. Jossey-Bass
Inc, Publishers: San Francisco, CA.
Moran, P. B., Eckenrode, J. (1992). Protective personality characteristics amongchild victims of maltreatment. Child Abuse & Neglect, 16(5), 743–54.
Nader, K., Pynoos, R., Fairbanks, L., et al. (1990). Children’s PTSD reactions
one year after a sniper attack at their school. American Journal of Psychiatry, 147(11), 1526–30.
Pessar, L. F., Coad, M. L., Linn, R. T., & Willer, B. S. (1993). The effects of parental traumatic brain injury on the behaviour of parents and children. Brain
Injury, 7, 231–40.
Peters, L. C. & Esses, 1. M. (1985). Family environment as perceived by children with a chronically ill parent. Journal of Chronic Diseases, 38, 301–8.
Power, P. W. (1979). The chronically ill husband and father: His role in thefamily. Family Coordinator, 28, 616–21.
Pynoos, R. S., Nader, K. (1989). Children’s memory and proximity to violence.
Journal of the American Academy of Child and Child Psychiatry, 28(2),236–41.
Pynoos, R., Steinberg, A., Piacentini, J. (1999). A developmental psychopathology model of childhood traumatic stress and intersection with anxiety
disorders. Society of Biological Psychiatry, 46, 1542–1554.
Rao, K., DiClemente, R J., Ponton, L. E. (1992). Child sexual abuse of Asians
compared with other populations. Journal of the American Academy ofChild and Child Psychiatry, 31(5), 880–6.
Rice, D. R., MacKenzie, E. J., Jones, A S., Kaufman, S. R., de Lissovoy, G. V., Max,
W. et al. (1989). Cost of injury in the United States: A report to Congress.
San Francisco, Institute for Health, and Aging, University of California,
and Injury Prevention Center, Johns Hopkins University.
Rishel, C.W. (2007) Evidence-based prevention practice in mental health:
What is it and how do we get there. American Journal of Orthopsychiatry,
77. 153–164.
Rotheram-Borus, M. J., Flannery, D., Rice, E., & Lester, P. (2005, in press). Families living with HIV. AIDS Care.
Rotheram-Borus, M. J., Lee, M. B., Gwadz, M., & Draimin, B. (2001b). An intervention for parents with AIDS and their adolescent children. American
Journal of Public Health, 91, 1294–1302.
Rotheram-Borus, M. J., Lee, M. B., Murphy, D. A., Futterman, D., Duan, N.,
Birnbaum, J., & the Teens Linked To Care Consortium. (2001a). Efficacy
of a preventive intervention for youth living with HIV. American Journalof Public Health, 91, 400–405.
Rotheram-Borus, M. J., Lee, M., Leonard, N., Lin, Y. Y., Franzke, L, Turner, B.,
Lightfoot, M. (2003). Four-year behavioral outcomes of an intervention
for parents living with HIV and their adolescent children. AIDS.
Rotheram-Borus, M. J., Murphy, D. A., Wight, R. G., Lee, M. B., Lightfoot, M.
A., Swendeman, D., Birnbaum, J. M., & Wright, W. (2001b). Improving
the quality of life among young people living with HIV. Evaluation and
Program Planning, 24, 227–237.
Rotheram-Borus, M. J., Stein, J. A., Lin, Y. Y. (2001). Impact of parent death
and an intervention on the adjustment of adolescents whose parents have
HIV/AIDS. Journal of Consulting and Clinical Psychology, 69(5), 763–73.
Workgroup on Intervention with Combat Injured Families — Conference Proceedings • 133

Rotheram-Borus, M. J., Swendeman, D., Comulada, W. S., et al. (2004). Prevention for Substance-Using HIV-Positive Young People: Telephone and InPerson Delivery. Journal of Acquired Immune Deficiency Syndrome, 1(37),Suppl 2:S68–77.
Rotheram-Borus, M.J., Flannery, D., Lester, P., & Rice, E. (2004). Prevention for
HIV positive families. JAIDS, 37(Supp2), S133–S134.
Rotheram-Borus, M.J., Lee, M., Lin, Y.Y., & Lester, P. (2004). Six year intervention outcomes for adolescent children of parents with HIV. Archives ofPediatrics & Adolescent Medicine, 158, 742–748.
Rotheram-Borus, M.J., Lester, P., Wen, P. & Shen, Q. (2004). Custody plansamong parents living with HIV. Archives of Pediatrics & Adolescent Medicine, 158, 327–332.
Rotheram-Borus, M.J., Weiss, R., Alber, S., Lester, P. Adolescent adjustment before and after HIV-related parental death. (in press). Journal of Consulting
and Clinical Psychology.
Roy-Byrne, P. P., Katon, W., Cowley, D. S., & Russo, J. (2001). A randomized
effectiveness trial of collaborative care for patients with panic disorder inprimary care. Archives of General Psychiatry, 58, 869–76.
Ruggiero, K. J, Ben, K. D., Scotti, J. R., & Rabalais, A. E. (2003). Psychometricproperties of the PTSD Checklist-CivilianVersion. Journal of TraumaticStress, 16, 495–502.
Rutter, M. & Quinton, D. (1984). Parental psychiatric disorder: Effects on children Psychological Medicine, 14, 853–880.
Rutter, M. (1966). Children of sick Parents: An environmental and psychiatricstudy. Institute of Psychiatry Maudsley Monographs No. 16 Oxford University Press: London.
Sack, W. H., Clarke, G. N., Seeley, J. (1995). Posttraumatic stress disorder across
two generations of Cambodian refugees. Journal of the American Academy of Child and Adolescent Psychiatry, 34(9), 1160–6.
Saltzman, W. R., Layne, C. M., Steinberg, A. M., et al. (in press). School-Based
Trauma/Grief-Focused Group Psychotherapy. In Schein, L. A., Spitz, H.
I., Burlingame, G. M., & Muskin, P. R., (Eds.), Group Approaches for thePsychological Effects of Terrorist Disasters.
Saltzman, W. R., Pynoos, R. S., Layne, C. M., et al. (2001). School-based trauma/
grief focused group psychotherapy program for youth exposed to community violence. Group Dynamics: Theory, Research, and Practice, 5(4),291–303.
Shakespeare-Finch, J., & Enders, T. (2008). Corroborating Evidence of Posttraumatic Growth. Journal of Traumatic Stress, 21, 421–424.
Shelton, K. K., Frick, P. J., & Wooten, J. (1996). Assessment of parenting practices in families of elementary school-age children. Journal of ClinicalChild Psychology, 25, 317–329.
Stein, J. A., Riedel, M., Rotheram-Borus, M. J. (1999). Parentification and its
impact among children of Parents with AIDS. Family Process, 38, 193–
208.
Tedeschi, R. G., & Calhoun, L., G. (1996). The Posttraumatic Growth Inventory: Measuring the Positive Legacy of Trauma. Journal of Traumatic Stress,
9, 455–471.
Urbach, J. R. (1989). The impact of parental head trauma on families withchildren. Psychiatric Medicine, 7, 17–36.
134 • Bibliography

Urbach, J.R. & Culbert, J.P. (1991) Head-injured parents and their children:
Psychosocial consequences of a traumatic syndrome. Psychosomatics, 32,
24–33
Uysal, S., Hibbard, M. R., Robillard, D., Pappadopulos, E., & Jaffe, M. (1998).
The effect of parental traumatic brain injury on parenting and child behavior. Journal of Head Trauma Rehabilitation, 13. 57–71.
Ventureyra, V., Yao, S.N., Cottraux, J., Note, I., & De Mey-Guillard, C. (2002).
The validation of the Posttraumatic Stress Disorder Checklist Scale in posttraumatic stress disorder and nonclinical subjects. Psychotherapy and Psychosomatics, 71, 47–53.
Verhaeghe, S., Defloor, T., & Grypdonck, M. (2005). Stress and coping amongfamilies of patients with. traumatic brain injury: a review of the literature.
Journal of Clinical Nursing, 14, 1004–12.
Visser-Meily, A., Post, M., Meijer, A.M., Maas, C., Ketelaar, M., and Lindeman,
E. (2005). Children’s adjustment to a parents stroke: Determinants ofhealth status and psychological problems and the role of support fromthe rehabilitation team. Journal of Rehabilitation Medicine, 37. 236–241.
Visser-Meily, A., Post, M., Meijer, A.M., van de Port, I., Maas, C., Lindeman,
E. (2005) When a parent has a stroke: Clinical course and prediction ofmood, behavior problems, and health status of young children. Stroke, 36.
2436–2440.
Vostanis P. (2006). Strengths and Difficulties Questionnaire: research andclinical applications. Curr Opin Psychiatry, 19, 367–72.
Weathers, F., Litz, B., Herman, D., Huska, J., & Keane, T. (October 1993). The
PTSD Checklist (PCL): Reliability, Validity, and Diagnostic Utility. Paper
presented at the Annual Convention of the International Society forTraumatic Stress Studies, San Antonio, TX.
Wooley, S., Blackwell, B., & Winget, C. (1978). A learning theory model ofchronic illness behavior: Theory, treatment, and research. Psychosomatic
Medicine, 40, 379–401.
Zabora J, BrintzenhofeSzoc K, Jacobsen P, Curbow B, Piantadosi S, Hooker C,
Owens A, Derogatis L. (2001). A new psychosocial screening instrument
for use with cancer patients. Psychosomatics, 42, 241–6.
Zatzick, D. F., Roy-Byrne, P., Russo, J. E., Rivara, F. P., Koike, A., Jurkovich, G.
J. et al. (200l). Collaborative interventions for physically injured trauma
survivors: A pilot randomized effectiveness trial. General Hospital Psychiatry, 23, 114–23.

Workgroup on Intervention with Combat Injured Families — Conference Proceedings • 135

136 • Bibliography

Appendix
1) Principles of Caring for Combat Injured Families and theirChildrenPrinciples of Caring for Combat Injured Families and their Children is a
product of the Workgroup on Intervention with Combat Injured Families
that took place in December, 2007 in Bethesda, Maryland. The document
communicates ten core principles of care intended to guide simultaneous
endeavors of scientific research and evaluation, and clinical interventions
aimed at mitigating family distress and dysfunction, and at improving communication around the injury across multiple settings: healthcare, family
and community.
2) Resources for Recovery
Resources for Recovery is a product of the Center for the Study of Traumatic Stress of Uniformed Services University of the Health Sciences. Resources
for Recovery is a public education campaign to educate military healthcare
leadership and civilian health professionals who work with and treat militaryfamilies affected by combat injury. Resources for Recovery is disseminated tohealthcare professionals as well as military families to enhance injury communication from the acute hospital setting (Stabilization Phase) throughout
long-term care (Sustainment Phase). Current and future installments of Resources for Recovery can be accessed at www.cstsonline.org.

Workgroup on Intervention with Combat Injured Families — Conference Proceedings • 137

138 • Appendix

Principles of Caring for Combat Injured Families
and their Children
Combat injury is a life-changing
rehabilitation over time. Often,
Injury to a parent is a major
event that impacts a service member,
adults do not know how to speak to
his or her children, as well as otherchildren about the injury, or how
threat to children of all ages
family members and loved ones.
much and what kind of information
and a challenge for even the
Military children are our nation’s
to share.
most resilient of militarychildren, and represent a vulnerable
As a result of parental combat
families.
population within the injured family
injury, many family members may
unit. Injury to a parent is a major
demonstrate initial distress thatthreat to children of all ages and ais likely to be temporary. Most
challenge for even the most resilient of military families.
children will remain healthy in the face of this stress, but
Parental injury disrupts the family system — itssome children may sustain life-changing trajectories inroutines, cohesion and sense of safety. Importantly,
their emotional development and/or their interpersonal
parental injury can alter the child’s view of the wounded
relationships. The simultaneous use and study of theparent, and undermine the child’s view of his or her own
following principles of care for our combat injured
physical integrity. Combat injury also affects existing
families will foster evidence based approaches thatpatterns of parenting, as both injured and uninjured
can support their healthy growth and recovery. These
parents experience their own emotional responses andprinciples can be used by hospital and community based
face the complicated reality of medical treatment andprofessionals in military or civilian settings.

Principles of Caring■■ Principles of psychological first aid (PFA) areprimary to supporting Injured Families. Careof injured service members and families shouldincorporate key elements of PFA: providing safety,
comfort, information, practical assistance andconnection to appropriate community resources— all serving to support healthy family recovery.
■■ Medical care for the combat injured must be family

focused. Care of combat injured service members
must attend to family needs and specifically should
work toward relieving family distress, sustaining
parental functioning, and fostering effective injury
related parent-child communication.
■■ Service providers should anticipate a range of

responses to combat injury. Serious injury will
challenge our healthiest families. Most service
members, their children and families will adjust to theinjuries they sustain. But, others may struggle withthe changes that they face. Some may even develop
problems that require treatment. Service providers
should expect this broad range of responses and be
prepared to meet family needs as they are identified.

■■ Injury communication is an essential component of

injured family care. Effective injury communication
involves the timely, appropriate and accurate sharing
of information with and among family members fromthe moment of notification of injury throughout
treatment and rehabilitation. Communication should
be calibrated to address patient and family anxiety andto sustain hope. Because families may be uncertain
how to share difficult information with their children,
they may benefit from professional guidance on what
to say and how to say it.
■■ Injured Family programs must be developmentallysensitive and age appropriate. Services and programsmust address the unique developmental responses ofchildren of varying age and gender, and recognize that
distress, care needs and communication ability willchange with children of different ages.
■■ Injured Family care is longitudinal, extending

beyond immediate hospitalization. Services need
to be tailored to the changing needs of the combat
injured family throughout the treatment andContinued

Workgroup on Intervention with Combat Injured Families
Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University of the Health Sciences

■■ rehabilitation process. Interventions must meetthe family where it is within the recovery process,recognizing a family’s unique strengths and challenges,
as well as anticipate its future needs through transition
to a new community or new way-of-life.
■■ Effective Injured Family care requires aninterconnected community of care. Effective
intervention requires collaboration and coordinationof services between the family, the health care system,
and military and civilian community resources. This
collaboration fosters a community of care that reaches
across traditional professional boundaries throughout
rehabilitation and recovery.
■■ Care must be culturally competent. Healthcare andcommunity professionals who interact with combat
injured families need to possess the cultural andlanguage competence to engage families that may be
traditional or nontraditional in their composition andmay be of broad ethnic and religious backgrounds.
It is essential that all healthcare and community
service providers understand and respect the uniqueexperiences and traditions of military families.

■■ Communities of care should address any barriers

to service. Barriers to intervention can complicate
the healthy recovery of combat injured service andfamily members. These barriers may include a family’s
difficulty in accessing health care or community
services. In addition, a community’s lack of awarenessor misunderstanding of the needs of a combat injured
family or a family’s reluctance to seek assistance (dueto stigmatization) can also limit family intervention
and recovery■■ Families, communities and service providers must

be knowledgeable. Individuals, families, professionals,
organizations and communities all have a need foraccess to quality educational materials to address thechallenges that confront combat injured families.
Effective education leads to the development of skills
in all parties, building empowerment in communities
and families. Development of new knowledge isfundamental to better meeting the needs of this uniquepopulation.

Place local contact information here

Center for the Study of Traumatic Stress
Department of Psychiatry
Uniformed Services University of the Health Sciences
4301 Jones Bridge Road
Bethesda, MD 20814-4799
Tel: 301-295-2470 | Fax: 301-319-6965
www.usuhs.mil/csts | www.centerforthestudyoftraumaticstress.org

Resources for Recovery

For Providers

Advancing the Health and Care of our Nation’s Combat Injured Service Members, their Families and Children

The Combat Injured Family: Guidelines for Care
Military families and children represent
a heterogeneous population and live in
geographically diverse settings: on military
installations, in civilian urban and suburban
communities, and in rural areas across thecountry. While military families are generallyrobust and resilient, the stress of war (combat
deployments, combat injury, illness or death)challenges the healthiest of families, be they
active duty, National Guard or reserve.
Combat injury is a life-changing event that impacts
the service member, his or her children, as well as otherfamily members and loved ones. Parental injury disrupts
a family’s routines, cohesion and sense of safety. Existing
patterns of parenting undergo change as both injured anduninjured parent cope with complex emotions and thecomplicated reality of medical treatment
and rehabilitation. Children are particularly
vulnerable and often adults do not know how
to speak to them about the injury, or how
much and what kind of information to share.
Many military families and children will
demonstrate initial distress in response tocombat injury that is likely to be temporary.
However, a number of children may sustain
life-changing trajectories in their emotional
development and their interpersonal relationships.
Experts in military medicine and the traumatic effects of
combat injury on families and children have developed
the following principles of care to guide the outreach of
hospital and community-based professionals in militaryand civilian settings.

Principles of Caring for our Nation’s Combat Injured Families and Children
As health care professionals, your role is invaluable
and needed in caring for the families of combat injured
service members. Your understanding and implementationof these principles of care can profoundly impact thehealth and recovery of injured service members and their
loved ones. Remember, there is no such thing as a combat
injured service member — think combat injured family.
Care and services should be delivered in a manner
which:■■ Provides a sense of safety, comfort, information,practical assistance and connection to appropriate
community resources that can foster the combat
injured family’s healthy recovery.
■■ Is family focused to help relieve family distress,

supports parental availability and effectiveness asmuch as possible, and helps guide a parent’s efforts incommunicating with their children about the injury.
■■ Reinforces a family’s natural resilience while addressing

special problems that might arise and require further
help and support.
■■ Is sensitive to the unique responses of children ofvarying age and gender, and recognizes that distress,
care needs and communication ability will vary
according to the age of a child or children.

■■ Is tailored to the family’s changing needs throughout

treatment and rehabilitation recognizing the family’s
unique strengths and challenges, as well as anticipating
future needs in their transitions to a new community or
new way-of-life.
■■ Fosters the collaboration and coordination of services

between the combat injured family, health care resources
and treatment — military and civilian — reaching acrosstraditional professional boundaries and levels of care.
■■ Respects the family’s unique background including

culture, language, composition (traditional or
nontraditional), ethnicity, religion and the traditions ofmilitary families.
■■ Helps the combat injured family access care andaddresses any barriers to service that can complicate
the healthy recovery of its service member and his/herfamily members. These barriers may include a family’s
difficulty in accessing health care or community services
or a community’s lack of awareness or understanding of
the needs of combat injured families.
■■ Is informed by knowledgeable service providers,

professionals, organizations and communities, whichhave access to and provide quality educational materials
that address the challenges confronting combat injured
families.

Guidelines for Care was developed in collaboration with the Workgroup on Intervention with Combat Injured Families
Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University of the Health Sciences

Place contact information here

Center for the Study of Traumatic Stress (CSTS)
Department of Psychiatry
Uniformed Services University of the Health Sciences
4301 Jones Bridge Road
Bethesda, MD 20814-4799
Tel: 301-295-2470 | Fax: 301-319-6965
www.usuhs.mil/csts | www.CSTSonline.org
CSTS is a partnering center of the Defense Center of Excellence for Psychological Health and Traumatic Brain Injury, andA component site of the National Child Traumatic Stress Network

Resources for Recovery

For families

Advancing the Health and Care of our Nation’s Combat Injured Service Members, their Families and Children

The Combat Injured Family: Guidelines for CareYour military loved one has been wounded
and suddenly your world has been turned
upside down. Combat injury is a life-changing
event that impacts a family’s routines and its
sense of safety and wholeness. Combat injury
especially affects children of all ages. Children
worry about the effect of the injury on theirwounded parent; how that injury will change
their bond with that parent and the parents’relationship with each other. Often, caring
adults do not know how to speak to children
about the injury and its impact on their family, or how muchand what kind of information should be communicated.
At this time, many resources of care and support will be
extended to your injured service member, to you and to yourfamily and children. Due to normal distress and anxiety, there

may be times when you will not hear,
understand or accept all that you will be
told.
Do not be shy about writing things
down or having an important person inyour life accompany you and take notes
for you. When you have questions orforget important information ask doctors
and healthcare professionals to re-explain
or repeat themselves so you can better
understand the information they haveprovided. Good communication between you and your spouse’s
medical team and between you, your family and your children
is essential for helping you cope and make important decisions
related to the care of your injured loved one and to the care ofyour family.

Principles of Caring for our Nation’s Combat Injured Families and Children
Despite the uniqueness of your family’s situation andyour loved one’s combat injury, there are certain principles
that should inform the care you receive. Understanding theseprinciples of care can assist you in recognizing what you require
and in seeking appropriate services to support your family’s
long-term health and wellbeing. Care and services should bedelivered in a manner which:■■ Provides a sense of safety, comfort, information, practicalassistance and connection to appropriate community
resources that can foster your family’s healthy recovery.
While the major goal of the health care facility is to provide
treatment to your loved one, there will be people on staff
who can assist in solving some of your family’s practicalneeds.
■■ Is family focused and understands that you, your family

and your children are all profoundly affected by the injury.
Treatment should help relieve family distress, support
your ability to be available to your children during thestress of injury recovery, and help guide your efforts incommunicating with your children about the injury.
■■ Reinforces your family’s strengths and resilience while

understanding that each family may respond in a different
way to the challenges it faces. Healthcare professionals must
be responsive to the unique impact of the injury on yourfamily and provide appropriate help and support.
■■ Is sensitive to the unique responses of children of varying

age and gender, and recognizes that distress, care needs andcommunication ability will vary according to the age of yourchild or children.
■■ Is tailored to your family’s changing needs throughout

what may be a long course of treatment and rehabilitation;
anticipating future needs as the recovery process unfolds
including discharge and transition to a new community or
new way-of-life.
■■ Encourages a partnership and bringing together of services

between your family, treatment providers (both military andcivilian), as well as community services. Quality care reaches
across traditional professional boundaries and levels of care.
■■ Respects your family’s unique background including culture,

language, composition (traditional or nontraditional),
ethnicity, religion and the traditions of military families.
■■ Helps your family access care and addresses any barriers

to service (unnecessary roadblocks that get in the way ofgood care), which can complicate the healthy recovery of
your loved one and family members. These barriers may
include a family member’s difficulty in accessing health careor community services, his or her reluctance to seek needed
help, or a community’s lack of awareness or understandingof the needs of combat injured families.
■■ Is informed by knowledgeable service providers,

professionals, organizations and communities that haveaccess to and provide quality educational materials to
address the challenges that confront combat injured families.

Guidelines for Care was developed in collaboration with the Workgroup on Intervention with Combat Injured Families
Center for the Study of Traumatic Stress, Department of Psychiatry, Uniformed Services University of the Health Sciences

Place contact information here

Center for the Study of Traumatic Stress (CSTS)
Department of Psychiatry
Uniformed Services University of the Health Sciences
4301 Jones Bridge Road
Bethesda, MD 20814-4799
Tel: 301-295-2470 | Fax: 301-319-6965
www.usuhs.mil/csts | www.CSTSonline.org
CSTS is a partnering center of the Defense Center of Excellence for Psychological Health and Traumatic Brain Injury, andA component site of the National Child Traumatic Stress Network

!

DEFENSE CENTERS
OF EXCELLENCEFor Psychological Health& Traumatic Brain Injury

Center for the Study of Traumatic Stress
Uniformed Services University of the Health Sciences
4301 Jones Bridge Road, Bethesda, MD 20814-4799
Tel: 301-295-2470 | Fax: 301-319-6965 | www.usuhs.mil/csts | www.CSTSonline.org
A partnering center of the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury