FO RU M O N H E A LT H AN D NATI O NAL SE CURI TY

Military Families in Transition:
Stress, Resilience, and Well-being

Conference Report

Center for the Study of Traumatic Stress
Department of Psychiatry
Uniformed Services University of the Health Sciences

FO RU M O N H E A LT H AN D NATI O NAL SE CURI TY

Military Families in Transition:
Stress, Resilience, and Well-being
Edited byRobert J. Ursano, MD
Frances H. Gabbay, PhD
Carol S. Fullerton, PhD

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

From the Conference Series:
FORUM ON HEALTH AND NATIONAL SECURITY

Military Families in Transition:
Stress, Resilience, and Well-being
Editor’s Note: This transcript has been edited, however, as in most transcripts some errors may
have been missed. The editors are responsible for any errors of content or editing that remain.

IPD 2014 by Center for the Study of Traumatic Stress
Department of Psychiatry
Uniformed Services University of the Health Sciences
4301 Jones Bridge Road
Bethesda, MD 20814-4712
First Edition

Contents
List of Panelists........................................................................................................................... i
List of Participants.................................................................................................................... iii
Preface......................................................................................................................................vii
Executive Summary and Recommendations......................................................................... 1

Panel 1: Combat to Garrison—Transitions Affecting the Soldier and the Military Family of 2025
Opening Remarks ............................................................................................................. 7
Robert J. Ursano, MD and Anthony J. Stamilio, MBA
Military Families in Transition: Stress, Resilience, and Well-Being....................... 11
Speaker: James E. McCarroll, PhD
Army Family Programs Overview.................................................................................. 15
Speaker: Lynn L. McCollum, LCSW
Military Families: The Aftermath of Ten Years of War............................................ 19
Speaker: Brian D. Leidy, PhD
Panel I Discussion........................................................................................................... 23
Moderator: Robert J. Ursano, MD
Panel 2: Problems Facing Military Families in Transition—Learning from the Science of Stressors
Military Service, War, and Families: Translating Research into Practices........... 29
Speaker: Patricia Lester, MD
Preventing Violence in Military Families Under Stress............................................ 35
Speaker: Eric Elbogen, PhD
Contributions of PTSD and TBI to Military/Veteran Family Risk.......................... 39
Speaker: Carol S. Fullerton, PhD, for Stephen J. Cozza, MD
Panel 2 discussion........................................................................................................... 43
Moderator: Robert J. Ursano, MDPanel 3: Fostering Resilience in Families—What Does the Science of Resilience Tell Us?
Fostering Resilience in Families: Lessons for and from Military Families........... 49
Speaker: Ann S. Masten, PhD, LP
Fostering Resilience in Military Families Over Time................................................ 53
Speaker: William Saltzman, PhD
Fostering Resilience in Military Families: Cascading Effects of
Positive Parenting........................................................................................................... 59
Speaker: Abigail H. Gewirtz, PhD
Panel 3 Discussion.......................................................................................................... 63
Moderator: David M. Benedek, MD
Panel 4: Effective Programs and Interventions—The Science of Program Evaluation
Population Impact Challenges and Strategies: Illustrations from PROSPER
Universal Prevention Research.................................................................................... 69
Speaker: Richard L. Spoth, PhD
Improving the Behavioral Health of Military Communities................................... 73
Speaker: Richard E. Heyman, PhD
Developing, Evaluating and Sustaining Stepped Collaborative Care
Interventions for PTSD and Comorbidity after Injury............................................ 77
Speaker: Douglas F. Zatzick, MD
Panel 4 Discussion.......................................................................................................... 81
Moderator: Douglas F. Zatzick, MD
Panel 5: Military Families and Transitional Stress: What Critical Information is Missing?
Military Families and Transitional Stress: What Critical Information is
Missing? .......................................................................................................................... 87
Speaker: James L. Schmeling, JD
Military Families and Transitional Stress: What Critical Information is
Missing?........................................................................................................................... 91
Wanda L. Finch, LICSW, CAS
Points to consider in Judging the Value of Interventions for Military
Families in Transition..................................................................................................... 97
Speaker: Stephen A. Maisto, PhD
Military Family Transitions in the Next Decade..................................................... 101
Speaker: Shelley M. MacDermid Wadsworth, PhD

Army Science and Technology Essential Core Competencies................................ 105
Speaker: Mark N. Glauser, PhD
Closing Discussion: Research and Military Policy — Thinking Forward
Research and Military Policy: Thinking Forward................................................... 109
Moderator: Robert J. Ursano, MDiPanelists
David M. Benedek, MD
COL, MC, USA
Professor and Deputy Chair, Department of
Psychiatry
Associate Director, Center for the Study ofTraumatic Stress
Uniformed Services University

Richard E. Heyman, PhD
Professor
Family Translational Research Group
Department of Cariology and Comprehensive
Care
New York University

Stephen J. Cozza, MD
COL(R), USA
Professor, Department of Psychiatry
Associate Director, Center for the Study ofTraumatic Stress
Uniformed Services University

Brian D. Leidy, PhD
Senior Extension Associate
Bronfenbrenner Center for Translational
Research
Beebe HallNYS College of Human Ecology
Cornell University

Eric B. Elbogen, PhD, ABPP
Associate Professor of Psychiatry
Forensic Psychiatry Program and Clinic
School of Medicine
University of North Carolina, Chapel Hill

Patricia Lester, MD
Jane and Marc Nathanson Family Professor of
Psychiatry
Semel Institute
University of California, Los Angeles

Wanda L. Finch, LICSW, CAS
CAPT, USPHSFamily and Community Resilience Program
Manager
Department of Defense Centers of Excellence

Shelley M. MacDermid Wadsworth, PhD
Director, Center for Families
Director, Military Family Research Institute
Professor, Human Development and Family
Studies
Purdue University

Abigail H. Gewirtz, PhD, LP
Associate Professor
Department of Family Social Science
Institute of Child Development
University of Minnesota
Mark N. Glauser, PhD
Professor, Department of Mechanical andAerospace Engineering; Associate Dean for
Research and Doctoral Programs
L.C. Smith College of Engineering andComputer Science
Professor, Department of Physics, College ofArts and Sciences
Fellow: AIAA, ASME, APS, Institute of Physics(UK)
Syracuse University

Stephen A. Maisto, PhD
Professor
Department of Psychology
Syracuse University
Ann S. Masten, PhD, LP
Irving B. Harris Professor of Child Psychology
Institute of Child Development
University of Minnesota
James E. McCarroll, PhD, MPH
Research Professor, Department of Psychiatry
Center for the Study of Traumatic Stress
Uniformed Services University

ii

Lynn L. McCollum, LCSW
Director, Family Programs, US Army
Installation
Management Command, Family and Morale,
Welfare and Recreation Programs
San Antonio, TX

Anthony J. Stamilio, MBA
Deputy Assistant Secretary of the Army
Manpower and Reserve Affairs
Civilian Personnel/Quality of Life
U.S. Department of the Army
Washington, DC

William R. Saltzman, PhD
Professor, Advanced Studies in Education andCounseling
Faculty, Marriage and Family Therapy
Program
Associate Director, Nathanson Family
Resilience Center
Semel Institute
University of California, Los Angeles

Robert J. Ursano, MD
Professor and Chair, Department of Psychiatry
Director, Center for the Study of TraumaticStress
Uniformed Services University

James L. Schmeling, JD
Managing Director, Co-FounderInstitute for Veterans and Military Families
Syracuse University

Douglas F. Zatzick, MD
Professor and Associate Vice Chair for HealthServices
Department of Psychiatry and Behavioral
Sciences
School of Medicine
University of Washington

Richard L. Spoth, PhD
F. Wendell Miller Senior Prevention Scientist
Director, Partnerships in Prevention Science
Institute
Iowa State University

Conference Planning Committee

Editing Committee

Frances H. Gabbay, PhD
K. Nikki Benevides, MA
Mary Lee Dichtel, RNJames E. McCarroll, PhD
Carol S. Fullerton, PhD
Robert J. Ursano, MD

Robert J. Ursano, MD
Mary Lee Dichtel, RN
Carol S. Fullerton, PhD
Frances H. Gabbay, PhD
James E. McCarroll, PhD
K. Nikki Benevides, MA

iii

Participants
Carolyn M. Aldwin, PhD
Professor, Human Development & Family
Sciences
Director, Gerontology Program
Oregon State University

Jill W. Chambers
COL(R), USA
This Able Vet®, LLC
Service Disabled Veteran Owned Small
Business

Patricia M. Barron
Director, Family Programs
Association of the United States Army
Arlington, VA

Kenneth R. Conner, PsyD, MPH
Acting Director, VA VISN 2 Center of
Excellence for Suicide Prevention
Associate Professor of Psychiatry
Co-Director, Center for the Study andPrevention of Suicide
University of Rochester Medical CenterPaul T. Bartone, PhD
COL(R), USA
Senior Research Fellow
Center for Technology and National Security
PolicyNational Defense University
Paul Bliese, PhD
COL, MSC, USA
Director, Center for Military Psychiatry and
Neuroscience
Walter Reed Army Institute of Research
Adrian Blow, PhD
Associate Professor and Program Director
Couple and Family Therapy Program
Department of Human Development andFamily Studies
Michigan State University
Debbie Bradbard, PhD, LCP
Deputy Director, Research and Policy
Blue Star Families, Inc.
Falls Church, VA
Teri S. Brister, PhD, LPC
Director, Content Integrity and NAMI Basics
NAMI Education, Training and Peer Support
CenterRory A. Cooper, PhD
FISA & Paralyzed Veterans of America Chair
Distinguished Professor, Department of
Rehabilitation Science and Technology
Co-Director, NSF Quality of Life Technology
Engineering Research Center
Human Engineering Laboratories
VA Pittsburgh Healthcare System
Anthony L. Cox, LCSW, DCSWCOL, USA
Director, US Army Family Advocacy Program
IMCOM, G9, Family and MWR Programs
Fort Sam Houston, TX
Delores Johnson Davis, MSW, LCSW
Office of the Assistant Secretary of the Army
Manpower and Reserve Affairs
Civilian Personnel/Quality of Life
Washington, DC
Peter J. Delany, PhD
RADM, USPHS
Director, Center for Behavioral Health
Statistics and Quality
Substance Abuse and Mental Health Services
Administration
Rockville, MD

iv

CPT Michael N. Dretsch, PhD
Chief, Neuroscience Applications
Comprehensive Soldier & Family Fitness
Program
Program Development, Analysis and Training
Integration Division
Headquarters Department of the Army
Arlington, VA
Cathy A. Flynn, PhD
Senior Program Analyst
Military Community & Family Policy
Office of the Under Secretary of Defense,
Personnel & ReadinessWashington, DC
Carol S. Fullerton, PhD
Research Professor, Department of Psychiatry
Scientific Director, Center for the Study ofTraumatic Stress
Uniformed Services University
Frances H. Gabbay, PhD
Research Associate Professor, Department of
Psychiatry
Director, Clinical Psychophysiology andPsychopharmacology Laboratory
Staff Scientist, Center for the Study ofTraumatic Stress
Uniformed Services University
J. Michael Haynie, PhD
Executive Director, Institute for Veterans andMilitary Families
Barnes Professor of Entrepreneurship
Whitman School of Management
Syracuse University
Kent E. Kester, MD
COL, MC, USA
Associate Dean for Clinical ResearchConsultant in Infectious Diseases to the Army
Surgeon General
Consultant in Medical Research &Development to the Army Surgeon General
Office of the Dean, School of Medicine
Uniformed Services University
Meredith Kleykamp, PhD
Assistant Professor, Department of Sociology
University of Maryland

Gina Lee-Glauser, PhD
Vice President for Research
Office of Research
Syracuse University
Catherine Mozden Lewis, RN, MSN, MPA
COL(R), USA
Deputy Director, Government Relations
Military Officers Association of America
Andrew London, PhD
Professor of Sociology
Faculty Associate, Aging Studies InstituteSenior Research Affiliate, Center for Policy
Research
Senior Fellow, Institute for Veterans andMilitary Families
Syracuse University
Trish Lowney, PhD
Assistant Vice President for Strategic Research
Development
Office of Research
Syracuse University
Jennifer Lundquist, PhD
Founder and Director of the Institute for Social
Science Research (ISSR)
Associate Professor, Department of Sociology
University of Massachusetts, Amherst
Harriet MacMillan, MD, MSc, FRCPC
Professor
Departments of Psychiatry and Behavioural
Neurosciences and of Pediatrics
Chedoke Health Chair in Child Psychiatry
Acting Director, Offord Centre for Child
Studies
McMaster University and McMaster Children’s
Hospital/Hamilton Health Sciences
Valerie Maholmes, PhD, CAS
Chief, Pediatric Trauma and Critical Illness
BranchEunice Kennedy Shriver National Institute ofChild Health and Human Development
National Institutes of Healthv

James D. McDonough, Jr.
COL(R), USA
Senior Director for Community Engagement
and Innovation
Syracuse University
Institute for Veterans and Military Families
Syracuse, NY
Deborah J. Monahan, PhD
Associate Dean for Research
Professor of Social WorkDavid B. Falk College
Syracuse University
Mike Monroe
VP of Military Initiatives
Points of Light
Washington, DC
Ruth Paris, PhD
Associate Professor and Director, Family
Therapy Certificate Program
School of Social Work
Boston University
Paul F. Pasquina, MD
COL(R), USA
Residency Director and Chair, Physical
Medicine & Rehabilitation
Uniformed Services University
Walter Reed National Military Medical Center
Eve E. Reider, PhD
Health Scientist Administrator
Prevention Research Branch
National Institute on Drug Abuse
National Institutes of HealthMartha Farnsworth Riche, PhD
Farnsworth Riche Associates
Trumansburg, NY
Lyndon A. Riviere, PhD
Research Psychologist, Military Psychiatry
BranchCenter for Military Psychiatry and
Neuroscience
Walter Reed Army Institute of Research

Rene J. Robichaux, PhD, LCSW
Social Work Programs Manager
Behavioral Health Division
U.S. Army Medical Command
Amy M. Smith Slep, PhD
Professor
Family Translational Research Group
Department of Cariology and Comprehensive
Care
New York University
Avron Spiro, PhD
Research Career Scientist
Massachusetts Veterans Epidemiology
Research and Information Center
VA Boston Healthcare System
Research Professor of Epidemiology andPsychiatry
Boston University
Marney Thomas, PhD
Senior Academic Staff
Military Projects
Bronfenbrenner Center for Translational
Research
Beebe Hall
College of Human Ecology
Cornell University
Froma Walsh, PhD
Co-Director, Chicago Center for Family Health
Mose & Sylvia Firestone Professor Emerita
School of Social Administration
Department of Psychiatry
The University of Chicago

viPreface
The health and well-being of military families is a key part of sustaining thehealth and readiness of our military forces. The Forum on Health and National
Security, sponsored by the Center for the Study of Traumatic Stress, addressedinterventions to mitigate the effects of stressors confronted by military families
and strategies to enhance the resilience and well-being of these families, as wartime
transitions to peace, garrison, and small group deployments. Participants represented
military and civilian leaders, and health care and family services educators,
researchers, planners, and providers. The goal of the Forum was to share knowledge
across disciplinary boundaries, and to develop new perspectives and vantage points,
in order to better understand the needs of military families.
Participants considered the challenges as well as potential solutions at different
levels, from the individual to the family to the larger systems in which soldiers andfamilies are embedded, including both military and civilian communities. In the
coming years, additional transitions, and new challenges, will confront militaryfamilies. Fewer resources will be available to mitigate the effects of the challenges,
requiring even greater consideration of cost-effective solutions. To facilitate difficult
decisions by leadership in a challenging transitional time, the group developed aset of recommendations addressing: (1) leadership; (2) training and education;(3) programs and interventions; and (4) research.

The health andwell-being of militaryfamilies is a key partof sustaining thehealth and readinessof our military forces.

vii

Executive Summary and Recommendations

1

Executive Summary andRecommendations
Our nation’s recent conflicts have brought unparalleled challenges for militaryfamilies. The high operational tempo of a decade of conflict has required frequent
deployments, with limited recovery, reset, and restoration time for service members
and their families. Many returning service members and veterans suffer the effects ofinvisible wounds such as posttraumatic stress and concussions with resulting mild tomoderate traumatic brain injury. These wartime wounds can greatly impact families:
injured soldier, injured family. Further, the recent conflict has relied heavily on Guard
and Reserve troops, for whom the unpredictability of military service imposes additional and unique challenges. Amplifying the effects of these circumstances, the recent
period of conflict has overlapped substantially with a significant economic downturn.
Against this backdrop, military families face new challenges going forward, as theforce adapts to the changing circumstances.
The military is committed to ensuring the well-being of the soldier and the soldier’s family, and members of the force depend on this commitment. How individuals
transition into, within, and out of service, and more broadly, how they feel about theirmilitary experience, impacts the future of the force. A service member’s evaluationof their service experience, and that of her or his family, affects the likelihood of reenlistment and even how the military is conveyed to the next generation. To sustain
a promise and to promote national security, the military maintains a sharp focus on
the families of its members. In the coming years, fewer resources will be available tomitigate the effects of challenges faced by these families, requiring leaders to identify
cost-effective interventions.
To facilitate difficult decisions in a challenging transitional time, the Center for the
Study of Traumatic Stress (CSTS) of the Department of Psychiatry at the Uniformed
Services University convened a two-day forum, Military Families in Transition: Stress,
Resilience, and Well-being. Participants in the forum, the most recent in a series on
health and national security sponsored by the CSTS, included nationally recognized
military and civilian leaders, educators, researchers, and health care planners and providers. In confronting challenges that will be faced by military families in the coming
decades, the forum addressed Strategic Goal 2 in the FY 2012-2016 Strategic Plan:
To strengthen individual and mission readiness and family support, and promote
well-being.
The discussion identified a broad spectrum of challenges faced by military

The military iscommitted to ensuring
the well-being of thesoldier and the soldier’s
family, and membersof the force depend on
this commitment.

2

Capitalizing on existing
interventions withdemonstrated efficacy,
the effects of which areoften cascading, canfacilitate cost-effective
and sustainable
solutions.

Military Families in Transition: Stress, Resilience, and Well-being

families, including deployment-related burdens on spouses and children, economic
concerns, finding services for family members wounded in service, inadequacies inthe dissemination of information necessary to navigate existing services, and unpredictability. These challenges may be exacerbated as the force changes.
These stresses and challenges notwithstanding, most military families are coping
well and even thriving. The families are resilient and, like all families, are capable ofbecoming more resilient as they face future challenges. Sustaining and enhancing thiscapacity for resilience is a priority, and is accomplished by reducing specific stressand exposure to risk when possible, providing access to positive assets, and harnessing the power of human adaptive systems, including the family and the militaryand civilian community. Capitalizing on existing interventions with demonstrated
efficacy, the effects of which are often cascading, can facilitate cost-effective andsustainable solutions.
The forum developed four areas of recommendations that serve these overarchinggoals. These recommendations relate to: (1) leadership considerations to facilitate thewell-being of the soldiers and their families; (2) training and education; (3) design,
implementation, and evaluation of cost-effective programs and interventions to address
the challenges facing military families; and (4) research to provide action-oriented
knowledge on stress and resilience in military families to aid decision-making by theleadership.
Leadership••

Recognize the changing characteristics of military (and civilian) families. For
the military of 2025, it is important to utilize a flexible definition of the family. Whereas families are diverse and evolving, the functions families serve are
relatively constant. However, how those functions are implemented may changeover time. Defining the family in a flexible way facilitates efforts to apply a wide
range of knowledge about families as well as those to harness the adaptive powerof families.

••

During the downsizing, maximize predictability for service members and theirfamilies. Knowing what is up ahead is extremely valuable to families, reducing
their stress level and increasing their capacity for resilience.

••

Identifying family risk and resilience factors can inform policy and direct
research, training, education, and programs to prepare for unknown future
engagements.

••

As is well known, and remains critical to future planning, identifying andimplementing the optimal frequency and duration of deployments and dwell
time substantially impacts service member and family function. To the extent
that the nature and character of deployments change, the issues of frequency,
length, and recovery time need to be reconsidered.

••

Implement programs by first integrating existing capabilities, as this is costeffective and associated with greater sustainability. Partnering with civilian
communities to provide services to Reserve as well as Active components may
provide additional advantages.

••

When allocating resources, determine the most important problems, and how
resources can be used to impact the greatest number of people.

Executive Summary and Recommendations

••

••

••

••

3

Consider cascading effects in cost-benefit analyses. Longer-term outcomes andcost-benefit considerations are often lost in the need to address downsizing andcost efficiency, but failure to take these into account can actually increase costsin the out years.

Identifying family

Now, and as a part of sustained operations in the future, invest in program
evaluation at the outset to more successfully identify cost-effective programs.

policy and direct

Support the development of historical reviews and leadership lessons learned inorder to capture the lessons on family support, family stressors, family resilience,and program operations. Manuals for family programs based on the experienceof the past ten years can facilitate the ramp-up to responding in the next conflict.
Consideration of where and how to house these lessons learned and how tosustain them is important to future engagements.

education, andInclude the Guard and Reserve when planning for transitions facing militaryfamilies, as they face unique challenges such as relative isolation and greater
unpredictability regarding their service.

Training and Education••

Maintain/enhance a leadership education group specifically at the Command andGeneral Staff College and at the War College, that teaches lessons learned fromthe recent and past conflicts on the soldier-family interrelationship to sustain thefighting force. Development of this curriculum should include specific leadershipquestions and tools for solutions in future conflict times.

••

Enhance methods and materials for communicating the issues of downsizing withmilitary families, in order to promote trust and manage expectations of the service
member and their family.

••

Train and maintain the core competency to deal with soldier and family issues inorder to be prepared and to sustain the force. In particular, train interventionists
to deal with posttraumatic stress disorder (PTSD), traumatic brain injury (TBI),
family violence, and child neglect, which are an ongoing part of service life andwhich will be an important part of future wars.

••

For family service providers, review and consider training in the followingintervention skills, which are now part of many family and individual interventions for stress-related exposures: emotion-regulation skills; problem-solving
skills; risk, safety, and motivational communication skills; goal-setting skills;
management of trauma and loss reminders; deployment separation reminders
management; collaborative parenting; and financial readiness/planning.

••

Train providers to: (1) recognize the effects of service member posttraumaticstress (PTS), PTSD, and other combat stress reactions on families; and (2) educate
families to recognize, monitor, and manage these stress responses as a team.

••Consider, where applicable, calling service providers trainers or coaches, in orderto reflect their role as strength builders, and thereby reduce stigma associatedwith care.

••

Sustain and further develop bridging education programs for civilian community
leaders, school personnel, health care providers, and others in the civilian com-risk and resilience
factors can informresearch, training,
programs to prepare
for unknown future
engagements.

4

Military Families in Transition: Stress, Resilience, and Well-being

munity, about military culture, PTSD, and TBI. The present knowledge base ishigher than in the past, but not historically high, considering World War II. Thisknowledge and sensitivity will decay over time. Continuing an active outreachto civilian communities will relieve soldiers and family members of being the
primary educators of their communities and maximize the ability of militaryfamilies to engage with communities. This is particularly true around smaller
installations and with Guard and Reserve service member units.

Programs musttarget multiple levels,
focusing on three
engines of resilience:(1) reduce the level ofstress and exposure torisk; (2) boost access••

When allocating limited resources, consider that cuts in training dollars areassociated with increased risks for lack of necessary skills in future times of rapid
mobilization/response, as was true in the present conflict.

••

Develop fellowships to enhance the skills and knowledge of military providers
and researchers in actionable research, program evaluation, and implementation
science.

to positive assets(e.g., good healthcare,money for food, andsafe communities); and(3) harness the powerof human adaptive

Programs and Interventions••

Programs must target multiple levels, focusing on three engines of resilience: (1)reduce the level of stress and exposure to risk; (2) boost access to positive assets(e.g., good healthcare, money for food, and safe communities); and (3) harness
the power of human adaptive systems, including families and the systems inwhich they reside. A focus on these engines of resilience — reducing risk, boosting assets, and harnessing human systems (RBH) — will promote sustainablechange.

••Aim to reduce risk factors and increase protective factors versus focusing
solely on reducing negative outcomes. It is important to proactively assess andaddress family risk and protective factors as well as risk and protective factorsof individuals.

••

Assess programs in order to determine if efforts to reduce risk and enhanceprotective factors are effective. Assessment requires more than process measures.
Measure both positive and negative outcomes of programs.

••

Develop programs that impact multiple outcomes, thus providing programs
that may be more cost-effective. Evaluate programs using multi-level analysis,
to assess their effects at various levels (i.e., community, family, and individual).

••

The strength of the community (both an installation and the surrounding
community) can sustain families and service members. Interventions that build
community strength and bridge to civilian communities are an important partof a programmatic approach.

••

Include a self-help strategy in programs, in order to empower families and build
their sense of efficacy. This approach helps families and individuals sustain theirown recovery.

••

Consider gateways, pathways, and configurations: (1) Incorporate gateway
managers, considering what the gateways are and how entrée is managed. Thisis central to engaging individuals and families, in order to reduce attrition, as thesystem in which military families live is large and complex. Provide user-friendly
access, and recognize that multiple points of contact are crucial, especially for
those that feel isolated or depressed. (2) Evaluate the pathways between pro-systems, including
families and thesystems in which they
reside.

Executive Summary and Recommendations

5grams. (3) Consider the configuration of programs across the system, acrosscareer time, and across new and emerging types of military families, in order todetermine the matrix of programs that best serves the diverse elements of the
population at various and critical points in their careers. This matrix is a ramp
up — ready to fight — tool for future engagements.

Modularized••

Modularized programs have the advantage that they can be adapted for emerging needs: (1) Identify core elements of interventions that might be universallyeffective and adaptable to different situations. (2) Construct programs focusing
on these core components, incorporating degrees of freedom so that programs
can be adjusted while remaining faithful to the core components. (3) Design
programs that are adaptable up front, allowing families to see an early win andengage. (4) Build a resilience component into programs, to promote problem
solving. (5) Assess continuously and adjust programs as needed, to meet theneeds of different families and situations.

emerging needs.

••

Where possible adapt existing (civilian as well as military) evidence-based programs to serve military families.

••

During implementation, focus sharply on reach: impact is a function of effect size
and reach. A small effect that reaches a large group (i.e., has substantial reach)has a large impact.

••

Implementing new interventions in interdisciplinary teams that include representatives of policy, front-line family work, and intervention science can expedite
program development, evaluation, and adaptation.

••

For expanded reach to active duty service members and families, as well as Guard
and Reserve, leverage existing: (1) mentoring relationships of spouses and service
members within the Army community across active duty, Guard, and Reservefamilies; (2) trusted community supports of each family (e.g. church, school); and(3) technological systems, especially to support geographically dispersed soldiersand their families.

Research••

Leverage existing opportunities: (1) Develop cross-linked historical and current
administrative health and behavior databases on military families and soldiers, inorder to facilitate analyses using new large data-intensive approaches of criticalreal-time and historic family-soldier health and career outcome questions (e.g.,
Army STARRS historical data analyses). (2) Develop similar databases on civilian families, which share risk and protective factors in common with militaryfamilies, for comparison where possible. (3) Increase the use of existing mobile
and real-time technology (e.g., use mobile devices and cloud computing technology to collect and evaluate process and outcome data). (4) Identify and reduce
unnecessary barriers to research and the use of existing data, to facilitate effortsof researchers to contribute to problem solutions.

••Examine family functioning in studies of deployment and recovery, as it is a
critical variable in soldier recovery and reset. Studies to identify the effects oflength and frequency of deployment, characteristics of deployment, and dwell
time on family function can greatly assist in developing interventions to sustain
resilience and promote rapid recovery of deployed service members.

programs have theadvantage that they
can be adapted for6Balance the informative

Military Families in Transition: Stress, Resilience, and Well-being••

The leadership must be educated in the use of tools to recognize the effects ofcumulative stress on families and service members and in intervention strategies
to deal with those effects: Stress is cumulative, and high cumulative risk canoverload the capacity of any system.

••

Identify risk and protective factors, the most effective times to apply interventions,and opportunities to impact a range of negative outcomes for families and individuals. Negative family outcomes for potential intervention include: family violence,soldier and family legal problems, child school problems, soldier and family mental
health problems, family breakup, as well as others. The grouping of these outcomescan provide additional power to identify risk times and groups and interventions
which may work across negative outcomes. Such an approach can strengthen
actionable research that can be used by leadership in a cost-effective manner.

••

Encourage a life-course and career perspective in research: Following individuals
and families over time enables an understanding of change and outcomes over time.
Using current statistical techniques, one can model patterns of change, in order to
identify time points of risk, groups at risk, and times at which interventions may
have maximal impact and, therefore, are most cost-effective.

••

Balance the informative power of long-term research and the immediate need toassist families, utilizing designs that also facilitate ongoing knowledge (e.g., multifactorial, rollout designs). Incorporate multiple outcomes into study designs as a
cost-effective way to evaluate effects of interventions on more than one problem
or system. Given the increasing number of women in service and as heads ofhouseholds, including an evaluation of gender differences in studies of active-duty
and veteran populations will be of continuing importance.

••

Program evaluation is an ongoing need for research going forward and a criticalcomponent of planning for the next conflict time.

power of long-term
research and theimmediate need to assist
families, utilizing designs
that also facilitate
ongoing knowledge(e.g., multifactorial,
rollout designs).

Panel 1: Combat to Garrison—Transitions Affecting the Soldier and the Military Family of 2025

7

1Opening Remarks
Robert J. Ursano, MD and Anthony J. Stamilio, MBA
DR. URSANO: The Forum on Health and National Security is the interface
between health and our military forces that sustains the capabilities of the nation. A
critical component of the health of our forces is the health of their families. Healthis a major aspect of our national security perspective. That can include the healthof the nation as well as the health of our Armed Forces.
The Center for the Study of Traumatic Stress began its work in 1987, and shortly
after that we had our first conference addressing this interface of health and national
security. That conference, which involved the U.S. Air Force, was related to the issueof chemical and biological warfare. The question at that time was, how could troops
operate in Europe in a chemical and biological warfare environment, and how would
they operate when their families were at risk? In particular was the question pertaining to the delivery of medical care. In the late 1980s large sewer pipes were buried
throughout Europe, and they remain there today. Those 20 ft x 30 ft or larger sewer
pipes were the contained environments in which medical care was to be delivered.
Soldiers, sailors, airmen, and Marines would go to the SCPS (Survivable Collective
Protection System) units, leaving their families behind, in order to continue to fightin the case of the chemical or biological warfare attack. We recently pulled out that
information due to the present conflict in Syria, and it has been circulated widely
throughout the DOD because of worries about facing similar problems.
The task for this meeting, as it was in that one, is to think together about what
we have not thought of before. For that meeting and for this one, we went throughhundreds of names to come up with a select group of people that could think throughand think forward. You are that group. Our challenge is to think together and totalk forward looking at what our families in the military face, as they represent a
critical component of our national security structure. We are doing that by having
thought-provoking presentations and discussions. The discussion is key. I want towelcome you to that process, and to the opportunity to join in thinking about how
the issues of health, security, safety, development, and growth of our military families,
and in particular the Army which has been our focus, will influence the capacity of
our national security to protect our soldiers and enable them to continue to perform
and protect our nation.
With that in mind, I would like to introduce Mr. Tony Stamilio. Mr. Stamilio is
Deputy Assistant Secretary of the Army for Manpower and Reserve Affairs. Underhim fall the family programs for the U.S. Army. He reports to the Assistant Secretary

The Forum on Healthand National Security
is the interface between
health and our militaryforces that sustains thecapabilities of the nation.

8

Through the 1990s wewere starting to develop
momentum aroundfamily programs andput many programsin place that are stillserved today.

Military Families in Transition: Stress, Resilience, and Well-beingof the Army. He is a 30-year Army retired officer and a graduate of West Point. He
has served as Chief Administrative Officer in the Capitol Police, and has served in
the Director of Strategic Planning Office for the Deputy Assistant Secretary. He hasreceived the Distinguished Service Medal, the Legion of Merit, and numerous otherawards. It is a pleasure to have him attend and speak with us.
MR. STAMILIO: Although I have spoken in front of audiences before, bothlarge and small, this is the first time I have spoken in front of an academic body.
Therefore, when Dr. Gabbay said, “We have people coming from a wide variety ofacademic environments. What would you like to have put on your name card?” I
looked around and everybody has letters at the end of their name, and I started to
get nervous because I have a letter in the middle of my name. I knew I would nevermake it as a Ph.D. or an L.C.S.W. or an M.D. I thought maybe I could sell myself as
an M.B.A., so I asked Dr. Gabbay to put M.B.A. after my name and then if somebody
asked me about it I could say that I am a, “Mind and Body Advocate.”
The topic of this piece of work that we will be involved in over the next coupleof days is critical — military families in transition. I am one of the key customers
for the work that you are doing. Not that I am the key decision maker in all things
that happen in the Pentagon, but I am the senior advocate for military families.
Therefore, I am interested in what you have to say, and I have three questions that
I hope to gain some insight on by the end of this meeting.
I can only talk about the military families in transition in the U.S. Army over a
period of about 40 years. However, I think that is instructive and sets some framework for where we should be heading in the future because it will be different. In
1974, when I showed up at my first duty station, I had to find a place to live for mywife and myself. I received the standard Army family response in the 1970s frompeople who lived through the Korean War and Vietnam War and were running theArmy, and that was, “Lieutenant, if we wanted you to have a family, we’d have issued
you one.” That was starting at point one, and my bride was absolutely enamoredwith the military from that point forward. The 1970s were a bit of a blur, but in the
1980s I recall spending significant time in Europe as the military won the Cold War.
We did not know we had won it at the time, but without firing a round we were able
to defeat the Soviet Union, and our families were part of that environment. It was
an upbeat, positive environment for families at that time. We lived in Frankfurt, andI recall counting the number of hours that it would take for the Soviets to get fromthe Fulda Gap to Frankfurt. The challenge was to get families evacuated and out
through Rhein-Main Air Base and back to the U.S. before Frankfurt was won over.
Around 1984 John Wickham, who was the Chief of Staff of the Army, published awhite paper focused on families. I happened to be serving in the Pentagon at thattime, and I was part of the first Army Family Action Plan team that put together aseries of actions that became programs for family members. That has since spiraled
into a significant set of policies and programs in support of families, and I could not
be more thrilled about that.
Back then the Army was a fairly static environment, so we could do things
that over the last ten years we probably could not do. We could be more deliberate
about how things happened. Enter the 1990s, and things began to change slightly.
We started having adventures to Bosnia and Kosovo, and that now, blink-of-an-eye
war that was Desert Shield/Desert Storm that took about 15 minutes on the ground,compared to the 11 years that we have been at the current set of conflicts. There
was a significant change in terms of what soldiers and units were required to do.

Panel 1: Combat to Garrison—Transitions Affecting the Soldier and the Military Family of 2025

Deployments were something that soldiers craved because they finally got to do what
they had been training for for years. It created some significant stress on families
because it was not just a training event; something bad could happen. As a result,the Army was somewhat responsive. Families were probably more responsive inwhat they contributed by way of family readiness groups and all that they entailed.
Through the 1990s we were starting to develop momentum around family programs and put many programs in place that are still served today. Obviously, the lastten years of war has created some significant challenges for us, not only because of
deployments and the casualties that are associated with that, but because of the vast
rate of change and the increasing pace of everything that has caused many things to
occur around the country and in the Army. Another significant thing that occurred
during that period of war is the government printed a bunch of cash, and there wasnothing our soldiers and family members needed that Congress was not willing towrite a check for. We had money, we had resources to build programs, and by andlarge we contributed significantly to the support of families as a result of this. It wascertainly not without our problems and not without ongoing challenges, but if wefound a problem or a challenge that we thought could be solved with money, thenwe wrote that check to solve that problem.
The transition now is one that I would like to set the stage for. With a little luck,
the Army will be in a more stable posture in terms of mobility, in terms of deployments, and in terms of conflict and engagement. Certainly, we will continue to be
deployed and be in dangerous places, but hopefully at a slower pace than we have inthe past. You can count on the Army being smaller because it will be perceived as a“peacetime Army.” It got smaller after Vietnam. It got smaller after we won the Cold
War. It will get smaller after these wars. As we all know and fully expect, resources
are going to shrink which will be a significant change. We are talking about halfof a generation of career soldiers who have had an expectation that if it could be
solved with money it would be solved with money. It is half a generation of soldiers
who have spent over half of their time deployed away from their families, and halfa generation of families who have had to deal with the challenges associated withwar, the challenges associated with deployed spouses, and a massively changing
environment. All of that is going to transition again. The question is, in this newenvironment with a smaller Army and with a more stable deployment cycle butwith fewer resources, how should we be transitioning the support that we provide?
I would offer that in the 1970s and 1980s life was simple and predictable. We
did not know how easy we had it, and we only had one enemy that we had been
watching for 30 years. From a family perspective, it was a normal two to four year
cycle, and then you PCS (permanent change of station) to a different place. Fromthe perspective of families, the impact of the military on families, be it casualties orsignificant deployments, was not terrible. Going forward, we will still have deployments. We will be serving with that half a generation who is now older, but who
have lived through, survived, and hopefully thrived in an environment of tremendous
turmoil and tremendous conflict. We will be living with those soldiers and family
members who have not done so well during that period, but are still serving withus. The Army will also be more populated with this younger generation. How willa bunch of Generation Xers manage with a bunch of Millennials being in the rank
and file in an environment of fewer resources? There are a number of dynamics there,
including the fact that we have half a generation of war heroes who have spent along time walking the walk in very dangerous places, and also a growing number

9With a little luck, theArmy will be in a morestable posture in termsof mobility, in termsof deployments, and interms of conflict andengagement.

10

If we only had one
dollar left, what
would you investthat dollar in for the
support of militaryfamilies in transition?

Military Families in Transition: Stress, Resilience, and Well-beingof people who do not have a great deal of that combat experience. What does thatsay for the force and what does that say for family members?
Over the course of this conference I charge us with the responsibility of answering three questions. First, if we only had one dollar left, what would you invest thatdollar in for the support of military families in transition? The second question
involves the collection of difficult issues that are being tracked. These issues are
suicide, child abuse, drug abuse, PTSD, risky behaviors, and several other issues
that we see statistics on all the time. How can we make some sense of that? Basedon the analyses of all of these things, what should we be doing next? The third
question is, what are the implications of the changing generational dynamics thatwill be evident in the Army over the next ten years? Given the generational changes
that will be occurring inside the Army in terms of the soldiers who have served incombat and are veterans, and those coming in and may not have ever had a chance
to serve in that type of environment — what are the implications for that? In termsof the demographic changes in the Army, given what we are doing with same-sex
couples and the diversity associated with that — what are the implications? Whatshould we be doing about that? How should we be thinking about all of these issues
as we fashion the thought pieces for the future?
I certainly do not have the answers, but as a fan of all that you do and as aconsumer of the work that you are doing, your insights in these areas and many
more would be extremely useful to me. I thank you all for doing all that you havedone in support of military families, and I look forward to the next several days of
discussion.
DR. URSANO: Everyone here today is coming from different value points anddifferent perspectives, and that is the tremendous value of this type of meeting.
In the forum I mentioned earlier, how would you begin to understand chemicaland biological warfare? One thing we did was bring in NASA. We also brought inpeople that understood submarines because they understood how people live in acontained environment. Similarly, for some of you, you will hear people talk aboutcommunities, but you work with individuals. You could be someone who delivers
care, but you will hear people talk about populations. The challenge is always how
to listen across the boundaries, how to think outside the box, and how to address
Mr. Stamilio’s wonderful charge, which might be captured as, we need to be able
to think about what are we going to invest in, what our actionable items are, andwhat the future holds.

Panel 1: Combat to Garrison—Transitions Affecting the Soldier and the Military Family of 2025

11

Military Families in Transition:
Stress, Resilience, andWell-Being
Speaker: James E. McCarroll, PhD
DR. McCARROLL: It is my pleasure and privilege to be a member of the firstpanel, and to provide you with an overview of the DOD and the military family andparticularly, the Army family. I will also talk about the current and future Army. The
purpose of this is to acquaint those of you who are not in day-to-day contact withthe military with some of the major themes in a broad way.
The first issue I will address is transformation and the implications of the transformation for the structure of the military, its mission, and implications for families.
The transformation poses a number of challenges, some of which might be familiar
to you. Finally, I will present some possible approaches to solutions and some of
the family research issues.
The Department of Defense (DOD) is a big force consisting of approximately
3.6 million people. By comparison, the island of Puerto Rico also contains about
3.6 million people. The active duty military consists of approximately 1.4 million
people including the Coast Guard, which is part of the Department of Homeland
Security. Also there is a wide variety of military reservists, active and retired andstand-by, and almost one-million civilian personnel in the DOD. The Army is thelargest military service comprising approximately 40% of the DOD. The Navy andthe Air Force are approximately equal, at about 22 or 23% each, and the Marine
Corps is the smallest service.
The number and percentages of married service members indicates largely amarried force. The Army and the Air Force are approximately equal at about 60%,
the Navy is above 50% and the Marine Corps has the smallest percentage of married personnel. The total is well above 50 percent. There are married personnel withno children, those who are married with children, dual military couples, and single
parents. These are complex populations to think about in terms of the upcomingtransitions for Army families.
I will now compare the DOD to the Army. The Army consists of about 1.4
million personnel including service members, spouses and children. By comparison,
Dallas, Texas, has a population of about 1.2 million. We are talking about very, very

The Department of
Defense (DOD) is a
big force consistingof approximately
3.6 million people.
By comparison, theisland of Puerto Ricoalso contains about
3.6 million people.

12Child neglect isthe most frequent
type of childmaltreatment in
the Army.

Military Families in Transition: Stress, Resilience, and Well-being

large numbers of people, spread all over the world, in installations and in communities, and living as individuals.
The Army is also a young force. About two-thirds of the Army population isunder 30 years of age. Almost half of the children are under 6 years of age. A recent
Institute of Medicine (IOM) report indicates that children less than 3 years of age
are at the greatest risk for child maltreatment. About three-quarters of the cases ofchild maltreatment are neglect cases.
There are many different Army reserve components. The Army National Guard is
the largest at about 42% and the Army reserve is about 24 percent. A large numberof people have served in the reserve forces and many are still serving. The Army
Guard has activated and deployed 376,000 people, the Army Reserve activated212,000 people, and there are over 50,000 currently serving.
Where are all of these Army personnel located? Active Army headquarters arelargely in the eastern United States with some in the Midwest and some in the South.
Many states do not have an Army Reserve headquarters. If you live in the western
United States, and you are in the Army Reserve, you might have to travel a long
way to your reserve meeting. The Army Guard is a different institution. There is an
Army Guard unit in every state.
What are the current Army missions? In general, the Army has to be prepared
for a number of contingencies. First is the counter-insurgency and anti-terrorism
mission. Humanitarian and stability missions are also important. Third, the Army
doctrine has long been to be able to fight a two-front war. At one time, the U.S. wasprepared to fight both the Soviets and the North Koreans. I assume that the doctrineof fighting the two front war is still in force. Finally, the Army has to be prepared
for limited engagements, including nuclear, chemical, and biological warfare. We are
all aware of the risks of war in places like Iran and Syria.
I will now address more about Army structure. The left shoulder of the Army
uniform has the patch for the current unit of assignment. The right shoulder has
the patch for the unit with which the individual was deployed. Divisions are madeup of brigades. During the era in which the U.S. was concerned about the Soviets
coming through the Fulda Gap in Germany, we were prepared to fight in divisions.
The Army figured out that this was not going to work in the current world environment and they began the process of what is now known as the transformation.
This transformation is currently ongoing and is expected to go through 2017. In
this configuration of combat units, the force is modular, can be deployed rapidly,
and can be task organized to respond to any potential mission. Divisions generally
have somewhere between 12,000 and 15,000 personnel. Brigade combat teams now
consist of about 3,500 personnel. Not long ago, the plan was to have 45 brigade
combat teams, however, that has since been reduced to thirty three. These changes
have been very rapid.
The Army will have improved information and weapons technology in whichmuch equipment will be operated by computers. This means that the Army will
require highly trained soldiers to operate this equipment and to operate it in different environments. As a result, the training commitment is going to be very heavy.
I will now address more specifically brigade combat teams in a division. In thisexample, there are four combat brigade teams, an aviation brigade, a sustainment
brigade and a headquarters battalion. Each brigade combat team has its own support. It has its own armor, its own infantry, and its own support. This configuration
allows the Army to go to war with a tailored force.

Panel 1: Combat to Garrison—Transitions Affecting the Soldier and the Military Family of 2025

Now let us look more specifically at Fort Hood, Texas, the largest installation in
the Army. Fort Hood includes many different components including a corps headquarters, a division, and separate organizations of engineers, intelligence, chemical,
and medical personnel. Physically Fort Hood is a very large installation. It includes
340 square miles, 7 elementary schools, 2 middle schools, 18 fitness centers, 2 commissaries and a large number of recreational facilities.
In general, you will find 4 types of support facilities on almost all Army installations: 1) morale, welfare and recreation facilities that provide recreation for soldiers;
2) the Army Community Service that is the lead family service agency in the Army; 3)Child, Youth and School Services, which provides support for children that include
gyms, after school activities, daycare centers, and many other child centered activities; 4) The Army Medical Department or Medical Center.
What are the implications of the upcoming transitions? Deployments are notgoing to go away. The current war will end, but there will be training deploymentsthat will occur worldwide. Therefore, the training environment will continue to beimportant. However, resource constraints will be imposed. What are the implicationsof those constraints? As I looked at the literature that was supplied to you for thismeeting, I noticed an emphasis on prevention. There are questions of how prevention
will be funded and how it will be targeted. Will we have standardized programs? Ifthere is a family program at Fort Hood, is it going to be the same program at Fort
Stewart, or will it be based on the military units at the installation there and on theindividual capabilities of the individuals who are on the installations?
There will be increased joint support. Under the joint basing concepts, there
are many installations in which the Army is joined with the Air Force, Navy or the
Marine Corps. That will have implications for how installations are run, the services
for families, and how services are delivered. It is a cultural change and one thatfamilies will have to adapt to.
There are many other upcoming family challenges. These include keeping
family stability, mental health needs, and the needs of single soldiers that includes
single parents. A critical need of parents is being able to take care of children during deployments. .Soldiers suffer battle injuries and non-battle injuries. We have
many different populations of wounded service members including those who haveexperienced other types of trauma during their deployments. Substance abuse is an
important factor in many of these situations. Women’s health issues, including sexual
harassment and sexual assault, are an important focus for care of female soldiers. In
addition, there will be financial stresses. Families have financial obligations imposedon them through deployments and through moves, which highlights the importanceof personal resources.
Family maltreatment is an important issue for the Army and has been an interest of the Department of Psychiatry at USUHS for a long time. Child neglect is themost frequent type of child maltreatment in the Army. During the period 2004 andslightly before, there was a large increase in child neglect cases. These rates have notdecreased during the recent sustainment of the conflicts in the Middle East, . Finally,
many people who come into the military have had difficult experiences in their lives.
They bring those experiences with them.
What are the goals of Army family programs? Will there be standardized programs or individualized programs at the installation level? How will prevention
and treatment programs be delivered? We live in a social media environment, a pop

13

In general, you will find 4
types of support facilitieson almost all Army
installations: 1) morale,
welfare and recreation
facilities that provide
recreation for soldiers;
2) the Army Community
Service that is the leadfamily service agency in
the Army;
3) Child, Youth and
School Services, which
provides support forchildren that include
gyms, after school
activities, daycare centers,
and many other childcentered activities; 4)
The Army Medical
Department or Medical
Center.

14

What are these
programs going tocost, and how do wemove from research
to practice? How
do we take what weknow and implement
programs and makethem available,
accessible, andworkable?

Military Families in Transition: Stress, Resilience, and Well-being

culture for many people. How do you get messages to them? How do you teachthem? How do you work with them?
Evaluation is a critical component. People functioning in Army staff environments have many questions. What are your limitations? What programs do you
want to keep and what programs can we get rid of? What are these programs going
to cost, and how do we move from research to practice? How do we take what weknow and implement programs and make them available, accessible, and workable?

Panel 1: Combat to Garrison—Transitions Affecting the Soldier and the Military Family of 2025

15

Army Family Programs Overview
Speaker: Lynn L. McCollum, LCSW
MS. McCOLLUM: Thank you, Dr. Ursano, for inviting me to attend the conference. I am delighted to be here and look forward sharing information with you.
Today I will talk about the Army Family Programs that currently exist at 78 Army
Community Service (ACS) Centers located at garrisons across the Army. I will also
talk about Army OneSource, which is our alternate service delivery system for thosesoldiers and families who do not live on Army installations. We will look at ouroperating environment, what we do in those ACS Centers across the Army, and atsome of our service and program data including the demographics of the soldiersand family members who will be coming in the Army of 2020. We will explore whatsome of their needs might be and how we can perhaps address some of the questions
that Mr. Stamilio raised.
Not only have we been at war for 12 years, but we have also had a significant
economic downturn, which has impacted the civilian world and our families suchas when they move and when they are able to sell their home. As we go throughsome of the transitions, we expect the Army to downsize from over a 600,000
person force to about 490,000. We will have folks that are transitioning out of the
Army who do not necessarily want to do so and transitioning into an economy that
does not yet have the jobs and careers that offer the same levels of responsibilities.
Earlier, we mentioned funding decrements. I am very concerned about this because
those resources that go to our family programs are a very small percentage of ourinvestment, but the return on the investment is very high for the amount of moneythat we put in.
We still have new families joining the military every day. Those young folks, 18
or 19 years old, who are coming in still need to learn basic life skills and resiliency
skills. We often say that the Army grows its own. An interesting thought is that thosefolks who are reintegrating today, have children who are very likely to join the Armyor the military and make that a career. Sometimes the success of reintegration has an
impact on the children that will become tomorrow’s soldiers and family membersin the Army.
Families like to have some sense of predictability and yet we have an unpredictable environment right now with the type of transitions that we are looking at. A
really good question is, “How do we measure what it is that we want to prevent?”
The media reports that we have serious problems with suicide, with child and spouseabuse, and with sexual assault. But we have many families who have done very

Families like tohave some senseof predictability
and yet we havean unpredictableenvironment right
now with the type oftransitions that we arelooking at.

16

With soldiers we tend
to look at re-enlistment,
and there have beenrecord numbers of
re-enlistments. But withspouses we tend to lookat satisfaction with theArmy way of life.

Military Families in Transition: Stress, Resilience, and Well-being

well. They are resilient and have managed to cope with the demands of the military
lifestyle and often thrive — not just cope. Importantly, many folks do really well.
Our rates of child abuse are much less than in the civilian sector. It is also importantto take a look at who is doing well, why they are doing well, and what has helped
them to do well. It is important that as we go through transitions we remember what
the job is about. The job is about those families that we are supporting.
Over the past three years, as part of the Base Realignment and Closure, theArmy’s family programs organization, Family Morale, Welfare and Recreation
Command, moved from the Washington, D.C. area to Fort Sam Houston in San
Antonio, Texas. In addition, the Army deactivated the Family Morale, Welfare andRecreation Command as a command and became an agency under the Installation
Management Command. Sometimes, those kinds of transitions are good in that they
force you to look at what the organization does, but do we lose focus on the people
that we serve? You always have to keep that in the forefront — who are we serving
and what are we trying to accomplish.
Every 4 or 5 years the Army conducts a survey of Army spouses. The last survey
was conducted in 2010. One of the interesting points was that there was an increasein Army spouse satisfaction with the Army way of life. That is something that is
important to measure. With soldiers we tend to look at re-enlistment, and there
have been record numbers of re-enlistments. But with spouses we tend to look at
satisfaction with the Army way of life. Would they want their spouse to continue tomake the Army a career? Those are the numbers that have increased. If you want
to see the whole survey, you can Google it, and can get that information. It is notjust that there is stress on families, but there is also satisfaction with the Army wayof life. I thought that was pretty remarkable because in 2010, when the survey wasdone, we had been at war for a long period of time.
The other key point is that it is a young Army and that is one of the things weneed to take a look at. As many of you who have children or nieces or nephews thatare 19 or 20 years old know, their phone is a permanent part of their body. They keep
it with them all the time. They would rather text then talk on the telephone. Thereis some research about how they learn — that learning needs to be fun. They areused to the internet and engaging with technology in a fun way. Those are important
things to keep in mind as we look at the future needs of families and soldiers.
We want to promote self-sufficient families who can manage the rigors of Armylife. We want safe homes for our families and we want cohesive communities andpeople who participate in their communities. We want to support the focus of the
Army which currently is reintegration. If the cycle changes, which it is likely to, thenwe need to be able to focus our efforts where families are focusing their efforts.
During the last couple of years, we have focused on ensuring access to services
for wounded warriors and their families and for surviving family members. How
do we keep those folks connected to a way of life, and then help them to transition
to a new way of life over a period of time? I think we have done an excellent job ofchanging the tide which is difficult. It does not change the tragedy, but we hear backfrom those surviving family members about the support they get from the Army.
The key question is how do we sustain the promises that have been made overthe last 5 or 6 years, and the support systems we have put in place in a fiscally constrained and challenging environment? With reintegration, we are seeing just the tipof the iceberg. We do not know the full picture yet, as families are just starting toreintegrate for an extended period of time. What kinds of issues might we see, andPanel 1: Combat to Garrison—Transitions Affecting the Soldier and the Military Family of 2025

what kinds of support are needed? I spoke with a social worker here this morningfrom Boston University. She talked about work they have been doing with home
visitation and working with families. This brings up some interesting issues that may
be helpful with reintegration over the long-run.
We have a great many family services on our Army installations. Included in the
ACS Center are the Exceptional Family Member Program, programs for families
with special needs, survivor outreach, and the Sexual Harassment Assault Response
Program (SHARP). These programs are designed to provide support for soldiersand families. Army leadership is currently focused on the Ready and Resilient Campaign. Many of the core programs of this campaign are in the ACS Centers. These
include the Family Advocacy Program, which is child abuse and domestic violence
prevention, intervention and response, the New Parent Support Program for home
visitation, and the Exceptional Family Member Program that supports families withspecial needs. There has been a great deal of focus in that area over the last coupleof years — not only in the military, but country-wide. It is a fragmented system of
support services for those families that have medically fragile children and disabledchildren. When they move from place to place they encounter problems with state
regulations. For example, if you are in New York and your child is on a Medicaid
waiver receiving many hours a week of respite care, and you move to Fort Campbell, Kentucky, there may be a 7 year waiting list for a Medicaid waiver. How do
we meet those needs for those families? How do we assist them? These are families
that tend to re-enlist at higher rates because they have access to medical care andmedical services.
The Army has also focused on mobilization and deployment, another ACS
service. These programs assist families with all stages of deployment and also withemergencies. Another ACS program is Financial Readiness. Finances and relationships are often at the root of some of the issues with suicides. How do we provide
the right kinds of education and reach families early?
The Army Family Programs under the leadership of one of my mentors, Delores
Johnson, established a partnership with Cornell University to ensure that we lookedat outcomes of our programs. Financial readiness is one of those programs where
we have data that show if you can reach families early and provide first-term education, their financial literacy increases, their indebtedness decreases, and that if family
members participate with the soldier the result is even better. There has been real
growth in the usage of our programs and service. It is telling you something about
whether folks find services helpful or not. Our needs assessment data from Cornell
tells us that when people use services, they find them to be helpful the majority ofthe time. Research shows that when families or individuals participate in programs
designed to build resiliency and self-sufficiency they learn skills they become more
resilient overall.
Although approximately 60% of soldiers and families do not live on Army
installations, we have made outstanding use of the Guard and Reserve during thelast 12 years of war. How do we provide a common level of service or support
to those families not living on Army installations? Our leadership has been quite
insightful by leveraging technology and community partnerships to provide support
to the geographically dispersed soldiers and their families. If you look at places likeIdaho, you will find that there is a significant military population in a very ruralstate with limited garrison support. They also have possibly the third highest suicide
rate among service members. We have been able to mobilize community agencies in

17

During the last coupleof years, we havefocused on ensuring
access to services forwounded warriors
and their families andfor surviving family
members.

18

People have also
made use of Army
OneSource, especiallythose individuals
and families who
are geographicallydispersed. Whenfamilies are given
information, and know
how to get assistance,
they can make better
choices and get theirneeds met.

Military Families in Transition: Stress, Resilience, and Well-being

those locations. How does the broader community in the State of Idaho develop an
action plan to address that concern?
People have also made use of Army OneSource, especially those individuals andfamilies who are geographically dispersed. When families are given information,and know how to get assistance, they can make better choices and get their needs
met. The public at large has overwhelmingly wanted to help support soldiers andfamilies. We have tried to focus in areas that align with Army strategic concerns andinitiatives. We have looked into how to increase awareness for behavioral healthproviders. The National Alliance for the Mentally Ill has partnered with us andmade sure that their professional chapters across the United States get training on
military culture and treating the invisible wounds of war. As a result of educatingthem on military culture and on PTSD and TBI, when a soldier or his or her family
use the services of a provider who is not associated with the Army, they do not haveto educate them about what it is like to be part of the military. These are some of
the things that we have done to support and increase the awareness and knowledge
in the private sector so that we do a better all-around job of supporting folks.
Last year we had a group come in to do some strategic planning about what we
think the soldier and family of 2020 will be like. It goes back to what we think someof the problems will continue to be the same. We are still going to have relationshipissues. We will still have financial and consumer advocacy issues. But, the way inwhich some of the younger generation learns may be different. They have definitely
leveraged technology. It is important to continue to put our efforts towards the
younger group that is coming up. These are some of the areas to invest in if we wereplanning to invest that last dollar.

Panel 1: Combat to Garrison—Transitions Affecting the Soldier and the Military Family of 2025

19

Military Families: The Aftermathof Ten Years of War
Speaker: Brian D. Leidy, PhD
DR. McCARROLL: It is my pleasure to introduce Brian Leidy from Cornell
University. Brian has a long history of conducting military relevant research withhis colleagues at The Bronfenbrenner Center for Translational Research. Brian willtell us about the current state of Army families and how to deal with the issues of
evaluation.
DR. LEIDY: Thank you for the opportunity to share my thoughts about the
future of military families. This panel covers the effects of transitioning on soldiersand military families in 2025. I do not think there is much we can say with a great
deal of certainty about soldiers and families 12 years from now, however, basedon a good understanding of where we are now and how we got here, there aresome important factors that need to be discussed and dealt with over the next 3
to 5 years. I am approaching this from the perspective of someone who has done
program evaluation and needs assessment in military family programs for the last
18 years with the Army, the Marine Corps, the DOD, and more recently, with Army
Reserve family programs. Much of what I am going say will be framed in evaluation
terminology that can be applied to family programs being delivered. I will address
the underlying logic for family programs including how they work and how they
accomplish what they need to accomplish.
Family programs support soldiers, civilian employees, and their families bymaking sure they have the information they need and are ready to face the challenges of military life. These programs teach in large group settings, such as in large
group briefings, classrooms, and one-on-one. They coach and leverage the natural
mentoring relationships that exist within the Army community. In many ways, family
programs get soldiers and families to stop, sit down, focus, get organized, make aplan, and then talk about how they are going to execute that plan. These programs
address issues such as: financial, relocation, deployment, and employment. This is
not done in a static environment. A great deal of this goes on in an environmentthat is constantly evolving. That is what I want to focus on today because in the 18
years that I have been doing this research, there has not been a single game changer
that has been as big as the decade of war that we have just completed.
Two million service members have been deployed in the last 10 years. Eighthundred-thousand have experienced multiple deployments. That number is par-In many ways, family
programs get soldiersand families to stop,
sit down, focus, getorganized, make a plan,and then talk about
how they are going
to execute that plan.
These programs address
issues such as: financial,relocation, deployment,
and employment.

20

The person who ishaving cognitive
issues will havedifficulty processing
information such asplanning, organizing,and preparing. Family
members who areexperiencing secondary
trauma can experiencesimilar issues.

Military Families in Transition: Stress, Resilience, and Well-being

ticularly important because soldiers and service members who experience multiple
deployments are 4 times more likely to experience serious mental health outcomes.
Three-hundred-thousand suffer from PTSD or major depression. I have also heardthat 20% of returning soldiers and other service members are experiencing PTSD.
Forty-four-thousand soldiers were severely injured with amputations, burns,
gunshot wounds, shrapnel wounds as well as other physical injuries. The “signaturewound” of the last 10 years of war is traumatic brain injury (TBI). An estimated 10
to 20% of soldiers returning from deployment have mild, moderate, or severe TBI.
The Hoge article from 2008, one of the readings on the forum website, maps out therelationship between combat stress and TBI. There are negative outcomes associatedwith TBI and PTSD. Outcomes associated with TBI include: poorer performance on
cognitive tests measuring decision-making and planning skills, lack of self-control,mood changes, problems sleeping, and memory loss. Negative outcomes associatedwith PTSD include: increased risk for depression, substance abuse, severe anxiety,obsessive-compulsive disorders, Alzheimer’s disease, and suicide.
There are Army programs that are designed to support these troops such as
Warriors in Transition and the Army Wounded Warrior Program (AW2). The Soldierand Family Assistance Centers were originally designed for the 44,000 soldiers withburns, amputations, etc., but early on they were seen as being a good resource forthese folks as well. The problem is that there are eligibility criteria. For example,
soldiers are required to have at least a 30% disability associated with one combat
condition, or 50% with all combat conditions. Not all of the injured soldiers ingarrison are eligible for those programs. They are eligible for the medical programs
if they can get treatment, but they need to do that more or less on their own. They
need to figure out what is going on and get the help they need. While the culture ofjust toughing it out and doing it alone is receding somewhat, there still are many
soldiers with these symptoms that are uncomfortable coming forth and getting treatment. In addition, they are not very supportive of family members who are trying
to get treatment on their behalf or trying to deal with the secondary trauma issues.
As we know, PTSD tends to get worse if it goes untreated.
Where does that leave family programs? The primary model of family programs
is to get people to sit down, stop, focus, pay attention, get organized, and makea plan The person who is having cognitive issues will have difficulty processing
information such as planning, organizing, and preparing. Family members who areexperiencing secondary trauma can experience similar issues.
The paper by Cesur and Sabia, on the forum website, examines the relationshipbetween PTSD and family violence. A good example of how this plays out is in oneof the Army’s family support programs, New Parent Support. Research indicatesthat support programs for new parents have practically zero efficacy when there isdomestic violence in the household. For example, if most of your time is spent trying
to avoid conflict and confrontation and protecting yourself, you are probably notgoing to focus on routines and meeting children’s needs. This is the biggest contextual factor that family programs are dealing with because it affects so many people.
However, it is not the only problem that family programs deal with. The Army, likeall the military services, has a tendency to raise its own. Today’s Army families areraising tomorrow’s soldiers, to a large extent. When we are talking 10, 15, 20%
of Army families having difficulties such as these, it gives one pause to think whatsoldiers and families might be like in 2025.
There are other issues that we need to consider going forward. Family programs

Panel 1: Combat to Garrison—Transitions Affecting the Soldier and the Military Family of 2025

have always had difficulty engaging some soldiers and some families and, inevitably,
those seem to be the ones that they need to engage the most. Prior to the past 10
years of combat there was stigma associated with some of the family programs. That
waned a bit, or went away for a while during these years of combat. Now that weare getting back to a non-combat situation, it remains to be seen if that stigma will
reemerge.
From 2003 to 2008, 75,000 individuals with criminal backgrounds were given
waivers to join the Army. These individuals have social histories, backgrounds, andtraits that are far more predictive of family violence than combat stress and deployment. This is not nearly as large a group as those with TBI and PTSD, but it is asignificant and important group that needs attention going forward. Many people
say that these issues will just go away and that in 3 to 5 years, these people will
either make the adjustment and the transition and get the issues that they are facing
under control. They will still be in the military, or else they will be gone and will be
the VA’s problem. Over the next 3 to 5 years, these types of issues will be dominant.
Over the last 20 years, there has been a trend towards more and more single
parents. I do not think that is likely to change. It is very stressful for both the soldier
and the family. Both the family and the military are very jealous institutions. They
want 100% of the individual, their time, and their focus. It is very hard when you
are a single parent. It is a more difficult situation for female soldiers or active duty
women who are parents. Unfortunately, in many cases, even if the father is civilian
and unemployed, the bulk of the child care and household responsibilities fall on
the active duty mother.
We talked about resource constraints. They were dwindling prior to sequestration and sequestration has just added to that. I am not expecting a new budget by
September 30th, or even a continuing resolution that is going to change or improve
this situation very much. My understanding right now is that only 70% of the family programs staff positions are filled. Many of the positions are currently vacant.
Because of promotions, retirements, and people leaving for other reasons, there has
been a freeze on hiring and refilling those positions. When the money does come they
will be dealing with all the staff turnover issues and trying to get people up to speed.
Transitions are never easy, and I am not anticipating that this one will be easy.
That is not just because I come from a background of program evaluation. Navigating any kind of a transition is easier when you have good feedback systems in place.
Process metrics are very helpful in terms of not only making reporting easier, butthey also help you identify who is and who is not being served. They also pose somepossibilities in terms of how you can reach out to the ones that you are not getting
to and do a better job of serving the entire population. If you have a good set ofprocess metrics in place you can track trends or spot trends much earlier.
Outcome metrics are important because you need to know what is working
and for whom. For those programs that are not working, you need to make adjustments and modifications in order to be successful with a much larger portion of the
population that you are trying to serve. Outcome metrics also give you some ways
to judge one program against another. If programs are trying to accomplish thesame outcomes, then outcome metrics can give you some suggestion of where you
are getting more bang for the buck with different sub-groups of your population.
Finally, translational research is important when you want to make sure that
there is fidelity when implementing program changes. This is true whether you are
just incorporating the latest research into an existing program or making wholesale

21

Outcome metrics areimportant because youneed to know what isworking and for whom.

22

For those programs
that are not working,you need to makeadjustments andmodifications in order
to be successful with amuch larger portion of
the population that you
are trying to serve.

Military Families in Transition: Stress, Resilience, and Well-beingchanges. You want to make sure that you are introducing changes as they wereintended. In addition you want to test to make sure that you are getting the resultsthat you intended.

Panel 1: Combat to Garrison—Transitions Affecting the Soldier and the Military Family of 2025

23

Panel I Discussion
Moderator: Robert J. Ursano, MD
DR. RICHE: I do research at the Center for Naval Analysis. I would like tounderscore Ms. McCollum’s point on understanding how to talk to the newer
generation. A few years ago we did a five-year project for the Air Force looking atdiversity and its effect on performance throughout the service. They thought we weregoing to come back with a talk about race, ethnicity, etc. But the most troublesome
aspect of diversity, in terms of performance, was when people of different functional
specialities work together and when people worked with other services. My pointis that the only troublesome demographic was age diversity, people of different
age groups not working together and having different values and different ways ofthinking about things.
DR. PASQUINA: I am from the Uniformed Services University. I am struck withwhat we were charged to do. If we were down to our last dollar, what would weinvest in? A great number of ideas have been presented. It seems like the military
has a tendency to just create new programs on top of new programs, on top of new
programs to solve problems without necessarily evaluating the effectiveness of eachone. An example of this is that ACS (Army Community Service) has many programs
available to our service members with TBI and PTSD. For those who have difficulty
making decisions and difficulty navigating complex systems we create a more complex system for them. We give them another counselor or another case manager tohelp them with that. Now instead of having one case manager they have five, each
one telling them something slightly different. I am outlining all the limitations thatwere presented, but the essence of my question is, how do we evaluate the effectiveness of each of these programs that the Army, Navy and Air Force have established
for our service members? Do we have any unified way of looking at the effectivenessof these programs?
DR. URSANO: You actually raised another point, and one that is central. You
are highlighting a systems-level issue, which is, never mind the programs, how dopeople navigate between them? How do people know how to get to a resource? I
can make that all come alive for any of you by saying, try and get an appointment
with your doctor, and then try and figure out how to ask them a question three days
later, and then a question after that, three days later. The question of navigation isa target for intervention, and a target that cuts across all of our areas. We can put
out as many programs as we want. Are people getting to where they can get what

But the mosttroublesome aspect ofdiversity, in terms of
performance, was whenpeople of different
functional specialities
work together andwhen people worked
with other services.

24

Try and get an
appointment with yourdoctor, and then try
and figure out how to
ask them a question
three days later, andthen a question after
that, three days later.
The question ofnavigation is a target
for intervention, and atarget that cuts acrossall of our areas.

Military Families in Transition: Stress, Resilience, and Well-being

we are offering? I want to highlight that because of this issue of trying to get people
to think out of the box.
DR. KLEYKAMP: I am from the University of Maryland. Most of my research ison veterans and employment. The word transition or in transition means something
very different to me than the way I hear transition or in transition being used today.
I was struck by that throughout and then by seeing the evidence of the dramaticincrease in the use of the Exceptional Family Member Program. These are people
who are much more likely to re-enlist and be retained in the Army, in large part,
because of the services and support provided to those family members. As much as
there may be many needs for military family members, we provide a great deal of
support and a safety net for military families. When they become in transition in adifferent way, they lose many of those supports.
We have retained some of the programs for people who lose a family member
through loss of life but when people separate from the Army family by leaving, what,
if any, responsibility is there for the Department of Defense to think about family
members’ preparation for that transition. Who is transitioning into what?
DR. KESTER: I am from the Uniformed Services University. Previously, I was
responsible for a many large research programs that were works in progress, andgoing back and saying, “What is it that you are doing? Is it really providing value?”If we make the analogy from healthcare and seeing your doctor and getting lab
tests done, it is a system adventure. Yet when we look at these support activities formilitary family members it is another type of system. We see in healthcare, driven
in part by cost, in part by legislative fiat and other things, that there is an increasingemphasis on value and quality.
This brings into perspective the whole aspect of whether we are able to deconflict the well-intended, well-meaning, and sometimes well-funded programs?
When you map them out, you find a crazy quilt of programs. If you want to invest
for the future we must assess what we are doing now, and whether we can develop
rational, cogent approaches to make a program better, and provide better value. The
systems engineering approach while sounding somewhat technical is really not. In
many ways it is just common sense.
DR. SPOTH: I am from the Partnerships and Prevention Science Institute at
Iowa State University. I also have a variation on the theme question concerning
how you maximize the bang for the buck, and moving from the status quo to the
future, but specifically with the focus on prevention. I was also struck by some of thethemes across the three presentations. One is that there will be increasing demandson the family support systems and at the same time there are going to be decreases
in resources. If you think about the idea that there needs to be increased emphasis
in prevention programming you also think about how that necessarily requires
an infrastructure development for sustained quality implementation, preferably
evidence-based programming. This must be integrated with evaluation of promisingprograms that are already part of the system. The result is that you have an incredible
increase in demand on resources to move in that direction.
It is really a question about how to think strategically at all levels, at the systems
level, at the program level, and at the individual level. How do you move in that
direction when you know you are confronting this incredibly difficult situation
where resources are scarce and at the same time you want to make some significant
changes? One specific illustration of what we know is that in order to get to the point
where you understand what is the most optimally cost-efficient and cost-effective

Panel 1: Combat to Garrison—Transitions Affecting the Soldier and the Military Family of 2025

way of programming, you have to invest on the front end in doing evaluation. How
do you incorporate that to get to the point where you are maximally using theresources that are available, especially in the context of scarce resources?
DR. URSANO: You are saying that to invest the dollar in program evaluation
science or activity or skills and capability, that you will not be able to answer thatquestion unless you have that capability. Where is that capability? It is sufficient?
Is it robust? Will it be able to respond to the ongoing demands coming up ahead?
DR. ALDWIN: I am a developmental health psychologist. One question I have iswith all this plethora of family programs is how well they coordinate with programs
at the school system? One of the themes that we are raising is that for the next
generation of soldiers, good emotion regulation capabilities are really important. If
the focus in on the kids you could actually cut through many programs by simply
investing in self-regulation programs in the schools for all children, regardless ofwhether their families are functional or dysfunctional. My question is, does theschool system at Fort Hood and other places have these programs in place? That iswhere I would invest my dollar if I had a choice.
DR. URSANO: One of the things you are asking is about the delivery system.
What are our best delivery systems for any given program? Does the school system
offer a delivery system and is it being maximally and effectively used for the particular programs it would be appropriate for?
DR. MACMILLIAN: I am from the Offord Center for Child Studies, McMaster
University in Canada. To what extent do you have a systematic approach to looking
at the evidence for certain programs? I am a family violence researcher; therefore
I will use family violence as an example. What do we know about the evidence forthe effectiveness of certain programs and their generalizability to the military? Weoften re-invent the wheel. New programs spring up and are put in place and we do
not know if they do more harm than good.
The assumption seems to be that doing something is better than doing nothing.
That is not always the case. With many prevention programs we do not measure
whether they are harmful. We do not do a very good job of measuring their benefits,
but we also do not incorporate ways of measuring their harms. Finally, there aresome general assumptions in family support programs like home visitation. We
assume that just by virtue of what they are that they are effective. However, we do
not actually know that. Home visitation is not home visitation, is not home visitation. I am a psychiatrist and a pediatrician and I can tell you that we would never
apply that principle to various types of medication. But we do it with psycho-social
programs that are in place. Back to my first question about what ability do you haveto systematically look at the evidence and the generalizability of that to the military?
DR. URSANO: I heard at least two pieces. One is that when programs are
adapted for the population it is to be delivered to, are those programs appropriate
for the population that is to receive care as modified or adapted? Then, secondly, one
level of program evaluation is to ask if harm is being created, not just is it effective.
The first level of evaluating a program is to seriously consider the harms and risks
and not to assume that every program is harm-free. Any program that is effective has
to have consequences that will be negative. Otherwise, it probably is not powerfulenough to make a change.
We would say the same thing about a medication. If a medication does not havea side effect it probably is not potent enough to be doing something. That side effect25

The assumption
seems to be that doing
something is better thandoing nothing. That
is not always the case.
With many prevention
programs we do notmeasure whether they
are harmful. We do
not do a very goodjob of measuring theirbenefits, but we also do
not incorporate ways ofmeasuring their harm.

26

The systems in the
Army are multi-layered.
Let us rememberthat individuals
are within families,
within units, andwithin communities.
For researchers thathighlights a wholeapproach of what
is called multi-level
analysis.

Military Families in Transition: Stress, Resilience, and Well-being

may be more or less severe. Evaluation for harm becomes an important criterion
to keep in mind.
MS. BARRON: I am with the Association of the United States Army. I am alsoa family member. If you had the dollars, where would you put the dollars? In thinking about our families, some being very well and some being very ill, but most ofthem being right in the middle, how do we handle that transition from leaving theactive component and moving into veteran status? This is something that many of
our families will be facing soon.
The resilience piece is incredibly important and it is something that the Army ispaying great attention to. If you could think about having a component of resiliencein every program of the Army Community Service then you are building resiliencein every portal that a family member enters. Most families will start with ACS andthey will go for financial services, relocation or deployment assistance, etc. If there
is a concentrated effort to speak the same language around resilience you will start
to build and sustain that to the point of transition into the civilian community.
DR. URSANO: We have another panel that is going to address resilience in moredetail. Can programs do two things: both problem-solve and “build resilience?” We
have many concepts related to building resilience so the question is, “What doesthat mean?” At the moment, we will use it as a term for strengths, skills, abilities,
and capabilities.
MS. JOHNSON: I am from the Office of the Assistant Secretary of the Army for
Manpower and Reserve Affairs. I would hope that our discussion will acknowledge
that the challenges the institution is trying to solve are multi-layered. Because weare in the military the system also has individual and unit components. It also has
a community component because people do not live compartmentalized lives. The
military lives their lives transparently. While we talk about ACS as a case study ofprograms and a collection of many programs, it does not mean that we are not also
talking about our liaison to the medical community or the criminal justice community. All of those are communities on and off the Army installation.
The other point I would like to make is about transition. We always have to havea discussion about the life cycle of that soldier throughout his or her career. Thatmeans that we need to be concerned about what pre-conditions we accept — theconditions on which we accept people, and the way in which we want them to leave
the military. It is like we are bringing them back again and that cycle gets repeated.
The third point I would make is that I hope we will discuss some kind of agreement about continuum of care. It is a reality that while we talk about the medical
model including prevention, intervention, and treatment, I do not know how many
services we actually have along that continuum of care that really gets at the things
that we want to get at. If we do not recognize a system problem then we do notknow what we are trying to solve. When it comes to trying to figure out under what
conditions what program or activity works, we really can not plug that in as cleanly
as we think we should be able to do.
DR. URSANO: I heard three things. Let me highlight a couple of them. One: thesystems in the Army are multi-layered. Let us remember that individuals are withinfamilies, within units, and within communities. For researchers that highlights awhole approach of what is called multi-level analysis. Paul Bartone is an expert inthat area, as well as others in the audience. Carol Fullerton has a paper coming out,
the only paper published, that shows that if you change a community you change
the rates of PTSD, and you do not just change the individual. The question of thePanel 1: Combat to Garrison—Transitions Affecting the Soldier and the Military Family of 2025

life cycle, meaning the changes across time, includes the stage of a career someone
is in, as well as the Army Force Generation [ARFORGEN] cycle.
We are going to have to identify what layer of the system we are talking about,across what time frame we are talking about, and lastly, the question of how wesustain continuity across all of those layers, and time cycles. Might one invest incontinuity of programs rather than in new programs? Might one invest in a gatekeeper, rather than a new program if that sustains the continuity that one wants tohave? If you think of an automobile engine, to be a non-engineer-engineer for the
moment, is one trying to change the brakes or the carburetor or the spark plugs, oralter the way in which the fuel comes in or is used? All of those are ways in which
we can think of addressing these problems as well as specific content questions.

27

Carol Fullerton has apaper coming out, theonly paper published,that shows that if youchange a community you
change the rates of PTSD,
and you do not justchange the individual.

28

Military Families in Transition: Stress, Resilience, and Well-being

Panel 2: Problems Facing Military Families in Transition—Learning from the Science of Stressors

29

2

Military Service, War, andFamilies: Translating Research
into Practices
Speaker: Patricia Lester, MD
DR. FULLERTON: Patricia Lester comes to us from UCLA where she is a
Professor of Psychiatry and the Medical Director at the Child and Family Trauma
Service at the Nathanson Family Resilience Center.
DR. LESTER: This is exciting to see so many people together thinking about theneeds of military families in transitions. I want to talk about 3 areas today related
to translating the science of stress into preventive responses for military families andkids. I want to talk about the research that has been done with military children andfamilies, particularly focusing on the research of the last 10 years. Dr. Cozza’s talksummarized some of the mental health pathways when parents have posttraumaticstress disorder (PTSD) and traumatic brain injury (TBI). I will address the researchon deployment separations and other ways that military families transition. This
research provides a framework for understanding what we already know about childdevelopment and family-centered prevention. This will provide an understanding ofwhat we might do now, kinds of implementation practices and processes, and theinfrastructures that are needed to bring evidence-based practice to scale.
We know that military transitions occur against the back-drop of prior family
experience, child developmental milestones, and family life cycles. Accomplishments and adversities from earlier transitions carry forward to later ones, even theexperiences before coming to military service. We know that stress accumulates overthis trajectory and shapes our experience of future stressors and that resilience canaccumulate over this trajectory cascading throughout other developmental domains.
It is important to remember that when we think about military children andfamilies, that they learn to adapt to new situations and environments often more
quickly than non-military children. They are good at making new friends and atbringing coping skills forward into these new situations. The bonds between families
may be stronger because they have gone through some of these challenges together.
How does existing research guide us? We started the current war 12 years ago.
There is very little information about how a prolonged conflict affects developingchildren. A child less than 10 years old in a military family may have spent a majorityof their lifetime away from one of their primary caregivers. There is a great deal of

We know that militarytransitions occur against
the back-drop of priorfamily experience, childdevelopmental milestones,
and family life cycles.

30

It is important toremember that when
we think about
military children andfamilies, that theylearn to adapt to
new situations andenvironments often
more quickly thannon-military children.
They are good atmaking new friends
and at bringing
coping skills forward
into these newsituations.

Military Families in Transition: Stress, Resilience, and Well-being

developmental literature that helps us anticipate and predict what might be goingon in these families and how this might shape their experience. The point was madeearlier that the majority of these families seem to do well. They seem to negotiatethese transitions well, at least by the ways that we measure resilience and adjustment in families.
We often use the absence of clinical symptoms as suggesting resilience in healthy
adaptation, but we know from the literature and the tiers of research that are unfolding over the last 10 years, there is an increased risk associated with cumulative
deployments. Teenagers appear to have increased risk-taking behaviors and somedecline in academic performance and have increased levels of anxiety. There aresimilar findings in school-aged kids.
Most of the data comes from cross-sectional analyses from convenience samples,but the samples are getting larger and the data is fairly convergent across a variety
of studies. We also know that there is increased mental health utilization, both forthe military at-home civilian parents and kids. The term secondary trauma might
represent the broader notion that the stress is relational. We see a direct relationshipbetween mental health and adjustment symptoms between parent and child, parent
and spouse, and although we do not know yet, between children in the family. It
appears in kids, but there is also transmission through parenting. For a number ofyou, this is the target of your work.
What are some models from developmental literature that helps us think aboutfamilies, mental health and stress in children? There is a large body of literature
showing that parenting predicts child outcomes. Interventions that target positiveparenting practices and healthy parent-child relationships help support healthy childdevelopment. We know that there is a spill-over effect of stress. When marriages
have high levels of conflict we see more difficulty for the child. When parents havetrouble synchronizing co-parenting and are off from each other for a variety ofreasons, or when there is a high level of conflict, kids have more difficulty in termsof their emotional adjustment.
The notion of both the impact of the separation on kids, and the inter-generational effect of trauma in these families could be informed by including attachment
research in our thinking about the kinds of data we collect. It has been very difficult to collect detailed observational data in young children. There is very little
information about young developing kids and their parents over time, but that is
an important area to look at because we would anticipate that separating from a
primary care-giver in the context of danger is a threat to the attachment system. We
see a fair amount of separation anxiety in teenagers, as well. These are important
issues to look at as well as when a parent comes back from deployment with posttraumatic stress, and, potentially, disorganized attachment style with their kids. Whatmight that mean in terms of inter-generational risk?
A systems model that is well-recognized is one in which the family is embedded in multiple systems. When we are talking about transitions it is important tothink about what exists for active duty families and the opportunities to integrate
evidence-based practice into systems. It is much more challenging when you transition to veteran’s status or if you are a Guard or Reserve family, moving in and outof civilian systems of care. Many of these systems do not even know that you area military-connected child or family member. Even the very first level, getting community providers trained to understand military culture, is a challenge that we facein translating what we know into actual practice.

Panel 2: Problems Facing Military Families in Transition—Learning from the Science of Stressors

I now want to talk about an example of doing this in an active duty setting
and the theoretical under-pinning of the Families Overcoming Stress (FOCUS)
model. I will focus more on this issue of implementation and how we can evaluate
our programs and use that evaluation to deliver better service, identify a need, andhave a real-time data-monitoring system. FOCUS was initially adapted from Dr.
Bill Beardslee’s intervention called Family Talk, a model for families with parental
depression. It is identified in the Substance Abuse and Mental Health Services(SAMHSA) National Registry of Evidence-Based Programs and Practices (NREPP)
Compendium. It has been well tested in various cultures and broadly disseminated. It
is based on a family-centered approach to addressing risk based on years of looking
at resilience factors and risk in these families. Like many family-center prevention
models, it focuses on education, developing family communication skills, developing a coherent family narrative, and developing a sense of shared meaning acrossthe family.
We also looked at core elements in our team’s other evidence-based interventions.
Bill Saltzman, Chris Layne and Bob Pynoos had done an intervention in Bosnia forkids in families affected by war. Mary Jane Rotheram had done an intervention forfamilies with HIV and traced those families over 3 generations. From that, we cameup with a core element and core process model for developing the FOCUS platform.
We tested it at Camp Pendleton in a collaborative relationship with their provider
team, their family support. From that data we standardized the core elements into
the FOCUS model. When we implemented it, it was important that we use somenew strategies because we got it to the point where normally you would have donea randomized controlled trial with this new adaptation of an existing intervention.
Then you would have spent the next 20 years replicating that and doing effectivenesstrials and then thinking about ways to disseminate it.
My experience from the HIV epidemic is that the problem would have changed
quite dramatically over those 20 years and what you would always be doing issome kind of adaptation or you have an irrelevant intervention. I am raising thesepoints because I think they are important. Nevertheless, we have two randomized
controlled trials of FOCUS currently underway. Steve Cozza is the lead on one andwe have just launched another.
Seven years ago, the Navy came to us and said, “We would like to do this as ademonstration project for our highly deployed sites.” This was based on the foundational evidence, the adaptation process, and their understanding of the literature. We
took the core elements from these evidence-based interventions, which were familycentered, and all of which had a circumstance of adversity. It was designed to be
selective and indicated prevention along the Institute of Medicine (IOM) continuum.
From the launch of the study we developed a continuous data-monitoring system
and leveraged cloud computing technology looking at both process and outcome
data. We used this both to manage the project and also to track outcomes within thefamily. We also used it to be able to do rapid adaptation. That has been central tobeing able to launch it quickly and manage it centrally. It is now at 22 installations.
There are some important concepts spelled out in an article by Mary Jane
Rotheram-Borus, Dallas Swendeman, and Bruce Chorpita entitled, “Disruptive Innovations for Designing and Diffusing Evidence-Based Interventions” in the American
Psychologist, 2012. This article focused on how we can use the notions of disruptive
innovation research strategies to scale evidence-based practice. They were not justlooking at family prevention. We used an array of flexible platforms taking the core

31

There is a large body ofliterature showing thatparenting predicts childoutcomes. Interventions
that target positiveparenting practices
and healthy parentchild relationships help
support healthy childdevelopment.

32

A critical component to
the intervention, evenat the consultation andgroup level, was forpeople to understandhow combat stress
reactions and PTSD
reverberated throughthe families, howfamilies could identify,
monitor, and manage
them as a collective
team.

Military Families in Transition: Stress, Resilience, and Well-being

elements of the intervention and putting them into a variety of platforms, but all
were informed by the same education, the same five key skills, the same notion ofassessment feedback, and a family narrative component. Not every level of intervention had that same intensity. We did this as a suite of services. It was a public healthapproach that cut across those systems of care. It was in schools, community centers,
and in medical facilities. The idea was that you were embedding a family-centeredapproach based on these core elements, and then training and maintaining fidelity
around the core elements.
The multiple platforms of the core intervention included family consultations
and group interventions for children and parents in multi-family groups for teachingthem skills. Those skills were: emotion regulation, problem solving, communication,
goal setting, management of trauma and loss reminders, and deployment separation
reminders. A critical component to the intervention, even at the consultation andgroup level, was for people to understand how combat stress reactions and PTSD
reverberated through the families, how families could identify, monitor, and manage
them as a collective team.
At this point, over 12,000 adults and kids have gone through or are currently
going through the multi-session full FOCUS model, which is an eight-session model.
Our providers are called trainers in an attempt to reduce stigma, and it works tosome extent. People like being trained up, being prepared. It fits with military culture.
They are trained how to do all of these activities, and so they are much more proactive than is typical of mental health workers. They use multiple points of contact
and encouragement to people who show an interest. They follow up knowing that
it is really hard for people who feel isolated, depressed, or withdrawn to come in.
They are not necessarily going to say, “Yes, I want to come do prevention.” It often
takes building the relationship with them to do it.
Some of these concepts, such as embedding the methodologist as part of theintervention team, come from the work of Naihua Duan. You also need to include
your programmers and your operations people as well as the training team. As
you collect data it is really important for the analyst to understand the conceptual
frame of the intervention, the family system, and to be able to help the operations
and management people work with the teams on the ground in a way that makes
them responsive and also supports them. Then issues can be fed back to the learning
community and the teams can learn from each other. We saw multiple new issues
arise over the last five years. There were issues around intimacy with certain kindsof injury and sleep problems in families. You are able to develop advanced training
and embed that in the learning community.
We perform multiple reporter evaluations on children, service members, spouses
and providers. We do all this within family reporting and there are longitudinalfollow ups over time. At least 70% of our families have consistently completed andfollowed up in this program. Remember, it is not research. There is no incentive. They
are engaged by the program, and they are willing to continue to check in with theirprovider because they may be interested in new services. You can also see process
information about how this has helped the family to become further embedded orconnected to the community.
We track referrals into and out of the program. We can see people coming inthrough the New Parent Support Program. For example, we identify issues where
the parent is finally willing to get treatment for PTSD. We can track and support
these kinds of pathways. We have done some longitudinal modeling with the data

Panel 2: Problems Facing Military Families in Transition—Learning from the Science of Stressors

looking at pathways of change. As we anticipated, improvements in family resilience
constructs, problem solving, emotional relatedness, and family communication
predict improvements in child mental health adjustment symptoms.
We have used time trend analyses. On the Strengths and Difficulties Questionnaire (SDQ) we found a mean of 12, about double that found in a civilian population. Our kids are pretty distressed when they come to the intervention, but we get
dramatic improvements in time. We do have a small group who are non-completers.
We have been able to look at non-completers compared to completers even though
we do not have a control group. We see that the non-completers drift back up overtime. We have the same kind of outcome repeated measures for parents.
Bill Beardslee has an article coming out that gives you a sense of how data
monitoring is an innovation or another pathway of how traditional biomedical
models for validating behavioral health programs can be used to more rapidly adapt,but also maintain fidelity of the core elements. We have as a core element a family
psychological health check-in with immediate scoring, feedback, and guidance to theprovider and to the family. We also now have a self-administered version available
for veteran and non-active duty families.
Psycho-education is another element of the model that is customized to thefamily’s reporting. If you are doing really well in one area, you are not going to getmuch psycho-education about that area. It can be customized to your particularfamily needs and then put on our narrative time line. Our resiliency skills training
is very similar to core elements in a number of cognitive behavioral interventions.
There has been a great deal of talk today about technology platforms. This has
been huge and is really important for Guard, Reserve, and veteran families, if wethink about those transitions and the particular generation we are working with.
Having tools that allow people to use emotional regulation skills and problemsolving in a fun, engaging way where they live is critical. A platform for delivering
this kind of intervention in-home as a virtual home visit is something we have beenworking on for the last year. We have developed it as a current service program andwill incorporate it into our National Institute of Child Health and Development(NICHD) randomized control trial for virtual home visiting.
The opportunity to do this program in the military is very unique because of theclosed system of care and because the leadership had the vision to push prevention
forward. Some of the processes that we have developed in this partnership with
Navy medicine, from my mind as a civilian preventionist, can help us think about
whether some of these similar tools could be used in other communities. As we have
moved to working with veteran and Guard families, we recognize it is much harder
to implement all these at once.
If you look at Patty Chamberlain’s stages of implementation, we just did a whole
lot of implementation stages all at the same time. In the community you have togo sequentially and really work to change these systems in which you are trying toembed care. I put that out as a challenge that I would like to discuss because it is adaunting one.

33

We have as a coreelement a family
psychological healthcheck-in with immediate
scoring, feedback, andguidance to the provider
and to the family.

34

Military Families in Transition: Stress, Resilience, and Well-being

Panel 2: Problems Facing Military Families in Transition—Learning from the Science of Stressors

35

Preventing Violence in Military
Families Under Stress
Speaker: Eric Elbogen, PhD
DR. FULLERTON: Eric Elbogen comes to us from the University of North
Carolina. He is Associate Professor in the Department of Psychiatry at the School of
Medicine and a clinical psychologist at the Durham Veterans Affairs Medical Center.
DR. ELBOGEN: Thank you so much for inviting me. I am learning a great deal
here, because I work at the VA, where we do not have family programs. But, at the
University of North Carolina, we serve over 12,000 Tricare patients a year. We havealso been doing research with military families. This research has been funded by
the National Institute of Mental Health and the Department of Defense.
What I have been hearing today is the question of how to evaluate all these
programs, and make sure that they are improving outcomes. This talk is a little
different than the previous ones, in that we are picking a specific outcome that has
been discussed the entire morning, violence. This research is based on a National
Institute of Mental Health grant to develop tools to assess and reduce the risk of
post-deployment violence. I will be talking about violence in veterans and militaryfamilies and the transitions in the process of separation.
I would like to take a poll so please write down your response to the following
question: If you had a random sample of all the service members who have served
since 9/11 and you asked them, “In the past year, have you physically hurt anotherperson?” what percentage of that random sample would answer, “Yes”? Raise yourhand to indicate the category in which your response falls: below 10%; 10–20%;
20–30%; 30–40%; 40-50%, and above 50 percent.? If I would have charted out
the bell-curve of your responses, it would have worked quite well. The amountis actually 33%. We did that in a national survey of a random sample, called the
National Post-Deployment Adjustment Survey. What we found was consistent withother studies in both active duty and veteran populations. About one-third are
self-reporting violence, which could be an under-estimate. These are self-reported
aggression problems. These are problems that are not necessarily reaching the levelof violence, but there is a sub-set of veterans and military service members who doreport engaging in what we called severe violence, which is using a weapon, threatening lethal violence or beating someone up to the point that they need hospitalization.
This was self-reported by about one in ten in our national sample. Most of those
involved family violence.

What we found wasconsistent with otherstudies in both active
duty and veteran
populations. About onethird are self-reporting
violence, which could be
an under-estimate.

36

The key thing to keep
in mind is that PTSD
does elevate risk.
Veterans and military
service members with
PTSD are at higher
risk of domestic
violence.

Military Families in Transition: Stress, Resilience, and Well-being

I became interested family violence about 10 years ago. There were incidents ofdomestic violence and homicides at Fort Bragg and immediately the media reacted,“Oh, it is PTSD. It has got to be PTSD.” It is a knee-jerk reaction. It turns out that if
you look at every study on the subject of domestic violence, the vast majority of families are fine, even in the context of PTSD. The vast majority of veterans and military
service members with PTSD, in all published studies, are not aggressive or violent.
The key thing to keep in mind is that PTSD does elevate risk. Veterans and military service members with PTSD are at higher risk. Most of them are not violent, but
it does increase their risk of domestic violence. There have been numerous studies
that have shown this. It is hard to keep both of these points in your head at once. It
is certainly hard for the media to do this, but it is important to realize that it does
elevate risk, but it is not a guarantee there will be violence.
What we have begun to do with domestic violence is to try to go beyond
PTSD to see if there are specific symptoms of PTSD that relate to different kindsof violence. Results of our national study showed that the anger symptoms andemotional dysregulation are not only related to family violence, but also related topost-deployment arrests, and that flashbacks predicted stranger violence.
The difference between family and stranger violence is not typically examinedin the literature, but what we are finding is that different symptoms of PTSD might
relate to different kinds of violence. In particular, for military families, the hyperarousal symptoms seem most implicated. Findings from our study and another report
have found that female veterans and service members are actually reporting family
violence at a higher rate than male service members and veterans. The men were
three times more likely to report stranger violence than the women.
The relationship between PTSD and family violence is complex. The knee-jerkreaction, “It has got to be PTSD that led to it,” is just the tip of the iceberg. Hereis where it gets complicated. Are people with PTSD at higher risk of violence thannot, or than veterans without PTSD? The answer depends on how you slice it. We
performed a longitudinal study of over 1,000 veterans representative of all 50 states
and all branches of the military. We assessed PTSD and alcohol use at baseline andthen looked at whether they were violent in the next year. A year later, 80% of theparticipants were retained. We found that, if at the first assessment they met criteria
for PTSD, a year later nearly 20% of them reported severe violence during thatyear. Alcohol misuse had the same increase. When you split it differently and lookat the co-occurrence of PTSD and alcohol misuse, it is the combination that seems
particularly elevated. It is not just alcohol misuse only or PTSD only, not that they
are zero, but it is a combination of the two that warrants attention.
In terms of how this might relate to family interventions, realize that if you
have a veteran or a military service member with PTSD, it might be useful to use
the evidence that is beginning to accrue that PTSD might be related to domestic
violence in specific ways. For instance, in your treatment of these veterans and service
members, make sure there are anger components, make sure there are substanceabuse components. In other words, make sure that there are non-PTSD components
in your treatment.
The other thing to remember is that military service members and veterans havethe exact same risk factors as civilians for domestic violence, such as being younger
and having a previous history of arrests. We have published that the veterans who
had previous arrests before they entered the military were at elevated risk of domestic
violence and for being arrested after their service in the military.

Panel 2: Problems Facing Military Families in Transition—Learning from the Science of Stressors

Other non-PTSD risk factors related to violence are economic and social attainment, such as not having money to cover basic needs. Among other contextual
problems are newer marriages, shorter marriages, and marital relationship problems,
just like for civilian populations. Make sure that any programs targeted at domestic
violence not only address PTSD, but also address variables that do not have anything
to do with PTSD or combat, but are simply risk factors in the general population.
Forensic psychologists frequently talk about risk factors, but at the end of theday, what do you do if you have found out that someone is at high risk? You haveto do something to lower it. We have done research to look at some of the factorsthat are linked to reduced risk of violence in military veterans. Again, these findings
are from our national survey of Iraq and Afghanistan veterans. We found a numberof social variables and protective factors were related to reduced risk of violence.
One factor is employability. Living stability may not be as relevant as when theservice member is on active duty, but once they transition out, they have to pay rent.
Veterans are disproportionately higher in the homeless population than civilians.
We also published a paper showing that physical well-being is related to reduced
risk of violence, better pain management and better sleep habits. Lastly, we measured
resilience and found an inverse relationship with domestic violence and veterans.
We also found that positive social support and perceived self-determination were
important protective factors.
How strong were these relationships? We measured the predicted probability ofviolence in a one-year period of time. The protective factors reported were: employment, that they could pay their bills, that they had resilience, that they did not havephysical pain and that they had good social support. The more protective factors
they had, the lower their risk of violence. We found a 92% drop in risk of violence.
I want to make a few points about this. The vast majority of these randomly
sampled veterans actually have most of the protective factors. This is what you havetalked about and this is what the media does not focus on. It is really a small sub-set
of veterans that have the most risk. One of the programs to reduce domestic violenceis helping veterans learn to budget better. Someone pointed out to me that insteadof violence, you could talk about cost to the system. Certainly, violence is costly. It
is cost-effective to teach veterans and service members how to manage their budgets
if it helps reduce their risk of violence by 92 percent.
At the VA, I have been running a money management group for the last 7 years.
Some of the mismanagement that I have heard is astounding. One might say, “Well,is that the same as the general population?” But, the Department of Labor did asurvey of military families and civilians, and found that military families were more
likely to be in credit card debt, less able to meet their basic needs, and they had moretrouble budgeting than civilians. That was found by the National Financial Literacy
Commission, 2010. If you apply this to a domestic violence program, this would
be a good way to frame and conceptualize reducing risk once you have assessed it.
In terms of the transition from active duty to civilian life, some people havementioned that many of those protective factors are present when someone is in the
military. For example, you do not have to worry about a job, you have self-direction,
your direction is clear, you have social support, your basic needs are met, and you
have living stability. In essence, when you separate from the military, the carpet ispulled out from under you and suddenly, you have to find a job and you have to
do a budget possibly for the first time in your life — and you are 30 years old. This
goes beyond just domestic violence. In thinking about instilling these protective

37

Forensic psychologists
frequently talk aboutrisk factors, but at theend of the day, what doyou do if you have foundout that someone is athigh risk? You have to
do something to lower it.

38

We have developed anevidence-based risk
screen that is currently
being rolled out andis going to be adopted
at Veterans Affairs
medical centers.

Military Families in Transition: Stress, Resilience, and Well-being

factors, possibly before separation, we are talking about preventing poor outcomes,
not just for violence, but for other kinds of outcomes after separation.In summary,in terms of what we know about violence in military populations, it is really a subset that we are talking about, and we know that most veteran families are fine andfree of family violence. The link between PTSD and violence is complex and needs
to be addressed in interventions that are going to be effective. Also important are
non-PTSD risk factors, just like in civilian populations, as well as thinking aboutprotective factors and embedding that concept in our research.
We have done 2 things with all of these findings. We have developed an evidencebased risk screen that is currently being rolled out and is going to be adopted at
Veterans Affairs medical centers, and we are currently testing an intervention undera DOD grant. The acronym is CALM — Cognitive Apps for Life Management. It isa family intervention aimed at reducing impulsivity using mobile technology. We aretrying to translate these into interventions that we are testing. In terms of how thisapplies to what we have been talking about today, it is obviously just one problem
among many. I hope it illustrates how having empirical knowledge of a specificproblem might help inform some of the many programs that you have been talking
about today, to help our military families.

Panel 2: Problems Facing Military Families in Transition—Learning from the Science of Stressors

39

Contributions of PTSD and TBI
to Military/Veteran Family Risk
Speaker: Carol S. Fullerton, PhD, for Stephen J. Cozza, MD
Dr. Steve Cozza is ill today and I am going to present for him. There were several
key points that he wanted to make. I would like to start with one of these points forpeople to think about as we walk through the material that Steve has put together;
PTSD and TBI as interpersonal disorders rather than individual ones. Many people
are affected by these disorders. The point that 55% of active duty service members
are married and 44% have children broadens the effects of these disorders. Looking at the longitudinal course of the disorders, there are effects on couples, such as
poor couple adjustment, negative communication, lower marital satisfaction, greater
mutual family violence and greater rates of conflict. There are also negative effects
on intimacy and the risk of spouse PTSD, parenting and child outcomes. This resultsin poor problem solving, communication and involvement with children, decreased
parenting satisfaction, greater perceived parenting challenges, and more challenges
and symptoms in children.
Another important concept that is often misunderstood is inter-generational
trauma. This was a concept that began with some of the Holocaust studies andrepresents a the vector of transmission of symptoms — the underlying mechanism
by which these symptoms are passed along. The term inter-generational is something
to think about in different ways, including the developmental effects on children.
There are important mediators and moderators of PTSD such as emotional
numbing and avoidance that are linked to interpersonal impairment and the relationships between spouses and partners, and with children. Anger and depression, as
well as the partner response, may also mediate or interfere with negotiating family
problems. Emotional sharing moderates the effects of PTSD. Emotional sharing, thus,
has an effect on the marital relationship, but also on the functioning as a parent.
These are examples of thinking of all these conditions as interpersonal disorders,more than just focusing on the individual.
For the past several years Steve has been conducting a study at a camp for families of injured soldiers. Although it is a small sample size, it is an important study
and an important sample. Camps are held every year for injured soldiers. In thisstudy, now conducted for the third year, surveys and focus groups are conducted
the families including the parents and the children. Preliminary findings show no
direct effects of the injury or the PTSD in the parent on child functioning. Parent

Looking at thelongitudinal courseof the disorders, there
are effects on couples,such as poor couple
adjustment, negative
communication, lower
marital satisfaction,
greater mutual family
violence and greater
rates of conflict.

40

There are important
mediators andmoderators of
PTSD such as
emotional numbing
and avoidance
that are linked
to interpersonal
impairment and therelationships between
spouses and partners,
and with children.

Military Families in Transition: Stress, Resilience, and Well-being

behaviors have varied direct effects on the child’s functioning. In particular, there
were no direct effects on involvement behaviors. Low monitoring of behaviors was
associated with child conduct problems. There were also interactive effects. As PTSD
goes up, and the parent monitoring of the child goes up, the emotional symptoms
in the child go down. However, as PTSD goes up and the parent’s involvement goesup, conduct problems go up. Monitoring is linked to conduct problems.
TBI is more distressing and more disruptive than other injuries. There areproblems that compromise parenting such as: parental irritability, anger, behavior
regulation, cognitive capacity and communication. Diminished parenting, in either
parent, results in more child emotional behavioral problems. Also, there is anincreased caretaking burden and the requirement for ongoing continuous professional help. Do the spouses take on the caretaking burden, and how does the burdenof care transition when the soldier returns home? The family, either the parent or
the spouse, becomes the primary caretaker. We have examined this in terms of thenatural caregiver, something that occurs in the family environment naturally, which
is an important target when you are dealing with TBI in families. Again, TBI can beseen as an interpersonal disorder and not just the individual.
Among the transition challenges are the long-term impact of soldier injury anddisorders. There may be reductions in national funding and cultural changes in how
the nation views the soldiers and their needs. Currently there is great concern aboutsoldiers. The nation has experienced a number of years of soldiers experiencing
multiple deployments and combat-related stressors. In the next year or two, how isthis going to change? As we get further out from this we know from the past that
support, including funding goes down. Obviously, these changes are going to affectsoldier and family adjustment.
There can also be problems in community reintegration and also clinical engagement. What will be the healthcare needs of soldiers and families? Patient-focusedservices may exclude family members. Again, this is the focus is interpersonal andnot just individual. There is a lack of clinical expertise, in dealing with this. The
soldier has PTSD, but what are the broader implications and affect on the family?
We have studied spouses of disaster workers and soldiers and know the importance,on different levels, of including spouses in treatment care.
There is a disconnect of veteran family health care in the VA system. Veterans areoften hesitant to include their family members in health care. There might be a stigma
issue or family members thinking, “Well, I do not have a problem.” The literatureshows that it is helpful and potentially critical that family members are involved inhealth care. There are also reactive, punitive and legal responses to domestic violence.
This is something that our group has studied, neglect and violence. What are someof the legal issues that prevent soldiers and families from getting care?
I will end with several recommended actions. Identify the need for sustained careand services over time. Remember that PTSD and TBI are interpersonal disorders,
not just individual. Over time, incorporate assessments of interpersonal impact andinclude psycho-education. Highlight the relationship between the service member
and the veteran and the family members’ health. Implement family-focused interpersonal treatments. Use relationship functional outcomes in addition to symptom
response. Teach collaborative parenting for PTSD and TBI. Utilize violence prevention programs that proactively address the risk in families. This point includes
assessing the risk in the families, not just the individual. Prevention includes family
emotion regulation, community, problem solving, and both conduct and emotional

Panel 2: Problems Facing Military Families in Transition—Learning from the Science of Stressors

responses of the children. Lastly, identify the hot-spots and triggers and build a safety
net through planning. Thank you.

41

Identify the needfor sustained careand services overtime. Remember that
PTSD and TBI are
interpersonal disorders,
not just individual.
Over time, incorporate
assessments ofinterpersonal impact
and include psychoeducation.

42

Military Families in Transition: Stress, Resilience, and Well-being

Panel 2: Problems Facing Military Families in Transition—Learning from the Science of Stressors

43

Panel 2 discussion
Moderator: Robert J. Ursano, MD
DR. URSANO: Thanks to our panel for a wonderful series of presentations. We
are going to have some discussion, but first I will highlight a couple of elements.
First, I would note that in this panel, we have addressed three problem areas, or atleast ways to think about them. One is illness, and although the first talk focusedon traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD), one
could think about illness, period, in the family and how illness is managed, howillness creates family problems and what are our resources for addressing illness inmilitary and in Army families. Twenty years ago, PTSD and TBI would have been
what we called MUPS, Multiple Unexplained Physical Symptoms. If it had been
after a deployment to Somalia, it might have been an outbreak of malaria that had
occurred. The point is that there will be militarily-unique illnesses that will occur
over the next years, to 2025. How will families cope ?
Second, was the area of separation and reunion after deployment. We can be
guaranteed that in the future, there will be separation and reunion. There will be
deployments. The question is whether or not those deployments are long or short.
If we move to a force that has deployments once a month for a week, is that better
than once every 2 years for 6 months? The issues of dwell time, which the Walter
Reed Army Institute of Research (WRAIR) folks and Paul Bliese and others, in particular, have focused on, highlight that issue. There is also the question of how long
does it take for a family to re-invest in each other? Not just for a soldier to recoverfrom PTSD, but what is a dwell time for family recovery and recovery of family
functions? We are not talking about the just the individual, which we can address,
but about the functional capacities of a family which are disrupted by deployment
and require new functional capacities. What is the dwell time needed for family
functional capacity recovery?
Third, there is Eric’s example of targeting a particular problem, the question of
aggression and violence, which came from an epidemic outbreak. Again, I would cite
WRAIR and Paul Bartone and his shop, where the issue will be epidemic outbreaks
that occur. One of those was Fort Bragg where there were with seven killings. The
military is marvelously set up with a model for deploying what are called EPICON
teams, Epidemiologic Consultation teams, which deploy to collect real-time information rapidly. In many ways, Eric’s work is an outgrowth of that response to an
outbreak, how one sees an issue, deploys to address and understand that issue, anddevelops a method of approaching it. The other nice thing that I would highlight…one could think
about illness, period,in the family and how
illness is managed, howillness creates family
problems and what
are our resources foraddressing illness inmilitary and in Armyfamilies.

44

We were able tolook at the questionof whether violence
was unidirectional orbidirectional. In otherwords, was this physicalviolence due to selfdefense? We found that
it was just as much
unidirectional as it wasbidirectional.

Military Families in Transition: Stress, Resilience, and Well-beingin Eric’s work is that of protective factors, not just risk factors. How can we takethose protective factors and roll them into programs or assess programs to determine
whether or not they are matching those or which ones work once we roll them into
programs.
Then, I would highlight data presented today on economics. Do people haveenough money to pay for their lives and does how that impact on whether or notthere is going to be aggression? How many soldiers are below the poverty line? How
many of them collect food stamps? Poverty is not only a problem of our nation; itis also a problem in the military. The transition out of military service, when one isunsure of economics, may be a particular risk time.
My final point — think about which time and what population each of theseaddresses. We cannot address the all Army, all the time. As Delores was saying, wehave to break it into time, cycle, and population. We have talked about populations
during illness. We have talked about populations pre- and post-deployment. We
have talked about populations at transition time, into and out of the military. Thus,
we have some new tools for our discussion. As we think through these issues, what
are our tools for addressing future issues and risks, future opportunities and target
populations?
DR. LUNDQUIST: I direct the Institute for Social Science Research and I am asociologist at the University of Massachusetts. Eric would you speak more to yourspeculation or theory of the gender differences that emerged with violence toward
family members, among women over men, particularly given recent policy changes
that women will be exposed more and more to combat and deployment. Is there
emerging research about female veteran expectionalism. An example is the higher
rates of divorce among female veterans compared to male veterans, as well as active
duty gender differences.
I was interested in how you operationalized your dependent variable in defining
family-based violence to whom, such as children versus partner. To what extent does
the exposure to parenting, that women generally have more of than men, control
for the gender effect? Is that something that you had a large enough sample size
to look at? One of the differences that the paper found was that female veterans
are more likely to enact or think about violence towards family members, whereas
male veterans who have been exposed to combat are more likely to have violence
towards strangers. Unpacking what may be driving that effect, how much of that is
methodological and how much of that is an explanation based on gender?
DR. URSANO: Your observation is that one needs to be alert to the question ofgender differences in veterans as one studies population risk and response. Talking
about service members may not sufficiently identify individuals in need of assistanceor adequately scientifically identify the population for a study. I really want to capture that because we have not had that comment yet. It is important for us to saythat we are talking about populations, deployment, and non-deployment. No one
has yet said, “What about men and women?” They are not the same.
DR. ELBOGEN: We can talk afterwards about the specific measurements. We
actually over-sampled women. We were able to look at the question of whether
violence was unidirectional or bidirectional. In other words, was this physical violence due to self-defense? We found that it was just as much unidirectional as it wasbidirectional. There was very little stranger violence by women.
DR. GEWIRTZ: I think this is a fantastic direction for future research, but I am
not too surprised. This somewhat parallels the findings over the last 5, 10 years, orPanel 2: Problems Facing Military Families in Transition—Learning from the Science of Stressors

15 years, showing increasingly that women report being aggressive in relationships.
It is a very important avenue for further research.
DR. HEYMAN: This is actually one of the most robust findings in the last 40
years of domestic violence research. Archer’s review and meta-analysis would be agood place to start, but this is something that is certainly not military-specific.
DR. PARIS: This is a question for Tricia, but may be bigger. It is a conceptual
question given some of the things we have been talking about so far today. On theprevious panel, Lynn presented the many different services that are available formilitary families. FOCUS grew in an amazing way to many different domains andto different installations. Now, you are branching onto the web. You described themodel about how to assess effectiveness when you are not following the one, two,
three, four step with one big clinical trial and replication.
I am struggling with that, partly because we have Lynn McCollum’s list of allof these different services available for families, and then you have FOCUS, which
was developed off of Bill Beardslee’s excellent work, working around depression.
My core question is, are we talking about the adaptation of other evidence-basedmodels to military populations and then an ongoing assessment of its usefulness indifferent kinds of situations? Are we understanding the military populations to be
unique in particular ways, and then we are adding on to other programs in existence
already? In terms of moving forward and jumping on, how do you put together
some of the things that you were talking about and some of what Lynn was talking
about in terms of what exists in the plethora of services that are already available
to military families?
DR. LESTER: This is a complicated question. I am not suggesting abandoning
traditional validation models. I am just suggesting that they need to be augmented
or we will never have evidence-based practices widely disseminated because they will
always be so far behind a moving transitional target. The model that I was proposing is based on a continuous data monitoring system. There was discussion earlier
that we need to invest in an infrastructure that would allow us to do that. My guessis that in the giant network of programs, many of them do not have a platform ofcontinuous data monitoring.
It is very hard to do things like delivery with fidelity, to monitor what is actually
happening in the room, and even to get effectiveness data. I am not going to speak
to the programs that were presented, but I do know that for a number of large-scale
programs you often have to go back after the fact. You are not integrating that into
what is a pretty fluid need for adaptation.
DR. URSANO: Let me capture a piece of that discussion because it states acouple of things that Patricia said earlier that were very valuable. If I highlight it
now, we will make sure we get it in our transcript for us to remember.
One was this issue you are presently talking about, program change for problem
change, which is a very nicely stated. Over time, the problems change. What are ourfeedback mechanisms for rolling problem change into program change, and how
can that be systematically accomplished?
How do we create a system that has that? I do not know that we are there yetin terms of families. I do not know that we are there yet in individual healthcare.
We are trying to do that within DOD.
The idea of a dashboard is something that sells well in DOD, where there isreal-time information for action. Do we even know what are the 10 things, are wemeasuring them, and are they measured in a way that we can use? We measure many

45

Over time, theproblems change.
What are our feedback
mechanisms for rollingproblem change into
program change,and how can thatbe systematicallyaccomplished?

46

We are focused on theillness, and then we arefocused on the person,
and then we are focusedon the family. But weare not focused on the
improvement.

Military Families in Transition: Stress, Resilience, and Well-being

things, but the concept of a dashboard for family function and problem identification
is absolutely right. Whether or not our science is there, is another question.
DR. ZATZICK: Part of the challenge in these conferences is getting people tospeak the same language. We have this incredible prevention science, behavioral
science, developmentalist group, and then we have many front-line, hard-line clinicians on the ground. Part of the context is that a group of us are trying to implement
FOCUS now in a very challenging post-injury military context. The behavioral
scientists and the social scientists are looking for a meta-theoretical construct thatwill help us with our implementation and our implementation science. There are allthese wonderful models. You need people to be able to understand the contextual
factors in a front line perspective. The behavioral science models probably will not
inform your behavior. The reason for that is that meta-theory here is in clinicalepidemiology. You are looking at how FOCUS was designed initially and what
the population was, but you do not want just an epidemiologic framework on thepatient population or a normative framework if you are coming from the clinicalpsychology perspective.
You want a normative framework on the patient population, for the providers
implementing it, and then you want the organizational context. Once you understandthose three things, you see that your incrementalism in modifying this intervention
study by study is completely out the window and you have to come up with something really new.
We have discarded the manual because the patients and the families that wererecruited, even in the military studies, were in much better shape than the people weare getting in. We are in pre-FOCUS readiness. We are trying to get people ready for
FOCUS. We have tossed out the manual and we are iteratively rewriting this into
an effectiveness design.
DR. MONAHAN: I want to ask the presenters to speculate about external validity and generalizability. Because we are in an era of big data, how influential will
we be with respect to the proliferation of individual intervention studies when they
are not linked to larger goals so that we can have more influence in Washington?
DR. DELANEY: There are a couple of points that are really important that I
want to build on. One is that I do not think that we can underplay the continuous
tension between clinical work and the research going on. This is paralleling at Healthand Human Services (HHS) pretty much every five minutes. The one thing that weare talking about is a change to a culture of data or a change to a culture of science aspart of our practice work. In looking at this and moving forward, we not only needto think about monitoring and continuous monitoring of what we do, but we needto think about quality. That is one thing I am not hearing about as we go forward.
I am sure that it is probably in the back of everybody’s mind, but we do need tothink about it. We are focused on the illness, and then we are focused on the person,
and then we are focused on the family. But we are not focused on the improvement.
Sometimes, we are looking at the illness as the target and we are trying to decrease
depression. If we decrease depression, but the family falls apart, we are not looking
at the quality of the services we are providing. I think this also speaks to a point thatyou raised earlier, Dr. Ursano, and that is the issue of maybe we need to be thinking
that instead of adding a service, we should be adding a connecting point. That is
missing in some of the discussions. It was particularly clear in yours, where FOCUS
came in and it was all over the place, and there is a great deal happening. MaybePanel 2: Problems Facing Military Families in Transition—Learning from the Science of Stressors

we evidence-based needed a connector between people to make it happen, but thenwe needed to look at the quality of those connections, as well.
DR. LESTER: Maybe I failed to make that point, which was having a way tomonitor not only outcome data, but process data, as it was unfolding, allowed us
to look at how those processes, by which the program was integrated, added value
at the ground level. I focused only on a couple of key outcomes, but most of these
programs are deeply linked to the overall policy goal, which is to mitigate psychological distress such as enhancing resilience and the capacity to cope with ongoingchanges in transition.
There are many interventionists in the room who are working on adapting
evidence-based interventions for military populations and many of these sharecommon core elements. One thought that comes to mind is Bruce Chorpita’s work
which has focused on identifying common core elements across evidence-based interventions as an approach to using evidence to guide practice. This type of approach,focusing on the synthesis and diffusion of common robust elements within evidencebased practice, rather than adding individually branded programs is an approachthat is particularly relevant to responding to need for rapid adaptation to urgent
needs such as those faced by military populations during wartime. Our traditional
biomedical model for validating and implementing evidence-based interventions
may not support the need to serve large numbers of people in a rapidly evolving
context, such as wartime operations. In particular, we need to focus research on thescience of implementation, with an emphasis on developing rigorous approaches
to dissemination that leverage real time data monitoring for quality improvement,
as well as being able to ensure quality in training, fidelity in delivery, and to informthe ongoing need for rapid response to address emerging contextual issues such as
timing, development and cultural differences. There is the ability to do that, but
it would require an investment and for people to work together, rather than in acompetitive way.
DR. SALTZMAN: Tricia just said my main point. I am responding to Doug’s
point that we threw out the manual. Actually, they are adjusting the manual. We
tried to construct a program on these core components that are empirically andtheoretically derived. This modularized, adaptive program can respond, even after
it is in the field, and it can be adjusted for the emerging needs.
DR. RICHE: I am a demographer from CNA and Cornell. I just completed astudy for the people who are managing transition policy at the Pentagon, the transition from active duty to veteran, and have done a comparison of life force statuses.
It is pretty clear that military people, as we just heard, are younger, but they also
are more likely to marry They marry earlier, they get divorced earlier, and they are
more likely to have multiple marriages. Given the remark just made that shorter,
newer marriages and marriage relationship problems are connected to violence,from a broader policy standpoint, one preventive strategy might be to scrub military
programs and practices to incentivizing early marriage.
MS. JOHNSON: As I was thinking through this, I think about a little history
and a policy point of view. One of the things that stymies research, in particular, isthat there is really no clear policy. As you talked about the goal of what the research
was, that is your medical goal. There is a personnel community that exists within
the military, and there is another undefined conglomeration of things that exist in
the military, and each of those segments has goals about what family policy should
be or programs should be. General Wickham’s white paper laid the foundation for

47

There are many
interventionists in
the room who are
working on adapting
evidence-based
interventions formilitary populations
and many of theseshare common coreelements.

48

Some of theevaluation criteria
of programs may
be similar to what
we are trying toaccomplish in
the military withunits, in terms offlexibility, modularity,
adaptability, whichgoes along with theearlier construct ofharm.

Military Families in Transition: Stress, Resilience, and Well-being

the research agenda that followed that era. Dr. Chu, when he was on the DOD staff,
developed a social compact which also set a research agenda.
But, absent those two very broad, strategic documents, there really is not amajor policy shift that links the medical community goals, that people should live
and be happy and be well, with the things that we should do within the personnel
community that help people adapt to a unique life style, and help mitigate thosestressors brought from the civilian sector.
Then, there is this largely undefined thing that you always struggle with, about
how you treat people in general. What does that mission culture bring to the table?
Maybe one of the things that we all struggle with in this conversation is this diversity
at trying to come at this issue without an overarching policy statement about what
we think about what we are trying to accomplish. You cannot do research if you do
not know what the programs were designed to do within that organizational context.
There is this framework that we keep coming back to, one that we do not have. I
think everybody assumes because it is military, it is structured. Probably, the humandimension is the most amorphous piece that we have. We are pretty clear when wetalk operations. We are not at all so clear or have unity of focus when we talk about
the human element in our respective institutions or across the services. We each havedifferent ways that we come at these issues, from a philosophical orientation, that
we have never articulated to drive research agenda.
DR. URSANO: Your comment, highlights the question of the differences in goals
and that there is not one like goal. We have the goals of health and happiness. We
have the goals of adaptation to the life style of the military, adaptation coming in,being in and then going out, and we have the concepts of what constitutes the humandimensions of a system taking care of each other. Those are related, but not the same.
DR. MASTEN: I am from the University of Minnesota. I have comments that
anticipate the shift this afternoon to resilience. One is that in many ways, it sounds
like we need family services and interventions that have the future character we hopefor in our military units. These are greater flexibility, nimble quality and modularity,that make it easier to fit and adapt interventions and services to changing people,
individual differences and needs.
Secondly, another striking theme in this panel to me was that the risks and protective factors that were discussed are very much in line with the general populationin the United States. Although military families are a select group, still, a lot of thefindings may well have much broader applications to the general population. What
we learn are much broader applications to general family resilience programs. The
research that is done in the military may be able to make important contributions
in a much broader way.
DR. URSANO: I want to also repeat what you were saying. Some of the evaluation criteria of programs may be similar to what we are trying to accomplish in the
military with units, in terms of flexibility, modularity, adaptability, which goes alongwith the earlier construct of harm. We have evaluation capacities of programs thatare not typical to just, “Is this program having an outcome that we are looking for?”Panel 3: Fostering Resilience in Families—What Does the Science of Resilience Tell Us?

49

3

Fostering Resilience in Families:
Lessons for and from Military
Families
Speaker: Ann S. Masten, PhD, LP
DR. BENEDEK: I am the Deputy Chair of the Department of Psychiatry, Uniformed Services University, and an Associate Director for the Center for TraumaticStress. This afternoon we will focus on a framework for research and implementationof programs that address resilience. Our first panelist, Dr. Ann Masten, is the Irving
B. Harris Professor of Child Psychology and Distinguished McKnight Professor at
the Institute of Child Development, University of Minnesota.
DR. MASTEN: I would like to start by saying why I am particularly glad to be
at a meeting like this. I was born into the military. I entered the military before I wasborn and not quite as a volunteer. It has been very exciting and pleasing to see theprofound transformation that has occurred in the conceptualization and concern
about families in the military. I am going to talk about resilience and introduce someof the contemporary ideas, and comment about lessons learned from all the decadesof research that have been done on resilience in children. I will also talk about what
the research and practice with military families can and will be able to contributeto our understanding of resilience going forward.
A good place to begin would be with a typical contemporary definition. Resilience is usually defined in terms of a systems dynamic. Now it is viewed as thecapacity of any system to withstand, adapt or recover from significant disturbances,and then continue with its life, development, or progress. When I say any, “system”,
I mean that this idea came from systems theory, and it really can be applied at thelevel of a neural system, a cardiovascular system, an individual, a family, a militaryunit, or the military as a whole. It could be applied to our economic system. We
are all hoping for resilience there, as well as for planetary resilience. Global climatechange is a concern of global resilience.
There have been five decades of research that grew out of interest in this fundamental question in resilience. How is it that some young people, or some families, orsome countries withstand great stress and do well and flourish, and others flounderand do not do well. What can we learn from studying this kind of phenomenon to
help inform what we do, to promote resilience in individuals or families who are
not doing as well? Over the course of these 5 decades, there have been tremendous

Resilience is usually
defined in terms ofa systems dynamic.
Now it is viewed as
the capacity of any
system to withstand,adapt or recover fromsignificant disturbances,and then continue with
its life, development, or
progress.

50

Some of the best
prevention programsand best resiliencebased intervention
programs actuallytarget positive goals.

Military Families in Transition: Stress, Resilience, and Well-being

advances in the way we understand resilience, the definitions of it, in the methodology that is used to research it, and in methods, both of basic research and intervention.
From the very beginning resilience always has had a practical goal. The pioneers
in this area were interested in helping children and families because the early research
was very much focused on children and families. Researchers recognized that eventhough research is always ongoing, we have to respond now, to the best of our ability,with what we know. That has always been the case in the resilience field.
One of the contributions from the science of resilience has been how to think
about promoting resilience, whether you are thinking about it in terms of promoting
resilience of individuals, families, or the military as a whole. I am going to talk very
generally, and my colleagues on this panel are going to talk very specifically about
particular programs. I am going to talk about an intervention framework.
Lesson one is to frame positive goals. I would like to challenge you to think
about positive goals more broadly than prevention because often when you think
about prevention, you are trying to prevent a negative. Some of the best prevention
programs and best resilience-based intervention programs actually target positive
goals. I would argue that many families and children as well are much more motivated by positive goals than they are by, “I can help your family avoid disaster.” They
are interested in, “I can help your family do well, succeed, recover, etc.”
Secondly, it is important to have models that include positive outcomes and positive influences as well as to include models that include risk factors and symptoms.
You need to be able to measure and monitor the positive outcomes and influences,and we have already heard some about that today.
I am now going to talk about methods. The research in resilience suggests
several basic strategies. The research suggests that you have to consider multiple
perspectives and multiple levels, both of analysis and measurement. You also have toconsider the multiple levels at which you might want to intervene. The three kindsof basic approaches to intervention that have been implicated by a general resilience
framework are: risk focused, asset focused, and process focused. One of the mostimportant strategies for positive change is to reduce the level of stress and risk thatan individual, family or other kind of system is subjected to. I wanted to highlight
this because sometimes people hear about a resilience perspective and they thinkthey are not interested in risk. This is not true. A resilience approach has to take into
account the level of risk and adversity exposure of the system. Sometimes you needto lower the risk. Another strategy is to boost assets which means increasing theresources or access to resources that are generally positive. The third strategy is toharness the power of human adaptive systems. These are the big engines of resilience.
I want to make a few other general comments from the literature that I hope you
will think about in our conversation today. It is important to conceptualize resilienceas dynamic. Many, many systems interact to shape the development of a person or
the development of a family or the development of a military. This also means that
there are many influences and there are many pathways to resilience.
The capacity for resilience — your adaptive capacity — is always in flux. It ischanging as a function of your health, your development, and the resources at yourdisposal. Your resilience is not a fixed commodity. It is a dynamic capacity and it
is also not in the person. This is a common misconception. Resilience is not a trait.
There is no such thing. There are certainly individual differences and personality
characteristics that are helpful in many kinds of threatening situations. In reality,Panel 3: Fostering Resilience in Families—What Does the Science of Resilience Tell Us?

resilience is distributed across multiple systems. In a very young child most of thecapacity for resilience is in the care-giving system that is supporting that child’s lifeand development. It is important to think about individual children in the militaryand individual families in the military as parts of larger interdependent networks
and systems. This is dramatically evident when you have a catastrophe.
I study children in war and natural disasters. When every system goes down atonce, which happens in a calamity like the Colorado flooding, a nuclear accident, atornado, or tsunami, you realize how interdependent all these systems are. It is very
hard for a family or a town to function if every system around them is not operatingwell. This conference and meeting represents the profound appreciation the military
has developed about the interdependence of systems.
Risks matter and I want to underscore this again. We have heard today thatrisks are cumulative. It matters what your history is and how much adversity you
have experienced in your life. There is really good evidence that if you experience atsunami or a deployment in the context of many other stressful experiences in yourlife, your risk is higher than if you experience some acute event in a context of a very
low-risk background. Sometimes, one of the most important strategies is to lower
the risk exposure level. If you have too much high cumulative risk, you can overload
the capacity of any individual, any family, or any town to recover and be resilient.
Resources matter and we have heard about that today. Economic as well as
human resources can be helpful at all levels of risk. It is helpful to have good healthcare and some money for food, no matter what the current risk level is. Protective
systems matter and many of these are in relationships and in culture and in many of
the other systems that have evolved in human life. We have to invest in and nurturethese systems in order to foster resilience.
Families are our focus today and families have had many roles in the development of competence and resilience in children and in all members of a family. It isvery important to support the function of the family because it is very hard to replace
all these roles in the life of a child. When state welfare systems remove a child from afamily and try to replace all these functional roles, they have discovered you have tohave a great adopting or foster care family to provide all of these activities. Some of
the ways that families matter are biological. There are effects on children before they
are born. Stress affects the mother and affects the epigenetic system that is inheritedfrom both parents. This can have lifelong consequences for children.
We have heard that military families have some unique risk. They have an
elevated risk due to certain kinds of blast injuries that are not commonly experienced
in the general population. They also have a different kind of deployment than you
see commonly in the general population. However, military families have a great deal
in common with many other families. They are struggling with similar issues. There
are families across the United States that are mobile for various reasons. Mobility, inthe context of poverty, is something I study in homeless families. There are similarities and differences, but there are some lessons that can be shared across sub-group
populations in the United States who have much in common with military families.
Military families also have opportunities that are important not to overlook. I
gleaned a great deal from growing up in the military, particularly from the opportunity of living in many different cultures and knowing many different kinds ofpeople. Those experiences have given me certain resources and capabilities that I
might not otherwise have.
I want to close by talking about lessons we can glean as a society from military

51

Families are our focus
today and families
have had many rolesin the developmentof competence andresilience in children
and in all members ofa family.

52

We are here to
discover the benefitsof recognizing theinterdependence offamily success andhealth, child successand health, and militaryeffectiveness or any
other workplace,or societal level of
effectiveness.

Military Families in Transition: Stress, Resilience, and Well-being

families. There is a special issue of, “The Future of Children” coming out soon thatis focused on military families and children. I wrote the final commentary for thisspecial issue and one of the things I was asked to write about was what can we learn
from military families. When you read the articles in, “The Future of Children” youwill be struck by all that has been learned. I will mention a few examples here.
The military now, in striking contrast to when I was young, has one of the bestearly childcare systems on the planet on military bases. We could learn from how
they went from having not very good early childcare programs to having outstanding childcare programs on military bases. They are beginning to struggle with theissue of how that was done on bases and what can be done about childcare in all theother places where our military families live. We can glean important lessons fromthe military about how to deliver quality childcare. The military has also done wonderful things for mobile school children. Growing up, I suffered the consequencesof many moves from school to school. It is amazing to see what the military does
now with programs like, Student to Student. I am a new member of the Board of
the Military Child Education Coalition. What they are doing to promote academic
success in military children is really great. The military record keeping systems, bothin healthcare and in educating kids, provide all kinds of lessons.
There are lessons to learn from a large organization like the military with various components and how they create a family supportive culture. The work is stillin progress but compared to decades ago, it is remarkably supportive of children
and families.
We are here to discover the benefits of recognizing the interdependence of family success and health, child success and health, and military effectiveness or any
other workplace, or societal level of effectiveness. There is potential for longitudinal
research on how we can promote resilience and how we can build the capacity forresilience by supporting families. I am very interested in research on the developmental timing of both trauma and stress and also interventions to mitigate trauma
and stress. The military can make contributions about how we learn to transform
systems so that they work better for families and children.

Panel 3: Fostering Resilience in Families—What Does the Science of Resilience Tell Us?

53

Fostering Resilience in Military
Families Over Time
Speaker: William Saltzman, PhD
DR. BENEDEK: Our next speaker is Dr. William Saltzman, a clinical psychologist and Associate Director of the the Nathanson Family Resilience Center at UCLA.
For the past 18 years Dr. Saltzman has developed and implemented trauma andloss focused programs for children and families exposed to trauma - military andotherwise. He is a co-developer of FOCUS (Families OverComing Under Stress), a
resilience training program for military families.
DR. SALTZMAN: I want to build on many of Ann Masten’s comments on resilience in a more applied fashion but specifically in terms of the great comment that
resilience does not reside within the individual. Some of the strategies Dr. Masten
mentioned are important. To be able to harness the natural processes or strengthsof the family system and to promote specific behaviors, interactions, beliefs, andattitudes that we believe support a resilient response are important strategies.
I am going to talk about family resilient processes drawing liberally from Dr.
Froma Walsh’s model and her work in strengthening family resilience. In the courseof my talk I have 4 basic ideas for Dr. Ursano that I want to highlight. I am going
to present a case example using a veteran family. I have been working a great deal
with active duty military over the last 7 or 8 years. I am also working in county
mental health in the veteran community and fielding services for veterans. This caseis a blended Army family. Mom brings 2 kids to the marriage with dad, who is an
Army Sergeant. They have one child who is 2 years old. Dad has had a total of 4
deployments, 2 of them since he has been married. During that time he saw a great
deal of combat action involving the death of 2 members of his unit. Post discharge
dad is experiencing PTSD and depression, for which he is receiving medication.
He has ongoing alcohol problems, a sporadic work situation, anxiety issues, sleep
problems, and some GI issues. He has initiated the contact.
I want to organize our discussion of family resilient processes drawing upon Dr.
Walsh’s work, in part, using 3 different family organization categories. Flexibility
is a balance between change and stability. At the heart of flexibility is the ability tomaintain care of the family while adapting to the ongoing situation. The Andersons
are able to do that. Dad has switched roles in many ways because his work is more
sporadic. Mom needs to work more. They have been flexible, although mom feels
badly that the kids seemed to be parked in front of the TV a great deal and some

To be able to harness
the natural processes orstrengths of the familysystem and to promote
specific behaviors,interactions, beliefs, andattitudes that we believe
support a resilient
response are important
strategies.

54

Sometimes couples
have different
approaches toparenting. Sometimes
there are problems
with injury
communication.
We see this problem
with some combat
injured veterans in the
FOCUS program.

Military Families in Transition: Stress, Resilience, and Well-beingof the care routines seem to be breaking down. In terms of cohesion, we see that
resilient families maintain a core of connection with engagement of the parents toprovide accurate types of support. In the Anderson family we see strong efforts inthat direction although things are also getting ragged. Mom is used to being a rulingparent and much more involved. She is not capable of doing that right now. It is
important for families under stress to maintain boundaries within and between thefamily and the outside world. Parental leadership is key to maintaining appropriate
boundaries within the family and to the outside world. The Andersons have difficultywith this. They have inconsistent parenting, as well as attending with a tendency to
become rigidly isolated. They have cut off some contacts to their support network
outside of the family.
The next category of family resilient characteristics is communication and collaborative skills. We will talk about affective and instrumental types of communication patterns. It is important for families under stress to maintain openness and tohave a tolerance of different types of expressions of distress. We have seen a great
many families in the FOCUS project and other places go into lock-down. Perhaps,
because of the parents’ irritability or their stress, they cannot tolerate the expressionof what is going on. The kids can actually become protective in some ways by notsharing their difficulties. We see some of that behavior with the Andersons. Mom
is overwhelmed and the kids’ communication has shut down at the affective level.
Instrumental communication is key. With the Andersons, there are efforts to maintainclear communication, but it is hard with mom working so much and the hand-off
between mom and dad is difficult.
Sometimes couples have different approaches to parenting. Sometimes there areproblems with injury communication. We see this problem with some combat injured
veterans in the FOCUS program. Mom, who has anxiety and serious GI problems
and has even been hospitalized, has not communicated clearly to the kids what isgoing on. When Mom disappears or she is acting ramped up, the kids do not knowwhat is going on. They worry about her and they worry about dad, who can be
explosive at times and has pulled back from the family.
This family has had difficulty maintaining family level collaborative skills. They
do not tend to hang together and have fun like they used to. Decisions are often
made unilaterally. They do not set family goals so that is a skill missing for them.
Affect regulation is an area to monitor family members’ levels of affect and distressand then to move in appropriately.
The third group of family resilient processes that are key involves family beliefs
and the capacity to make meaning in adverse situations. This includes the operative
aspects of a family identity. It involves how a family appraises threat situations
and their capacity to respond. It involves whether they tend to be more optimisticand hopeful, as well as whether they can draw upon religious or even transcending
values. The basic idea is that the dominant beliefs within a family often determine
how a family responds to adversity and stress. Key parts include what has been calleda mastery orientation. Parents teach the family that adversities are comprehensible
and family members can understand what is going on. Family members do not haveto be overwhelmed. They can navigate a path forward. Behavior is modeled by theparents in many different ways. It is modeled by reactions and discussions that parents have along the way with kids. The next part is the capacity to make meaningout of stressful and de-stabilizing experiences. This is critical and this is where theparents come full center to help deal with affectively charged events and help thePanel 3: Fostering Resilience in Families—What Does the Science of Resilience Tell Us?

children to organize, manage, and make sense of their experiences. Parents’ examples
and skillful encounters help shape the child’s experience and memories and build the
expectation for both young children, as well as older children. We can get throughthis by working together. We can understand this and develop a pro-active plan.
Parents can also help kids in the family navigate their way toward positive beliefs
and attitudes that will be adapted for the long term. It is important to understandthat parents play a key role in promoting protective beliefs and attitudes. Throughscaffolding conversations with kids, parents help make sense of scary or very challenging types of transitions and situations. Parents can help move children throughdifficult situations by talking with them.
Generally speaking, we believe that you can target and try to enhance specificfamily resilient processes through a fairly brief type of program. There is a great dealof skill required as well as structured exercises that are helpful. I want to emphasize
the centrality of belief structures and the meaning-making capacities for long-term
resilience and recovery of the service member and the family. It is at this level atwhich many military families take a hit in terms of their belief structures, their trustin each other, their institutions, as well as ongoing trust in the world. This is an area
where military families can sustain some real damage. In fact, when the Andersons
first came in they appeared beaten down, despondent and hopeless. They had difficulty finding a path forward and difficulty remembering their strengths and theirprevious successes.
What are the tools that are available to help families construct meaning and tobuild resilient in the family? A quote by Bruner (1986) provides meaning, “It’s byconstructing a narrative that we make an experience knowable, integrated into ourconscious life, and then access it as a memory.” This quote gets at the idea that weare hard-wired in certain ways to use the narrative or story form to make sense ofthings, especially affectively charged traumatic events. Those of us who do trauma
work know about the use of narrative to help reduce reactivity. What I am promoting
is a family level narrative. This is what we do in the FOCUS program to try to bridge
estrangements in the family. We have a graphic approach to eliciting narratives fromall the family members.
We have a time-line for parents who have experienced multiple deployments.
There are many points in which mom and dad’s lines converge and some points
where they diverge. This highlights the fact when you explain this with a mom anda dad present, they can see the differences in their experience for the same events.
In the FOCUS program we have parent sessions in which we elicit narratives frommom and dad, or we work with the single parent or the care-giver to elicit theirstory. A graphic representation provides a way to bridge misunderstandings acrossthe care-givers, as well as to provide an opportunity to see the whole context ofthe multiple stressors they have been through. It is a way to normalize and validate
their current levels of distress.
We have a different format and different ways of working with kids in which
we elicit stories about their experience across deployments and whatever points areimportant for them. We call the story telling, Time Map, and we use a color-coded
method from green to yellow, orange and red, to show what was distressing for thechild. We have a graphic representation with their drawings, their ratings, as wellas their specific questions and concerns that they have not felt comfortable expressing to mom and dad. With the child or teens approval we use the Time Map when
we meet with the parents. We use this tool to help the parents prepare for a family

55

Generally speaking,
we believe that you
can target and try toenhance specific family
resilient processes
through a fairly brief
type of program.

56

Over time, individuals
and families havedifferent emergent andchanging needs after
they have experienced
trauma, stress, ortransition.

Military Families in Transition: Stress, Resilience, and Well-being

session where we can share individual narratives, questions and concerns. We aremoving more towards a family narrative or a shared understanding of what thefamily has been through and where they are now, as well as to highlight their current strengths. We identify what they bring to the table and then we move towards
development of specific skills that would be most useful for that family.
The next idea is the utility of the narrative approaches and methods to enhanceparental skills and co-constructing children’s experiences and understanding of thestressful events. Using this platform combined with the narrative sharing, we findthat we can enhance all 3 levels in terms of resilient processes. We see improvement
in many cases. This is anecdotal but we see improved family organization, communication, and collaborative skills. The family is able to find the more positive aspectsof their family identity and confirm adaptive and positive beliefs to help them deal
with their current difficulties.
This next piece has to do with something that we talked about earlier. Overtime, individuals and families have different emergent and changing needs after they
have experienced trauma, stress, or transition. At different phases of recovery fromtraumatic events the individual may have very different needs and different resilient
processes may be more or less important at specific times. Some of the early work
by Lietz identified families who had a resilient response to a range of traumatic oradverse situations. They identified a series of stages of response and recovery, as well
as different types of family factors that seem to be most helpful for those specificperiods of time.
We can start to look at where the family or an individual is in terms of their arcof recovery. We cannot assume that the same things are always good for all stages.
In survival stage, perhaps external/internal support is taking charge, as well as drawing upon morale and spirituality. In adaptation, flexibility and communication are
key. In the acceptance stage, families are growing stronger and finding meaning so
the belief aspect comes more into play. Finally, families felt that helping others wasan important end stage for their recovery. The prime idea is that there are different
approaches and different pieces and we want to factor in stages of time as well.
I have had the opportunity over the last 20-some years to respond to a host ofdifferent types of trauma or disaster events. I have been involved in the immediateand long-term recovery from school shootings like Columbine and Santana. I worked
5 years on the World Trade Center and for 6 years on the Bosnian War developing
programs for kids and families. What was very clear is that it was like trying to hit
a moving target. We started off with pretty clear trauma programs with a trauma
and PTSD focus. I remember very clearly when Chris Layne and I were up in Banja
Luka, which is a Serbian entity, and their psychologist said, “Bill, it’s not the trauma.
It’s the death.” This was 3 years after the war. The grief and complicated bereavement issues were more prominent at that point and we had to shift our intervention.
In closing, families are dealing with a complex mix of many types of exposureand difficulties. There are different trajectories for different problems, whether it
be PTSD, TBI, or bereavement. Each has a very different cycle that we have to be
responsive to. The centrality of belief structures and meaning-making capacities
for long-term resilience is key. I am not saying we need to do cognitive processing
therapy. That is different. I am talking about family level focus on belief structures
and that these belief structures are a lynch-pin in a family’s resilience response. The
utility of narrative approaches to enhance parenting skills for making meaning andunderstanding is key. This is teachable and learnable and is a wonderful tool to build

Panel 3: Fostering Resilience in Families—What Does the Science of Resilience Tell Us?

resilience across families. Understanding the changing set of skills and changes in
the resilient processes during a family’s recovery trajectory is key. Understanding thedifferential impact and trajectory of grief and moral injuries for the service member
and the family is important. These types of injuries have a different half-life than
PTSD. Grief often picks up in year one and two, for many different reasons, as does
TBI and other chronic medical difficulties. We have to have a complex understandingof structuring these interventions.

57

There are different
trajectories for different
problems, whether
it be PTSD, TBI, or
bereavement. Each has
a very different cyclethat we have to be
responsive to.

58

Military Families in Transition: Stress, Resilience, and Well-being

Panel 3: Fostering Resilience in Families—What Does the Science of Resilience Tell Us?

59

Fostering Resilience in Military
Families: Cascading Effects of
Positive Parenting
Speaker: Abigail H. Gewirtz, PhD
DR. BENEDEK: Dr. Abigail Gewirtz is Associate Professor, Department of
Family and Social Sciences at the Institute for Child Development, the University of
Minnesota. Dr. Gewirtz will continue to discuss the research framework for resilienceand give us some examples of implementing this in military populations.
DR. GEWIRTZ: I want to acknowledge our sources of funding for our researchand our program: National Institute on Drug Abuse (NIDA), National Institute ofChild Health and Human Development (NICHD), and the Substance Abuse andMental Health Services Administration (SAMHSA). In addition, I have a fantastic
team of co-investigators and collaborators from across the United States.
I am going to talk about fostering resilience by supporting parenting. I would
like to start by answering one of the questions that was put to us this morning. Whatwould you spend your last dollar on? If I re-frame it as what would you spend yourlast dollar on to support military families, which I think was the intent, my answer
would be parenting. My goal is to explain why. Why do we focus on parenting? I
will talk about the role of parenting in the lives of children who experience stressful events and what we know from decades of parenting research. Excellent sciencehas shown us that you really can strengthen parenting and strengthening parenting
has cascading effects, not just on children, but throughout the family system. While
we have many services and supports for families within military systems, there is achallenge in terms of empirically supported data.
I will begin with a theoretical perspective that is the perspective of social
interactional learning. Gerald Patterson is the father of social interaction learningtheory, which previously was known as coercion theory. Patterson was a WorldWar II veteran. When he was 17 years old he enlisted and was sent to the islandof Okinawa. After an injury and after having seen several of his buddies killed, he
was discharged. Patterson spent the rest of his career studying families who get into
trouble, and what he found was that kids learn how to get into trouble because
they have stressed parents. The interaction between parents and children becomesincreasingly coercive. You can predict childhood arrests or youth arrests 3 years

Excellent sciencehas shown us thatyou really canstrengthen parenting
and strengthening
parenting has
cascading effects, notjust on children, but
throughout the familysystem.

60

Our conceptualizationis that deployment is amilitary family stressor.
… separations andcombat stressors, andreintegration are very
special opportunities
for changing
trajectories.

Military Families in Transition: Stress, Resilience, and Well-being

later from the intensity and the frequency of coercive interactions between parents
and children. This is pretty powerful science.
This was not just Patterson’s idea. There are a group of family researchers whodeveloped a model called the Family Stress Model. The idea is that in stressful situations children’s adjustment is mediated through the effect of these stressful situations
on parents’ parenting. Steve Cozza and his group highlight that in a very nice way.
There are specific parenting practices that are associated with, and that predict,children’s positive adjustment and children’s problems.
Our conceptualization is that deployment is a military family stressor. Why is ita family stressor? For 2 reasons; separations and combat stressors, and reintegration
are very special opportunities for changing trajectories. If we take a family stressperspective what we understand is that it is the parenting practices of the parents
that mediate the impact of deployment stress on children’s outcomes. There is arobust literature on a variety of civilian populations showing how these conditions
impair parenting under a variety of stressors including: parental psychopathology,socio-economic stress, economic conflict and family transitions like divorce andre-parenting. When parents are stressed, their interactions with their children are
more coercive and you see the results in detrimental impacts on child adjustment.
What are effective parenting practices? The parenting practices that I am discussing come from the model that emanates from Patterson’s social interaction learningtheory. It is the Parent Management Training Oregon Model and is the most widely
tested model that is out there. SAMHSA’s NREPP (National Registry of Evidencedbased Programs and Practices), represents the largest category of evidence-based
parent training programs. There is literally 40 years of research on these programs.
The research shows that when we strengthen parenting practices, not only doesparenting get better, but children’s resilience improves. What do we mean by effective
parenting practices? We mean teaching positive behaviors through encouragement.
Effective parenting practices involve encouraging kids and using non-coercive
discipline that is consistent and includes: follow through, family problem solving,and parents teaching children to approach problems in a flexible, structured waythat results in a resolution. Enjoying children, positive involvement, monitoringand supervision are also important. Steve Cozza’s data talked about the associations between monitoring and problematic child outcomes. I am pleased to see thatfinding in the military literature. These associations have been replicated time andtime again in the civilian literature over the last 40 years. Pont DuCharme’s work
is a good example of this.
Regulating parent emotions and helping parents deal with their children’s emotions is a particularly salient issue for military families. We have heard a great deal
about experiential avoidance associated with PTSD. As my colleague, Jim Schneider,puts it, “The family is the crucible for strong emotions.” It is not surprising thatexperiential avoidance would be one of the key factors associated with difficulties
in the family. The Oregon model for parent management training is arguably themost well-validated parent training model. It has been shown to improve parenting,does not rely on self-report, but actually what you see when you video tape parents
and children interacting together prior to and following a randomized control trial.
What do we mean by improving children’s resilience? When you improve parenting, kids do better in school, with friends and in social situations. They have fewer
behavioral problems, less depression, less substance use, less truancy, and fewer
school problems. What is beautiful about this model is that that you see changes toPanel 3: Fostering Resilience in Families—What Does the Science of Resilience Tell Us?

children’s adjustment and development, as well as concurrent changes or subsequentchanges.
My colleague Marion Forgatch conducted a 9 year follow-up study of a groupof single mothers who were randomly assigned to either participate in a groupbased parent training intervention, or to receive services as usual. Nine years later,
the mothers who were randomly assigned to the parent training group had children
who were doing better on all the dimensions I mentioned earlier. Those mothers
also had less depression, less substance use and were earning more money. They
were better educated and had better jobs than the control mothers. To me, that is
the ultimate definition of a cascading intervention. In addition, another study of thissame model with step-parents showed that this parenting intervention had impact
on the co-parenting structure as well. The study showed improved parenting andmarital satisfaction among the step-parents.
Unfortunately, this parent training intervention has not been implemented in a
military context, with the exception of one program. There is an experiment that wehave been conducting over the last few years, with the support of NIDA, to modify
this parent training intervention for military context specifically for families who
have deployed. We heard earlier about the importance of thinking about deployment
and reintegration as key stressful points. This randomized control trial is specifically focused on reserve component families. These are families who do not havethe benefit of the structure and support of the military installation. They are often
isolated. They live in pockets and they may not know another military family.
After deployment Adaptive Parenting Tools (ADAPT)) is a 14-week long webenhanced parenting program for families where one parent has returned from
deployment and with a school-aged child between the ages of five and twelve. In
collaboration with the program developer, we made some significant modifications
for the military culture. Specifically, we focused on emotion regulation. We spent agreat deal of time teaching skills related to what we call a united parenting front.
Being on the same page, as well as addressing barriers to participation are key issues
that parents talk about as reintegration stressors. We are conducting a large-scalerandomized control trial with 400 families in the Midwest. We are midway throughthe trial, but we are already seeing six and twelve month outcomes.
Our program addresses the issues related to prevention science and how to bringresearch into practice, as rapidly as possible, without compromising our scientificintegrity. We teach specific skills in a group with the use of videos of family interactions illustrating specific points. Skills training is typically more challenging if you
are dealing with individuals with PTSD or high levels of experiential avoidance, etc.
After parents have spent a couple of hours in a session with other parents, practicing
this skill over and over again we send them home to do home-practice. They have anadditional video to watch that shows parents actually practicing this skill. We thenbuild on this. We teach parents about encouragement and then we spend quite a bitof time on emotions. We teach parents about discipline, problem solving, managing
and monitoring conflict, co-parenting, dealing with the transitions associated with
deployment, and how to manage that in a family context.
We were concerned that we would get a great sample of mothers not in need ofskills training; however, it is the moms who generally come in first. In this National
Guard population they are mostly civilians. Mothers and fathers attend equally andbenefit equally, as do parents in our pre and post analyses. We are pleased to findthat parents at both high and low risk at baseline seem to benefit equally.

61

Our program addresses
the issues related toprevention science andhow to bring research
into practice, as rapidly
as possible, withoutcompromising ourscientific integrity.

62

We teach parents about
discipline, problem
solving, managing andmonitoring conflict,co-parenting, dealing
with the transitions
associated with
deployment, and how
to manage that in a
family context.

Military Families in Transition: Stress, Resilience, and Well-being

The second question from this morning was what are the future research questions we have? Parenting is very close to my heart. One of the beautiful things about
doing a large-scale randomized control trial with military parents is that we include
military dads. This is important since we do not have as much information about
dads as we do on moms. We have military moms as well and I want to finish witha quote from one of our first study participants. She is a single mother and a highranking officer in the National Guard. She speaks so beautifully of the challenges
that are associated with being a deployed mother:“When I left they [my children] were mommy’s girls, just two school-age
girls. I took them to day-care, I picked them up, I did everything. Then when
I came back, there was a lot of conversation about what I missed. They werewith their dad. When I came home, my youngest, would not let go of me. She
held me so hard it would actually hurt sometimes. She would just squeeze me.
They would talk about how they were the girls who went places and everyone
else but them had a mom there. Moms carry that guilt. You, as a mommy,
think that you are supposed to be there all the time — not that men don’t
have the same experience. But when I was talking to my male counterparts,
when they were coming home it was to play with kids. They would not talkabout coming home and now have to take care of the kids. It wasn’t thatthey were going back into a care-giver role.
I joked with my office mate when we were in Afghanistan. If we could
just get child-size protective vests, then we could bring our children over,because other than being away from our children, we both loved being on
deployment. We were doing our jobs. We were doing what we were trained todo. It is sort of like if you’re talking to your kid, as if they were a dancer, butnever got to dance in a dance. Wouldn’t you really want to dance in a dance,
if given the opportunity? If all you did was train and prepare to be a soldier,but never had the opportunity to be a soldier in a combat situation, when
given the opportunity, you’d feel like you’d missed something important.”
I love that quote because it brings depth what soldiers experience, somethingthat is missed when we focus only on averages or scores. We have a great deal ofdata on mothers; however, narrative experiences such as this one bring an importantdimension to the experience of our military families.

Panel 3: Fostering Resilience in Families—What Does the Science of Resilience Tell Us?

63

Panel 3 Discussion
Moderator: David M. Benedek, MD
DR. BENEDEK: I want to remark on the common themes from the morning andthe afternoon and some lessons learned. First and foremost is the idea that resilience
does not reside in the person. I have always thought of myself as a resilient person.
But in reality, I have to thank the systems that I have been brought up in including
my family and my employer. I also like the idea of thinking about system resilienceand planetary resilience.
The other theme that was important to me is the notion of consistent meaningacross family members. People coming home have a shared meaning of their experience with those who stayed at home and the challenges associated with that. We see
this in the importance of the reception at home in terms of family members and interms of service members.
DR. WALSH: Just as resilience does not reside in an individual as a set of traits
that are immutable and either you have them or you do not, we have to be carefulwith families. We cannot think that some families are resilient and some families
are not resilient. Think of these as processes over time and that a core principleof a resilience approach to intervention is the conviction that all families have thecapacity to gain resilience. Families may not all reach the same end point, but thereis that core conviction.
DR. BLOW: I am excited to hear about the inclusion of multiple family members
and treatment this afternoon, and in Steve Cozza’s presentation this morning. I likethe phrase, “cascading effects.” The more we include family members in primary
treatments for disorders like PTSD, TBI and the other issues we have talked about,
we will have a much larger impact. It may cost more in the short-term to include
more family members; but in the long run, I think we will save millions and hopefully, even billions of dollars.
DR. SALTZMAN: In terms of the bang for the buck issue, I agree wholeheartedly. We know some practical things and there are strategies to meet families
where they are. In terms of sustainable change, it is important to focus on children
and parents and to work within their system. We can have an enduring impact thatis under their control.
DR. LONDON: I wanted to comment about cascading effects. That finding cameout of a nine-year study and as Ann Masten said, we may be able to learn a great
deal from studies of military families that could extend to other kinds of families.
Meredith Kleykamp talked about the importance of veteran families and following

First and foremostis the idea that
resilience does notreside in the person.

64Long-term follow-up
is required to really
understand theconsequences of
military service andthe lessons learned
from the interventions
we do with families
who are facing
different kinds ofstressors.

Military Families in Transition: Stress, Resilience, and Well-being

families longitudinally over time. All of the comments linking across multiple sessions today point to the need for more of a life course perspective for studies thatcompare veterans to non-veterans or follow interventions with families over the
long-term. Long-term follow-up is required to really understand the consequencesof military service and the lessons learned from the interventions we do with families
who are facing different kinds of stressors.
DR. BENEDEK: Your comment about the need for longitudinal examinationof interventions and the challenges of military transitions is consistent with Dr.
Saltzman’s comments about the differential trajectories of the kinds of stressors ourservice members experience. I concur with your observation.
DR. GEWIRTZ: How much research is enough before you go large scale? Oneof the reasons we picked the model to develop ADAPT is because the model has 9
years of research behind it. Also, this is a model that has been implemented on awide spread basis in 5 countries in the world, and in 4 states in the United States. It
has been implemented on a wide spread basis in the children’s mental health system,
the child welfare system, and in prevention systems. What do we need to do in orderto get it out?
In prevention science, we have some really good findings and good data. We
have a large body of effective programs of the highest standards, gold standard
effective programs, and we also have a growing number of programs that have beentaken to scale with implementation infrastructures that are validated. Not only are
the programs validated, but the implementation infrastructures are validated. They
have fidelity systems that have been shown to have predicted validity. For example,
in the Parent Management Training-Oregon Model (PMTO), you observe what afacilitator does in a group and score it. There is a reliable system for scoring and thelevel of fidelity with which the facilitator delivers the program predicts the amountof change in parenting. These are all empirical findings that can and should be built
upon in the military. There is no need to reinvent the wheel.
DR. COOPER: Hearing about these models raises a question in my mind. In the
military you have a slightly different situation. You could have a two-parent family
and then you have a deployment, which leads to a one-parent family, and then you
have the return from the deployment, where you return to a two-parent family. What
I heard is that these are dynamics about how to co-parent better or how two parents
work it together. The military, by its own nature, essentially creates an intervention
that we can learn from. We know a little about what to do when the parent returns.
We know how to prepare parents while they are together, but we do not have any
models for while one parent is deployed.
DR. MASTEN: I would agree there is less general research within a militarycontext on that, but I do think there is an extensive relevant literature on families
that get separated for other reasons. A family could be separated due to a businessdeployment, due to divorce and separation, and for many other reasons. Many of
the findings that undergird the interventions that we are talking about and fromthe resilience literature, have strong implications for how you would support asingle-parent family, or a family that is in transition. I do agree there is less evidence
and that would be a very powerful way that the military could contribute to ourknowledge base.
DR. GEWIRTZ: Bob, this morning you posed the question of multiple deployments and high operational tempo. We do not know anything about the impact ofshorter, more frequent deployments. That kind of research would provide a hugePanel 3: Fostering Resilience in Families—What Does the Science of Resilience Tell Us?

contribution because I understand, in the future, wars will be fought by small, highly
trained, frequently mobilized units. What is the impact of coming in and out of thefamily two or three times a month?
DR. BENEDEK: Another lesson we learned this afternoon is that transitions arealso opportunities, and this morning we talked about the risk factors. There is an
opportunity for the military to leverage the models of different length transitions
and study and learn from them. What are the effects and what are the best ways tomitigate the effects is always before us. We should invest in that.
DR. COOPER: There is also the question of learning. When a person is deployed
they need different parenting strategies. They have their own unit, their mission to
fulfill, and the safety of their team and themselves. But they also want to have a rolein the family. That is an aspect that we do not understand very well. Their role needs
to change while they are deployed.
DR. MASTEN: I wanted to underscore that point. It is a very important issue
and as I think back, I have a personal anecdote. When I think about the situationof my father parenting when he was in Vietnam, it is profoundly different thanhow deployed parents in recent years have enacted the parenting role. In thosedays, you sent little recorded tapes that would arrive every day, except during the
Tet Offensive. They shut down everything for three weeks, and you are panicking.
Those little messages were so monitored. My father was actively changing what hesaid to be supportive to us as kids. Listening to the tapes, you would have neverrealized that he was in a war zone and a Battalion Commander. He was parenting
in a protective way.
That does not work anymore. The world of 24/7 news, CNN and text messaging
presents a new set of issues that we need more knowledge about. How does a parent
know when to Skype and when not to? How do you manage live interactions when
you do not want a child to be fully aware of every little stressor?
DR. BENEDEK: That is an excellent point. We have discussed the technology
and the utility of technology, and importance of technology. It is a double-edged
sword if we are trying to be a real-time parent while ducking bullets. On the other
hand, we do not necessarily want to be doing that.
DR. THOMAS: I was very happy to hear Dr. Gewirtz’s presentation about somelarger studies on parenting programs. Very respectfully, I disagree about the fact that
there is one empirically driven program that all of the services use. All four services
have the nurse home-visitation program. This program comes out of a very strict,randomly controlled design that has been replicated again and again. Dr. Gewritz isabsolutely right, that once you have an empirically defined program and you implement it, you do get effects and it addresses the issue of a single parent, a temporarily
single parent, and parents together. This is a place where you can see a great deal of
prevention and intervention happening.
DR. GEWIRTZ: I stand corrected. My population is 5 to 12 year old children.
DR. MacMILLIAN: I was going to make the same point, and that is why I
think it is so important to ask systematically what your target audience is, what theintervention is, and what are your outcomes? For example, even with this particularage group, if you are interested in the reduction of violence or the prevention ofchild maltreatment, then it would be a different parenting program. By altering theoutcome you are interested in, from behavior problems in children to prevention ofchild maltreatment, you will then get different levels of evidence.
That is why it is so important to bring people together, like the people present-

65

Another lesson welearned this afternoon
is that transitions arealso opportunities.

66

There are different
ways to measureoutcomes, anddifferent stakeholders
have different viewsof what success is in
a program.

Military Families in Transition: Stress, Resilience, and Well-being

ing this afternoon, but also people who are more at arms length. This is somethingthat Manuel Eisner from the University of Cambridge talks about. If we are going
to be clear about what the evidence is, it needs to be the people who have a vested
interest in the outcomes of particular programs. I say that as somebody who works
very closely with David Olds, who developed the Nurse Family Partnership. But thenwe need to have people who have the critical appraisal skills to do the systematic
reviews, who are at arms length, and can look at the effectiveness of intervention
with those issues in mind.
DR. BENEDEK: That goes very much to Delores Johnson’s point earlier thismorning. There are different ways to measure outcomes, and different stakeholders
have different views of what success is in a program. There are different programs
to address a better war fighting machine, or diminished inter-spousal violence, or
kids who are better decision makers. We would like to think there are some coreelements of interventions that might be universally effective and adaptable to different situations.
MS. BARRON: It is important to remember the component that you are working with. Is it an active duty or reserve component family member? The cultures aredifferent and the intervention could then also be informed from that perspective.
DR. REIDER: At the National Institute of Drug Abuse (NIDA) we have a portfolio on substance use prevention that spans the prenatal period through the young
adult and adult periods. We have 40 years of research that includes efficacious andeffective interventions, as well as systems level studies. We have been very fortunate
to have funding that has followed many projects over time from childhood throughyoung adulthood. We have evidence of the long-term effects on substance use prevention as well as effects on a broad array of behaviors not targeted by the intervention.
We have a good idea of what works and what does not work. The big issue
is getting it out into communities. We think many of these interventions would
be relevant for military families. NIDA has been funding these studies along withother institutes to see if they work when they are adapted and tested in military andveteran communities.
DR. BENEDEK: The nature of the comment is perhaps we do not need toreinvent the wheel, if in fact, it has already been invented and tested. In some places
that may the case. This forum is designed to exchange those kinds of ideas and getsome cross-talk going.
DR. SPIRO: Do many of you know the Cochrane Collaborative? It is evidencebased medicine. Do you know about the Campbell Collaborative? That is a place
where they evaluate, with independent people, the efficacy of a variety of different
kinds of interventions. It is a place to go and find things that have been tested andvalidated. I am not sure whether that would be relevant, but it certainly would bea place to look.
An interesting question I would ask is whether it is worth focusing on the prevention of disorders or is it worth focusing on the fostering resilience or adaptive
skills in a non-disorder approach?
Another point I would like to address relates to whether some parenting skills
may be generic and the outcomes question asked earlier about whether we are trying
to make better soldiers, or better parents, or better children, may be answered byfocusing on the processes.
DR. BENEDEK: One would hope that there are some universal elements ofutility.

Panel 3: Fostering Resilience in Families—What Does the Science of Resilience Tell Us?

DR. LESTER: I was struck by the fact that within the foundational programs, theintervention that is targeting parenting actually resulted in positive outcomes acrossthe whole family system. That is a consistent finding across many family center preventions. It is not just prevention of disorder, but it is the enhancement of resiliencecapacities and processes that probably hold the most weight in the long term. In our
10-year outcome of a similar intervention the psychological health reductions andsymptoms wore off; but we found long-term developmental improvements for the
kids. They completed school, delayed first pregnancies, and had healthier adaptation
as they transitioned to adulthood. This kind of investment in prevention and using
these foundational programs does make a great deal of sense. We also need to talkabout the infrastructure processes for implementation.
DR. MASTEN: It is important to think about adaptive processes because manyof the fundamental systems that serve a protective role in high-risk or high-adversity
context are the very same adaptive processes that promote positive human development in general. We have heard about these processes many times today, for example,
self-regulation, capabilities, close relationships, and families’ cultural practices. There
are some core processes that play a very important role in human development under
all circumstances that also function as resilience processes in threatening situations.
It is similar to your immune system. We do not want to go into surgery with an
immune system that is compromised. Many of the things we are talking about arelike the immune system that is the core protection for your health. How do you
foster a healthy immune system? We also want to inoculate people for infectious
diseases because there are situations where we need the antibodies for the infectionin order to survive. It is very useful to think about the specialized protections wewant, under certain circumstances. What are the fundamental processes that promote
positive adaptation in human beings? What are the different points in developmentthat are very flexible and that you can use to adapt to many situations?
DR. DELANEY: I want to reiterate what Dr. Lester said. These studies are
critical. I manage the National Registry of Evidence-based Programs and Practices(NREPP) out of my office. People come back and say to us, “It didn’t work out
right.” We have a large number of tools that work very well, but they only work
well if you implement them with fidelity and you manage them over time. Part ofthe problem and challenge is that doing the science does not address what you do
to keep programs running well. We have an implementation science, but that is getting to the point where it is its own little field. It has its own little meta-analysis ofwhether we did the right study on the implementation of the meta-analysis, whichsomehow is cyclical in its argument.
The Centers for Medicare and Medicaid Services (CMS) will not pay for aclinical social worker, a clinical psychiatrist, or a clinical psychologist to supervise
a clinical person so that they can evaluate their work. I was trained on Current
Procedural Terminology (CPT) when I was working at Bethesda. From that training, I was supposed to implement it. Patty Lester will tell you there was no ongoingsupervision to make sure we did it right.
The part that we really need to be thinking about is how do we change thestructure? How do we collect data and use that data to help people implement
programs over and over again with fidelity? We are going to be back here in 4 or 5
years, having very similar conversations. We have really good data, and we know
how to do a great deal of this stuff well. We will not have made the changes that
we really wanted to make because it works great. I was at the National Institute of67

I was struck by thefact that within
the foundational
programs, theintervention that istargeting parenting
actually resulted inpositive outcomes
across the wholefamily system.

68…is it worth focusing
on the preventionof disorders or is it
worth focusing on thefostering resilienceor adaptive skills
in a non-disorderapproach?

Military Families in Transition: Stress, Resilience, and Well-being

Drug Abuse (NIDA) with Eve Reider. Everything worked great while we were there
funding it; however, it does not always work very well when our funding goes away.
DR. BENEDEK: You make a good point for sustainability science, or postimplementation science, or at least post-implementation stewardship.

Panel 4: Effective Programs and Interventions—The Science of Program Evaluation

69

4

Population Impact Challenges
and Strategies: Illustrations
from PROSPER Universal
Prevention Research
Speaker: Richard L. Spoth, PhD
DR. ZATZICK: The topic of Panel 4 is program evaluation. As we preparedfor our panel discussions we considered implementation science and sustainability.
That is something we are trying to integrate into our preventive programs. Our
first speaker is Dr. Richard L. Spoth. He is an F. Wendell Miller Senior Prevention
Scientist at Iowa State University.
DR. SPOTH: I would like to pick up on Abigail Gewirtz’s cue and talk about
how I would spend that last dollar. If I had the choice of how I would spend my last
dollar, I would spend 33 cents on programs that had demonstrated efficacy with theprimary socializing environments of the children and families that we were targeting. I would spend another 33 cents on developing the infrastructure to support
both sustained and quality implementation through effective training and technicalassistance. Perhaps 33 more cents would go into evaluation and data systems with
2 goals. The first goal would be providing data through the implementation process
to do the kind of continuous quality improvement that we talked about, adapting
where adaptation made sense. The second goal would be to evaluate promisingprograms that were not yet available to reach the defined populations of interest. I
am holding out on that last penny!
As Doug Zatzick referenced, our panel will talk about implementation science.
When we were planning for this panel one of the questions we posed was, how do webest achieve impact with military families? I will be addressing that though the lensof universal programming. One of the things that worked out well for this panel wasthat each of the three of us will talk about a different type of programming. I will befocusing primarily on evidence-based, universal preventive interventions and delivery
systems. Over the course of this talk I will present some context for translation scienceof relevance to population impact and provide illustrations to prompt discussion concerning the focus on universal intervention. I will then suggest some primary future
directions. Our model, which provides a framework for our work, follows the 1994

The first goal would be
providing data throughthe implementation
process to do the kindof continuous quality
improvement that wetalked about, adapting
where adaptation madesense.

70

We start with preadoption researchbased on a businessmodel approach thatlooks at consumer
preferences, market
feasibility, and considers
the organizational
implementation setting.
The next phase isadoption.

Military Families in Transition: Stress, Resilience, and Well-being

Institute of Medicine (IOM) model for prevention called the Preventive Intervention
Research Cycle. This is a preventive intervention model that starts with an empiricallydriven intervention design that is intended for ultimate scale-up. We need to consider
the ultimate goal which is population impact and scaling up evidence-based interventions to achieve that population impact.
We start with pre-adoption research based on a business model approach thatlooks at consumer preferences, market feasibility, and considers the organizational
implementation setting. The next phase is adoption. In this phase the decision is madeas to whether or not an intervention is implemented. There is an emerging literatureon this topic. The W.T. Grant Foundation has done a review about how different groupsof people make decisions, such as school administrators. Implementation is the next
phase and the final phase is sustainability.
One must always consider translation functions in multiple contexts. Context influences how programs are adopted, implemented, and sustained. One of the core challenges we talk about are the desperately needed practice and research infrastructures,
especially infrastructures that facilitate a careful integration of practice and research.
I am going to talk about our research program and how it addresses some of thesetranslational issues. There are two windows of opportunity for universal intervention
in the case of substance misuse in youths: first, before initiation of substance use, andsecond, before advanced use. This is a theoretical framework for some of the work that
we do. It focuses on programs that are specifically designed to reduce transition. The
youth that are targeted by these programs have an age related pattern of reuse. We
know that for every year of delay in initiating use there is a significant reduction in theodds of eventually developing an alcohol dependence disorder or drug use dependence
disorder. What we are trying to do with these programs is delay onset and delay transition to more serious use.
One of the big points to be made across multiple prevention trials is that the interventions we have tested have had affects up to 14 years past baseline. Therefore, westart working with these kids in middle school and we see multiple cross-over effects.
We see improved youth skills, improved school engagement and grades, decreased
aggressive behaviors and conduct problems, decreased mental health problems,decreased health-risking sexual behaviors, and improved family functioning. We target
outcomes that are related to family functioning, the mediators of ultimate problematicuse. We have data and published articles about outcomes up to 14 years past baseline.
Our results indicate that the programs address common risk and protective factorsthat have demonstrated effects on primary socializing environments. We need more ofthese kinds of programs. We need an effective way of reaching the families, kids, andcommunities that can benefit from these programs.
We have conducted survey research in multiple types of settings, including school
settings. However, most programs are not evaluated, and some that are evaluatedare not effective. Others are evidence-based interventions that are consistent withset standards that are produced by the Society for Prevention Research. Even fewer
are sustained and responsible for quality implementation. When looking at longitudinal outcomes, program benefits are rarely demonstrated. We began our program ofresearch, an analyzed control trial, focused on two universal family programs. We wereconcerned about implementation and we had access to The Land Grant University basedoutreach system. It is a 3 tiered structure that evolved over 24 years. This is what we callour sustainability model because we have sustainable local teams that are responsiblefor quality implementation and a sustainable technical assistance team.

Panel 4: Effective Programs and Interventions—The Science of Program Evaluation

We have discussed the difficulty in engaging families, bringing them in, recruiting
them, and having them continue to be involved in programs. We have the problem
of implementation drift. We also have the problem of communities generating funds
to sustain the programs on their own. We conducted a study in 28 school districts,
14 in Iowa and 14 in Pennsylvania. They were randomized to a full partnershipsupport or they were delayed by 3 plus years. It was a random sequential cohort
design, multi-method, multi-informant measurement and now we are collecting datawith the participants, now young adults.
The last data point we have analyzed is through 12th grade. This is a representative
outcome. Again, the primary target is substance abuse, but we also look at conduct
problems. We have another paper on outcomes at 12th grade. There is a diverging
trajectory. There was a significant difference in growth over time between controls andintervention groups. Each point, the 12th grade, 11th grade, and so forth, is significantly
different. We have published multiple studies focused on moving towards populationlevel impact with community-based interventions. The findings I want to emphasize
are process related outcome studies. Most of the effective mobilization of community
teams and teams’ sustaining programs have reached the 12 year mark. For the mostpart, the teams are self-sustaining, have high recruitment rates, and are implemented
with high levels of quality. We examined proximal outcomes for which I will refer people
to look at our published findings.
I am most enthusiastic about how the intervention has actually changed the social
networking among the youth in the community. We are also conducting economic
analysis that show cost efficiency which specifically relates to having that effective
system. This is such a broad area that we have identified research priorities specific toeach of our four translation functions. We have a table showing 13 priority areas and 40
key research questions. There is still a great deal of work to be done, especially in theareas that have not received as much attention such as implementation. We need tounderstand more about the consumer cycle of demand-related systems. For example,
how do you use social media to create a demand? How do you better understand themarkets for these kinds of programs?
There is so much we need to know in this area, including the importance of references to the dynamically changing systems. For example, if you want to use social media
with kids, such as a new app to help them better engage with the programs, by thetime you set up a 5 year randomized control trial the technology has changed. Finding
financing is also an issue. We have a network team that has been designed to scale up.
We have worked for 5 years on the scale up challenges, and we just recently got funding
to do an adaptation of the model for military families.

71

We have discussed the
difficulty in engaging
families, bringing themin, recruiting them, andhaving them continue tobe involved in programs.
We have the problem of
implementation drift.

72

Military Families in Transition: Stress, Resilience, and Well-being

Panel 4: Effective Programs and Interventions—The Science of Program Evaluation

73

Improving the Behavioral
Health of Military Communities
Speaker: Richard E. Heyman, PhD
DR. ZATZICK: I would like to introduce Dr. Richard Heyman, Professor at
New York University. He will talk about implementation science involving an Air
Force Program.
DR. HEYMAN: I am going to be presenting work on two different prevention
programs that we have done in partnership with the Air Force. And I do not know
exactly why, of our team, I was the one who was asked to present. Amy Slep who
is in the back could have just as easily done it.
We’ve been working on NORTH STAR for about 15 years with the Air Force ina programmatic series of things that have been funded by some of the people whoare in this room. And the second program, ARMOR is more recent, but has also
benefitted from similar investment.
The challenge that we have been talking about at various times today and thatthese two programs I have referred to focuses on problems that we have labeledunder the umbrella of secretive problems. We are referring to family maltreatment,child maltreatment, partner abuse, alcohol abuse, drug use, and suicidality. These areissues that people tried hard to keep from the community. It is the classic tip of theiceberg kind of problem. The Air Force has data from 4 different community surveys
collected every 2 years over the past 10 years. The surveys give us information on
about 50,000 people with each data collection. These numbers suggest that the sizeof the iceberg is about a third of the active duty population. This varies dependingon which of those secretive problems you are talking about. But somewhere between
1 and 6 and 1 in 20 members are reporting clinical levels of these problems when
you ask them in behaviorally specific ways.
About 1 out of 6, or 1 in 20, including those in uniform, do not report the extent
of these problems. So people are doing a pretty good job of keeping the extent ofthese problems hidden. The community becomes aware of these issues when, forexample, someone gets a DUI, or someone has security forces come out to their homewhen there is a domestic dispute. But largely people keep these problems from thecommunity. This poses a challenge for prevention because these are also people whoare not going to attend preventive programs. For the most part they receive help
when they get into trouble or a problem comes to the attention of the authorities.
The NORTH STAR project started as a data gathering prevalence project that we

We are referring tofamily maltreatment,child maltreatment,
partner abuse, alcoholabuse, drug use, andsuicidality. These areissues that people tried
hard to keep from thecommunity.

74

The goals of NORTHSTAR were first,
to reduce secretive
behavioral healthproblems by improving
the risk and protective
factors, and second, to
profile the communities
without the “Santa
Claus” effect.

Military Families in Transition: Stress, Resilience, and Well-being

were conducting with the Air Force Family Advocacy program and it was expanded
to include other behavioral health problems similar to those I just mentioned. At acertain point we realized that we were spending time building this data gathering
infrastructure that provided information about prevalence, risk and protective factors; however, the information was only going to headquarters for planning.
In addition, there was an implementation infrastructure at every base that was
required by the Air Force to have the prevention and human service agencies coming
together in an integrated way to deliver prevention care; however, these agencies
were not guided by anything other than their own resources. Therefore, we thought
this is our Reese’s Peanut Butter Cup type of opportunity to do cutting edge prevention science. We had the makings of what modern prevention science would say
are necessary; however, we were not integrating these elements into a prevention
program. We were fortunate to get the support to pull a program together.
We borrowed from the Communities That Care (CTC) model, which wasusing a data driven approach to help community planners guide their choice ofevidence-based interventions, implement them, and then collect the data to determine whether the interventions were working. CTC was aimed at youth problems;
however, nothing similar existed for adult problems. We thought that this was an
excellent opportunity to take that same approach that was becoming recognizedwithin the prevention science world and apply it to adult problems. The beauty of
the CTC approach is that it targets risk and protective factors. It allows the data to
guide you to identify the strongest leverage points and the ones that have the mostin common. This allows you to tackle the risk and protective factors instead of theoutcomes, while providing the opportunity to measure the outcomes and determine
whether you are both increasing the resilience and the capacity of the community,
as well as reducing the outcomes. This ties together some things that were discussed
earlier today, such as using empirically supported activities to achieve desired goals.
The goals of NORTH STAR were first, to reduce secretive behavioral healthproblems by improving the risk and protective factors, and second, to profile thecommunities without the “Santa Claus” effect. That is, without us coming in andproviding money and resources to develop interventions and then once the funding
for the research dried up, leaving with nothing in place that can be sustained. We
planned to do this without providing any additional implementation resources otherthan integrating the capacities that were essentially already there and then testing
them. That is what the research was designed to do rather than providing extra
resources. In this approach there is local control, local decision making, and local
sustainability. The data is used to help set priorities, to choose risks, and to let thecommunity choose their priorities and choose risk and protective factors to target.
One of the amazing things that happens when you actually use data to guide this isthat you are able to assess and decide what the 2 or 3 key outcomes you are mostinterested in are. If we targeted “A” that everybody thinks is important, that would
hit one of these outcomes. However, if we target factor “B” that we also think isimportant that hits 8 out of the 9 outcomes, the data can guide you to a problem
that gives you the most leverage. You then help the local community by choosing
to implement emphatically supported activities, monitor the impact, and evaluate
the effectiveness.
We conducted a randomized controlled trial. One of the problems is that wewere doing this with the community as the unit of randomization. We had 4 pilot
sites in our initial outline, and then we randomly assigned 24 communities to test

Panel 4: Effective Programs and Interventions—The Science of Program Evaluationor control conditions. Twenty eight communities represent a third of the Air Force.
However, we still ended up with an underpowered study because the fact that you
have tens of thousands of people in your surveys at those bases only adds to yourprocession a little bit, you still only have 12 and 12 in your test and control conditions. Regardless, we were able to get significant main effects for reduced alcoholabuse. We also had a moderate effect size on child emotional abuse which was justshort of statistical significance, but was nevertheless fairly strong.
Interestingly, if you looked at the pre-implementation adverse conditions where
there was less command support, the committee that was charged with doing the prevention did not function as well. For the bases that received a NORTH STAR there
was an interaction that had significant effects on partner physical abuse, suicidiality,and prescription drug misuse. I should mention that at those 12 bases that received
a NORTH STAR, we went in with the naive notion that because the program was
required by Air Force regulation, they would have a community action plan that
their leaders would follow. One third of our bases implemented their action plan as
designed, one third at least did something, and one third of our test bases did not
do what was on their action plan. There were only 12 bases and one third of themwere not even “taking the medicine,” yet we still got these effects.
There is a great deal of variability within the community prevention teams.
NORTH STAR was attempting to help with that, and it did. Our sense was that thework units were the place where you would have the most impact. They are mostadversely affected by secretive behavioral health problems, they have the greatest
incentive to act, and they are an action-oriented group. NORTH STAR is able tostreamline the decision making and implementation process for military commanders rather than human services people on a prevention committee. We could makeit more actionable in that way and we would get more statistical power. This has
been funded and we hope to begin data collection soon.
We are beginning a new randomized control trial (RCT), ARMOR. The plan is touse data to guide community prevention, and to look at these items in an ecologicalway. One of the things I did not mention earlier is the data on individual, family,
work unit, and community. It was built with an ecological model in mind from the
beginning. Both of these approaches, NORTH STAR and ARMOR, are not thestandard RCT in looking at individuals or individual families. They are looking atthings in a more integrated way.
ARMOR is attempting to build on the Triple P model, Positive Parenting Program, that Dr. Matt Sanders created with some 90 studies in 15 or more countries
and 2 large meta-analyses. It is a well established prevention program focusing onparenting. We thought the model was great for parenting, but there was nothing
for couples. We had been working with Air Force Security Forces and with the Airman Family Readiness Centers who wanted to do something for couples. Based on
their needs and the vision they were describing, they were unwittingly describing
something like Triple P, but they wanted it for couples. Therefore, we are trying toadapt that. The idea is to merge these together in a unified strategy. The brilliance of
Triple P is it tries to get people what they need, when they need it, and from whomthey prefer to get it. The example in Triple P is if your child is having sleep problems
you might mention this to your childcare worker at the childcare center. If that community node whom you trust and happen to be bumping into in a just-in-time way,
could be delivering some just-in-time evidence-based intervention to bump you in
the right direction, you might be able to prevent a great deal of problems.

75

The brilliance of Triple
P is it tries to getpeople what they need,when they need it,
and from whom they
prefer to get it.

76Palatability is a criticalissue and the focus
on risk and protective
factors, not the
problems themselves
helps to make things
more palatable.

Military Families in Transition: Stress, Resilience, and Well-being

Triple P indicates that you are able to prevent many problems. Yet if the parents
decide that they need more, you are helping build in the trust, and then you areintegrating the levels of intensity in a way that the parents are receiving something
consistent. We are attempting this stepped approach with level one being the more
universal step. Level one includes public awareness campaigns and helps couples
see that their challenges are normal. Most of the focus to this point has been onlevels two through five. Levels two and three are similar; both are brief, structured
advisory sessions, but with slightly different level of intensity. Both consist of 5-10
or 10–15 minute sessions with a follow up session. Levels four and five are moreof a workshop approach, including individual, couple, and group prevention workshops. One of the ways that this differs from other programs is that we have had to
be extremely flexible. The Army has a version called Strong Bonds which is a great
program, but is only reaching 4 couples a year. That is not reaching our targets. The
Air Force wanted flexibility so that people could come and go in a way that fits with
their schedules or their interests.
The ARMOR program uses pamphlets for decision-making. What Triple P calls
tip sheets we call action sheets. For example, we have a pamphlet on stress. It is atri-fold pamphlet with an action strategy. It is billing as a meta-self-regulation skill
that asks the person, what am I trying to achieve, what am I doing now, and what
are the pros and cons of what I am doing now? What are the rewards for my current behavior that I am going to need to supersede in order to change my behavior?
What is my plan in a specific operational way? Then the person can review thepamphlet afterward to be able to see what worked and what did not. We try to boil
down what is known from the evidence-based literature on that topic in a concise
way, and give some quick actionable suggestions of what the person might do. The
idea is that they will select the thing that best fits their situation and decide, “This is
the one thing I would like to implement that might make a difference based on myknowledge of my own situation.”
We were asked to lay out some discussion points for our panel. The ones that I
selected were secret behavioral health problems which require a different approachthan problems that are out in the open. Palatability is a critical issue and the focus
on risk and protective factors, not the problems themselves helps to make things
more palatable. Another discussion point is a tremendous focus on reach. When you
see what the prevalence rates are, reaching four couples a year, no matter how good
the program is, will not reach far enough when your data says you need to get 500
in order to see improvements. Access is another key discussion item — breaking
free of the formal agency model. Finally, for Guard and Reserve soldiers these issues
are even more pronounced because there is no centrality of an installation to knit
everything together.

Panel 4: Effective Programs and Interventions—The Science of Program Evaluation

77

Developing, Evaluating
and Sustaining Stepped
Collaborative Care
Interventions for PTSD andComorbidity after Injury
Speaker: Douglas F. Zatzick, MD
DR. ZATZICK: I would like to begin with my developmental history as a clinicalinvestigator. I started out in the mid-1990s doing a VA fellowship, treating mostly
Vietnam Veteran populations with both PTSD and substance abuse, and many otherissues. We did a number of epidemiologic studies with the National Vietnam Veterans
Readjustment Study (NVVRS), showing a strong association between PTSD and corefunction, physical limitations, and unemployment. In 1999, I left the VA thinking
there would not be another land war in Asia, and did prospective work at innercity trauma centers. I worked at the equivalent of Baltimore’s Shock Trauma Centeron the west coast, Harborview Medical Center. I had a long standing interaction
with Chuck Engel and with Bob Ursano’s group. After the Pentagon attack in 2001,
Chuck had this brilliant idea to reduce stigma with an evolving collaborative, embedded, behavioral health model and primary care. The idea was to put social workers
and nurses in the 10 Pentagon primary care clinics to be present for behavioral
health issues as they came up. I was doing work for PTSD in acute care settings andI was the coach for Operation Solace in that Pentagon trial. I have done a numberof other things, including spending one day a week with the WRAIR (Walter Reed
Army Institute of Research) group and Chuck Engel as part of the civilian behavioral
health team. I worked at Fort Hood as part of the civilian behavioral health teamafter the shooting in 2009. I have been part of a 4 year Institute of Medicine (IOM)
study of PTSD. Therefore, I have a policy background as well.
Currently, I am working with Carol Fullerton, Bob Ursano and the Center for
the Study of Traumatic Stress group on the Mortuary Affairs intervention study
at Ft. Lee with Carol Fullerton as principal investigator (PI). STEPS-UP (STepped
Enchancement of PTSD Services Using Primary Care) is a six-base collaborative care
trial with Chuck Engel as PI. I coach the nurse care managers who are implementing

The idea was to put
social workers andnurses in the 10
Pentagon primarycare clinics to bepresent for behavioral
health issues as theycame up.

78

Step two is harm
reduction. This is anelemental procedurecompared to thecomplex familyinterventions wehave heard about
today. Step two
involves motivational
interviewing targetedat risk behaviors.

Military Families in Transition: Stress, Resilience, and Well-being

this integrated behavioral health primary care model. I also work on the FOCUS-CI(Families OverComing Under Stress – Combat Injury) project with Pat Lester andSteve Cozza. That is my developmental trajectory. We are bringing this integrated
model, which is collaborative care, together with family focused projects and trying
to make it work in the unique context of the DOD.
Referring back to spending that last dollar mentioned throughout the day, I do
not know if I would spend any money on an intervention that I was not convinced
would have legs in what I think is one of the most challenging contexts to intervene in, which is an active duty or in-theater DOD context. I also do not know if I
would do more research at this point after this 4 year IOM study if there were not
Data and Safety Monitoring Board (DSMB) factors and organizational consistency
across the forces in the decision about how an intervention would be implemented.
I do not know if it is worth it. Delores Johnson and others have asked about theseorganizational factors today. After an immersive experience as a clinician, 330 cases
into STEPS-UP, unless we have a robust design construct from engineering and leanmanufacturing, I do not know if I would spend much money on it.
There is an excellent evidence-based study of over 60 injury survivors looking
at depression and primary care using the collaborative care model. It is a disease
management strategy that targets chronic conditions, combined with diabetes anddepression. There is a New England Journal of Medicine article about it, and it is
now the bread and butter of medical interventions.
If you combine general medical providers with mental health specialists you get
stepped measurement-based care. We created a basic care management model for an
injury. Everyone gets assigned a care manager at the time they are injured and thenwe step up care. We deliver motivational interviewing interventions to target risk
behaviors such as recurrent injury, alcohol use, or carrying weapons, followed by
medication and cognitive behavioral therapy for PTSD. Richard Heyman presented
on stepped care earlier. The first step of our stepped care model is post-trauma support engagement. It asks, “Of everything that has happened to you since your injury,
what concerns you the most?” In all of our preliminary studies we took random
samples of injured trauma survivors, asked this question, transcribed the results,
and got domains of concerns. That is how we targeted our care management. We
keep it simple because, for example, after a Humvee hits an IED and half the unit
gets taken out, what is concerning you the most right now? We have looked at earlyintervention trials, we track it, and there are no negative results. Maybe it does notprevent PTSD, but it is essentially unbreakable. We did it in Haiti with less-than-highschool educated HIV workers who had to reconstruct things after an earthquake.
It is simultaneously an empathic question and an assessment. At the end of theassessment a person says, “I need a bag of rice. I need a tent. I am concerned about
my 17 year old daughter in this new camp after the earthquake. She is coming in atnight after her job and I am afraid she will be assaulted.” The psychological piecetakes off after basic need provision. That is step one and we think it is unbreakable.
Step two is harm reduction. This is an elemental procedure compared to thecomplex family interventions we have heard about today. Step two involves motivational interviewing targeted at risk behaviors. We are now trying to do it over
Skype. Skype is a communication strategy that can be embedded almost anywhere.
For example, you are a drinker and you are getting your cast off at the orthopedists
office and now you really want a drink. You can have a 10 minute discussion via
Skype about the pros and cons of drinking. It is embedded within care management.

Panel 4: Effective Programs and Interventions—The Science of Program Evaluation

The third step is cognitive behavioral therapy and medications for PTSD. The
nice thing about this model is you can take it apart, and you can put different elements in for families. It is built to be taken apart and put back together.
I want to spend a minute here discussing acute medical care/surgical-psychiatry
integration. There is a classic article in Milbank Quarterly by Theresa Greenhalghfrom 2004 concerning the diffusion of innovations in service organizations. You
can let it happen, which is passive diffusion, or you can help it happen. Everyone in
the DOD is in a “help it happen” mode. We have these models with great evidence
behind them, and here are all the ways we can help you think about this, or help
get this implemented. The National Health Service (NHS) in England is supposed
to work like this, but in the United States in acute care medical settings trauma
surgeons regulate care. There is a book called Resources for the Optimal Care of
the Injured Patient. You have to do what is in the book if you want to be a trauma
center that is accredited by the American College of Surgeons (ACS). Every three
years the ACS shows up for a review. If you are not doing what they say you should
be doing, you lose points towards accreditation and funding. The Patient Protection
and Affordable Care Act has grant funding for trauma centers. That is one piece ofa “help it happen” implementation framework.
Our group conducts clinical trials and because we are in a “help it happen”
system, we get buy-in up front. There is not enough money for large scale pragmatic
trials, or for any trials. So the ACS will make a policy decision based on one trial. If
there is a second trial that contradicts it, they will change the policy, but they willgo with the best evidence they have. However, before the trial is conducted you havetrauma surgical empiricists who are going to review the literature and take action
based on that. Simultaneously, next month I am a full time trauma center provider.
I am not a scientist just thinking of something that is going to get me a treatment
effect .We have an alcohol screening mandate, a brief intervention mandate at
every trauma center in the United States. It is being extended to level two whereas
previously it was just level one. Every scientific piece also applies to my front line
clinical provider hat. There is no distinction. Now you can do this in interdisciplinary teams. I am not saying all prevention scientists should become clinicians, but
you can build a team this way. It is policy, front line clinical work, and intervention
science all in one group.
If you are interested in clinical epidemiology, this brilliant guy, Dr. Tom Koepsellat the University of Washington, derived a basic epidemiologic theorem from theweighted average rule of disease rates. That is the population impact of a randomized
trial related to 2 things: the treatment effects and the reach. If you want to target
reach and get a high reach so your population impact is high, you do not exclude
anybody. We do not exclude people from our studies. If you have made an intentional
suicide attempt you are excluded, but just about everybody else is included. For
example, in one trial a 32-year-old veteran with a pre-military psychiatric history
was in a sandstorm in Iraq, his Stryker tank crashed, and he suffered a TBI. He getsout of the VA care and is driving with his father in the passenger seat. They are bothdrinking, he crashes the car, and his father dies. He is on our trauma ward with
polytrauma and a TBI. Luckily, he is randomized to the intervention group. You
can quibble about the ethics of having him in the control group. About one third offolks are that bad off. There is a middle third, and then there are people like us in
bad motor vehicle crashes.
With that treatment effect we have a 5 point movement on the SF 36 PCS (Short79

Our group conducts
clinical trials andbecause we are ina “help it happen”
system, we get buy-in
up front.

80

Our tenet and how
we are designing ourpragmatic trials is that
population impact
equals effect size
multiplied by reach.

Military Families in Transition: Stress, Resilience, and Well-being

Form health survey-Physical Component Summary), basically orthogonal to PTSD
symptoms. That is like one chronic condition going away after 6 months. But the
12 month point is tricky in these trials if you get the population of the worst one
third. I think we are getting the worst of the worst in FOCUS-CI. One of the things
you have to watch out for is massive differential drop-out in your clinical trial. At
the end of the first year it was 80% follow up in the intervention group and 40%
in the control. This was because we had a lenient DSMB and internal validity was
only part of what they were concerned about.
Our tenet and how we are designing our pragmatic trials is that population
impact equals effect size multiplied by reach. This is what we think is going to takethe day in terms of large scale implementation. It is like flipping a light switch;
you do in the trial what tomorrow you would like to do in your service. But what
happens is you start your clinical trial and you have one month to do it in, but you
think these are complex interventions that take a great deal of time. You have tosave your time; you cannot go on a fishing expedition. Therefore, you are going to
use the electronic medical record to find the cases with PTSD. The corollary of this,in terms of the population of your screening procedure, is going to be related to all
the diagnostic sensitivity and specificity area under the ROC but it is also going to
be related to risk. In acute care, as soon as you have five gurneys lined up, no one isgoing to screen for PTSD. Therefore your impact is zero, so you might as well use achart review automated screen and actually find the high risk cases. That is where
we are now, along with clinical decision support tools that can be deployed by us.
You can do this after the earthquake in Haiti now as long as you have internet
access. You can get your decision support and your supervising psychiatrist long
distance. This is what Chuck Engel has in RESPECT-Mil (Re-Engineering Systemsof Primary Care Treatment in the Military). The DOD has this, but they are canningthe program. There is this tremendous movement in flux. We should talk about that.
Is it worth investing anything when programs that are successful all of a sudden aregoing to disappear?

Panel 4: Effective Programs and Interventions—The Science of Program Evaluation

81

Panel 4 Discussion
Moderator: Douglas F. Zatzick, MD
DR. BENEDEK: This was an excellent panel presentation, which segued nicely
into a call for sustainability efforts, sustainability research, and for those of us thatwere not aware, some evidence that such things already exist in some places. In
addition, we had an excellent discussion of stepped and collaborative care.
DR. BLIESE: When we have done randomized trials of soldiers, particularly
focused on resilience post-combat, we have been surprised to find that relatively
small interventions have an effect and that we can detect that effect. It is a curious
finding that sometimes a small effect done at the right time can have a long lastingchange in the trajectory of individuals going forward. I think one of the key challenges that we have is to think about what types of interventions those are and how
to maximize them.
DR. BENEDEK: Timing is very important. What is the moment of maximal
impact for something such as a motivational interview? Small things can make a
big difference if they are done at the right time.
DR. ZATZICK: In terms of RCTs there are two methodological routes you
can go. Dr. Thomas Ten Have at the University of Pennsylvania was a big name insequential randomized designs. You administer your small intervention and somepeople respond and others do not. That is sequential randomization. The other routeis from a statistician at Harvard, Dr. Jamie Robins, using a measurement-based
approach. This is what the RESPECT-Mil program is. You give the increment to a
population, and then measure it to see if people are better or worse. If they are worseor have not improved then you step it up, but you only have a single randomization.
DR. CONNER: In reference to Richard Heyman’s presentation, if you have 12
bases doing the NORTH STAR intervention and the intervention chosen is essentially their decision, how do you prevent chaos in terms of 12 different interventions
at those bases?
DR. HEYMAN: That issue was by far the hardest part in getting the project
funded because it goes against the grain of people who are used to traditional RCTs.
What you are testing is a framework, and that is what is invariant. Everybody went
through the NORTH STAR process in the same way. However, the evidence-based
interventions that they chose or the target issues they were wanting to focus on was
up to them. There were some similarities, but there was variation in the programs.
There was no program that was being tested. You are testing a framework for
implementing a data-driven approach. Once the light bulb goes on it does not seem

Timing is very
important. Whatis the moment of
maximal impact
for something suchas a motivational
interview? Smallthings can make a big
difference if they aredone at the right time.

82

Part of our target
should be theidentification of
inflection points
or tipping point
opportunities. How do
we identify those for
maximum impact?

Military Families in Transition: Stress, Resilience, and Well-beingthat different from traditional approaches. We are testing a framework, not testinga program.
DR. COX: Back in 2003, I think it was Avshalom Caspi et al. who did a study
on resiliency. They were looking at resilient kids related to the 5HTT allele, andthere has been some replication in different populations; I think even in different
species. Someone stated earlier that resiliency is not a trait. Well these studies seem toshow that if you have two long alleles you actually have a better resiliency capacity
than those with short alleles. My question is, has that been debunked? If it has notbeen debunked, are we adding those behavioral or biological pieces into our model
developments, and are we testing for that when we look at who is actually being
successful?
DR. ALDWIN: That particular study has been difficult to replicate. A number ofpeople have tried and have not succeeded. The field has moved to more epigenetic
effects. You can show first, that stress effects epigenetics which is the gene regulation, and second, that interventions can reverse epigenetic changes. If you want tobring in biology that is the direction I would go. I liked Ann Masten’s discussion that
resilience occurs at multiple levels. I think what this conference is getting at is that
we need systems level thinking. I am surprised that I have not heard anybody talkabout the various new statistical design programs that can do systems level workand test out models based on the available data before you run them, and then apply
them. I would like to work on a large model looking at physiological, individual,
and community regulation and see how they all fit together.
DR. ZATZICK: That model is in the American Journal of Public Health fromRuss Glasgow of the National Cancer Institute (NCI) and David Chambers of
NIMH. They have a translational model that is circular. Our automated screen in
the hospital, ROC.72 looks at gender and PTSD, low income, ethnic diversity, andprior trauma admissions with a hospital E-code. It is a whole population. Kerry
Ressler, a world renowned genetics researcher, is looking for the ten biomarkers thatwill predict PTSD. He is taking saliva and blood and running snips. It takes 10 or
20 years, but it costs $7,000 right now to run those 70 snips. If we have a patientleaving the hospital tomorrow, we have 72, you can add another ten points to our
ROC curve. But they cannot get this to us for 2 weeks. Epigenetics, methylation,
shake a test tube, put it in a machine, have it spit out, that could go right into ourscreen. But that is the circle. That is how this public health, real world, front line, intheater, acute care feeds back to inform basic research. That is how the public healthapproach feeds back to inform the basic science, and that is the kind of dialogue wereally want to have. We are open to basic scientists, but we have to tell you what
will work so that this can fly tomorrow, not in a hundred years.
DR. REIDER: Prevention science, if you are using randomized control trials, isexperimental etiology. Dr. Gene Brody at the University of Georgia and his RCT ofstrengthening African American families, which is a drug abuse prevention intervention for middle school aged African American families, showed that it ameliorated
genetic risk. We have other examples of prevention interventions changing neurobiology including Dr. Phil Fisher’s work at the University of Oregon with preschool
aged kids in the child welfare system who are very dysregulated. If you teach foster
care families parent management training and special techniques with the children
it actually regulates their behavior and their neurobiology. That is the impact ofprevention on neuro-biology and genetic risk.
DR. URSANO: Wonderful discussion, however, it belongs in a different forum.

Panel 4: Effective Programs and Interventions—The Science of Program Evaluation

This is the area of discovery science, far from the question of implementation science.
But the question of a forum that adjusts gene-environment interaction in military
populations would be marvelous to undertake.
DR. SPOTH: Bringing it back to implementation science, I want to pick up ona point that Paul Bliese made about carefully considering developmental timing
and how that can yield larger effects than what you might otherwise see. Even withpropagated effects over time with cascading processes within the family, we normally
expect small effects from universal interventions. We have seen large effects proximally, and effects that have grown over time. What that highlights is the prospectof bigger bang for your buck. Think about the potential for population impact. If
you have a universal intervention with a large effect size that you are effective in
implementing, then the reach is great, the effect size is great, and you have greater
population impact. How do you think strategically in this climate of increased
demands and reduced resources? How can you best use the scarce resources?
Practically speaking, it brings me back to the question of, how do you structure theconversation tomorrow to get to those key strategic points that have been referenced
here in light of what needs to happen, given the realities of the funding environment?
DR. URSANO: Part of our target should be the identification of inflection points
or tipping point opportunities. How do we identify those for maximum impact?
Motivational interviewing is a nice example of that. There is not much researchthat actually looks to find what the best point is. It is expensive and difficult to do
repetition across time. We do not even do that in animals, let alone in people. We
are trying to identify the spot for intervention versus what is the intervention. It isa great topic.
DR. SPIRO: The Army used to have the slogan, “An Army of One.” There is anapproach to doing clinical trials of one, which might be useful for something liketrying to find inflection points rather than a $50,000,000 randomized trial that you
cannot adaptively modify. Another approach that we have developed in the VA iscalled, Point of Care Randomization. If you have two efficacious treatments and apatient comes in with a condition, they can volunteer to be randomly assigned toeither treatment at the point of care. You can build trials in relatively inexpensive
ways to look at psychotherapy combinations with or without medication for treating
anything. I am not sure if you can use them as easily in behavioral interventions, but
I think it would be worth exploring.
DR. ZATZICK: The NIMH has a funded trial where they are using that technology. I think it is depression in primary care and medical comorbidities.
DR. LESTER: I wanted to discuss something said earlier about attention to acontinuum of care. That includes all the pieces that come between universal prevention and acute treatment, especially as we have shrinking resources. The continuumof care is useful in thinking about how we can use science to identify risk groups so
we can better allocate our care for people who are perhaps not tipped into clinicalservices, but could benefit from brief windows of intervention.
I also wanted to add to the discussion about timing. I think it is both developmental windows and the readiness of the family around all these different cycles andtrajectories that are overlaid on top of each other, particularly for military families.
Often it is that window of opportunity and readiness that we need more information
about, and how to identify and maximize them.
DR. BENEDEK: Unfortunately it may be that one member of a family is in thewindow and another one is not, so it gets more complicated in these interventions.

83

The continuum of careis useful in thinking
about how we canuse science to identify
risk groups so we canbetter allocate ourcare for people whoare perhaps not tipped
into clinical services,
but could benefit frombrief windows ofintervention.

84

Concerning thepoint about dosage,
in thinking froma developmental
perspective, one of theinteresting things isthat we see dose-effectrelationships thatdisappear over time, inpart because of effects
on social influences andsocial networks.

Military Families in Transition: Stress, Resilience, and Well-being

DR. GEWIRTZ: Colonel Bliese’s comment was like a Rorschach inkblot because
what he mentioned was not just timing, but also dosage of an intervention. I think
it is an important issue that has been addressed in multiple prevention studies in thecontext of randomized control trials. Our intervention is 14 weeks long. What is to
say that 14 is the magic number? Could it be done in seven? Does it have to be twohour sessions? Can it be one hour or half an hour? We know motivational interviewing is the best example of an intervention that did not even start as an intervention.
It started as an assessment tool and just a few minutes of that is powerful enoughto effect change. I think these are critical questions that can be, and are, answeredin the context of trials.
DR. SPOTH: I want to underscore the point that Pat Lester made concerning
the continuum of care. I think that is why some of the tiered models are potentiallyso effective. They can enhance the effect across the spectrum of risk. If you use theuniversal approach as a way of moving people up the line, they could potentiallybenefit. You would still benefit the broader population that does not necessarily need
intensive treatment well enough to have a good effect without that intensive levelof care. I think these tiered models are intriguing and potentially very effective andcost efficient. It is not only developmental timing, but family readiness. Interestingly,
our research suggests that often the developmental timing produces the readiness ofthe family. For example, the child starts experimenting and the parents start sensingthat there is an issue, which brings them in for care.
Concerning the point about dosage, in thinking from a developmental perspective, one of the interesting things is that we see dose-effect relationships that disappear over time, in part because of effects on social influences and social networks.
For example, we may have 30% of the families that participated, but we are seeing
community level effects. We have the mediating mechanism of our social network
having empirical influence. Anecdotally, we know that these networks are influencing each other even though they did not receive the intervention. There is an initial
dose-effect that dissipates for good reason because of social influences rather thansocial networks.
DR. MACMILLAN: I have a comment about translation science. Comingfrom Canada, I wonder the extent to which the concept of integrated knowledgetranslation has caught on in the U.S. One of the things we are doing in some of our
Canadian trials is getting the policy makers involved from the beginning. For downthe-road implementation they are onboard from the start in terms of the question,
the design, and the outcomes. This is because at the end of the day, if they are notgoing to fund the intervention, then what is the point of doing it? And this way
whatever the outcome—negative, positive or whatever— they have been involved
through the whole process.
We did this in a province-wide randomized trial of intimate partner violence(IPV) screening, which was negative just like the CDC trial in the U.S. However,people have gone ahead and implemented IPV screening through the Affordable CareAct with two negative trials. The point is that in Ontario the policy makers were
onboard from the beginning and we had the capacity to implement IPV screening
with the universal health care system. However, when the policymakers saw theresults, having been involved through the whole process, they were able to say there
is no evidence of effectiveness so we are not going to implement it.
DR. ZATZICK: That is an outstanding point. The NIMH had a conference 4
years ago on dissemination implementation and Roy Cameron of the University ofPanel 4: Effective Programs and Interventions—The Science of Program Evaluation

Waterloo in Canada gave a brilliant presentation. There was an office of researchtranslation as part of the political organizational structure. Other countries are on
to this but for Bob Ursano and the DOD group, you have a top down, hierarchicalorganization. In the military, if you had a four star general equivalent to a trauma
surgeon or a Canadian policymaker, and you had a body of evidence that wasgood and applicable to your population pragmatic trials, could you not mandate
something like that?
DR. HEYMAN: You can guess from the work I presented that it is a partnership.
There is no way you could randomly assign a third of the Air Force to your intervention without the help of the Air Force policymakers. I think that for something
really to have legs, that support has to be there from the beginning. The huge caveat
is that this system does not support sustainability. For example, a new leader comesin and has a different way of looking at things or they are not going to get a bullet
on their performance report to be promoted if they are not doing something novel.
Therefore, there are a great deal of policy and structural things within the militarythat argue against continuing with the same thing.
DR. ZATZICK: Remember, anything that happens within the military is truly
an act of Congress. I was given wonderful advice when I first came into the DOD.
I was asking questions like, “How do you ever change anything?” I was a Second
Lieutenant at that time, and I was talking to the senior consultant to the Army
Surgeon General. His response was, “Do you know how to sail?” And I said no.
He said, “Well, do you know about tacking?” I said, “Yes, you kind of head in thisdirection and move in that direction.” He said, “Yes, you tack towards your goal anddo it for 20 years.” That is absolutely true. One of the dilemmas within the DOD
is that it can be a hard system in which to get a change. But if one can get a change
in the conservativeness of the system, one will also keep it there. So there are pros
and cons in all those directions.
DR. SPOTH: Involving the leadership is one thing, however, involving the policychangers to the degree possible, is another. I also think that is an excellent point. It
is contemplated in that model I was showing talking about the contextual influences
and how they are part and parcel with what happens when it comes to all thesetranslation functions and sustainability. Picking up on Rick Heyman’s point, it is
one thing to have leadership, but you also need people who can effectively change
the policy incorporated into that process. I do not know if there is a model for that.
I do not know what the practical strategy is, but there has to be a strategy.
DR. JOHNSON: The bureaucracy is focused on incremental change and thatis just the nature of the beast. It is not about just the Commander or the policy.
At a practical level, you have great variability in knowledge, scientific depth andbreadth, and in people’s ability to devote time to the research that you are talking
about, whether it is a survey or randomized trials. When you have people walking
through the door in some great element of crisis, what you are offering has to be a
substantial change. In a great deal of cases, even with the data that you are talking
about today, it is a quantum change in the kinds of programs and the results that
we are getting. It is difficult to say to someone on the ground who has people coming in who are in some level of pain, “Wait a minute, I want to do something new,”when what you are suggesting is probably only 5-10% different than what they are
already doing. Plus they have to be trained in it, understand it, and then train all
their people. Therefore, it is a whole system that you have to engage with multiple

85

I think that forsomething really tohave legs, that support
has to be there fromthe beginning. The
huge caveat is that
this system does notsupport sustainability.

86

The issue is always
what is coming, notwhere we are now. The
real challenge is, whatis the Army in 2020 or
2025? What is coming
over the horizon?

Military Families in Transition: Stress, Resilience, and Well-being

components because it is a closed community. Everybody has to be in all the timeto get the kind of change you want.
We did that in family advocacy 15 or 20 years ago, where we worked with Cornell and we had the whole system moving. I think the best thing we can say aboutthat is we identified the resources and we taught people a language of outcomes.
When you come in and begin to talk to people on the ground, for those who actually
stayed in those positions, they can have fairly reasonable conversations with you
about what it means and why they should be doing this, and why it is important tohave an evidence-based strategy. That is the tacking that has occurred over 20 years.
DR. URSANO: The reason we are having this meeting is because of a 15 year
relationship with Delores. It was her vision 15 years ago that has led to our ability
to have this meeting.
DR. WADSWORTH: I was thinking about the opening remarks that Dr. Ursano
made today and that we are trying to figure out what we think the Army ought to be
thinking about 10 or 12 years from now. I am not sure that when Dr. Ursano madethose remarks he was necessarily thinking that by the end of the day we ought tobe talking about which program was better or how to figure out which program isbetter. In other words, the challenge that the Army has is a higher level challenge,
which is a whole system of trying to ensure that a ready and prepared and fully
supported force can do its job. How do we take where we are now and move it up
to the more strategic level of the additional questions and problems that need to beaddressed beyond this thorny set of problems that we are currently dealing with?
DR. URSANO: The issue is always what is coming, not where we are now.
The real challenge is, what is the Army in 2020 or 2025? What is coming over thehorizon? The amazing thing within the DOD is that you are always waiting for theunexpected. When I put on the science hat, we are dealing with what we have now.
When I put on the DOD hat, we are dealing with what is coming that we cannot
quite see yet and trying to get ready for it.
When I talk to the people at our Center I refer to us as the Mini Cooper. We
are not a Hummer. We are not big enough to take on huge things, but we are highquality, we move quickly, and we try to look at what is coming over the horizon
before other people can see it. That is what we are engaged in here today. Can we
anticipate what is coming over the horizon? Can we provide tools for what is coming
over the horizon without even knowing what is there? Those are the tools we needto have to be ready for the unexpected. The issue is not, can we solve the present
problem. That is only a piece of the story to the extent that it gets us ready for the
problem we have not yet seen.

Panel 5: Military Families and Transitional Stress: What Critical Information is Missing?

87

5

Military Families andTransitional Stress: What
Critical Information is Missing?
Speaker: James L. Schmeling, JD
DR. URSANO: Our goal this morning is to think about some of the gap areas, andin particular, what is missing that we have not yet talked about. Our first speaker is
Jim Schmeling from Syracuse University. Jim is the managing director and co-founderof the Institute for Veterans and Military Families at Syracuse University.
MR. SCHMELING: Unlike many of you in the room, I begin to work withmilitary members when they are thinking about their transition — or with spouses
as they are thinking about their post service careers. Much of my interaction begins
about a year before people are transitioning. The Institute for Veterans and Military
Families is focused on the post-service life course. But what we have found is thatfor many veterans, their transition planning either begins a year or more ahead orit does not begin until they are actually in the process of transitioning. We believethat the transition of veterans and families post service is a national security issue.
We wrote about this in our national veteran strategy policy document, which was
published in February, 2013.
How veterans transition will impact the future of the all-volunteer force. Theirexperience in the military will impact their post-service life course. This includes thethings that they have learned, their education and training, their experience withmultiple cultures and with deployments, the experiences that they have with theirfamily and spouses, careers, their dependents’ education, and special education forstudents with special needs.
The experiences that people have during transition, and finding out whether
military service benefitted them and their families, is a key to whether or not future
generations of their family will serve. We were actually quite concerned that wemight be losing generations of families because of the experience that militarychildren have had with multiple deployments, for instance. We are working withmany spouse networks, including the Military Officers Association of American(MOAA), the Military Spouse JD Network, and others. These organizations havebrought many issues to our attention. In fact, we just launched a survey with MOAA
to better understand the experiences of spouses as they transition from one place toanother and as their spouses transition out of military service.

How veteranstransition will impact
the future of the allvolunteer force.

88

Transition stressors
include employment,
education, housing,healthcare, financial
literacy, andissues for spouses
and dependents,
particularly
issues pertaining
to education of
dependents, including
special education.

Military Families in Transition: Stress, Resilience, and Well-being

This transition really begins long before separation and includes family even if
they are not consciously thinking about it. They are beginning to gather the skills,
education, and training that will serve them in their post-service life courses. There
are many policy and practice issues that can impact that transition and favorably
impact national security by increasing the likelihood that people will serve in the
all-volunteer force.
Transition stressors include employment, education, housing, healthcare, financial literacy, and issues for spouses and dependents, particularly issues pertaining to
education of dependents, including special education. Often families are uncertain as
to what they are going to find in their post-service life—for example, what services
are available for military families and for veterans in states where they are settling.
We do not do a very good job at this point of helping our veterans understand what
their post service life opportunities will be.
Although we have an excellent transition assistance program, when it is fully
taken advantage of, and when people opt for many of the optional segments, thereality is we do not yet educate veterans and their families on what their real options
are. For example, where are the geographic opportunities for their employment?
What education benefits are available state by state? What are the opportunities fortheir spouses to take their licensure and certification across state lines.
Many of these initiatives now are happening around the country, thanks in partto initiatives like Joining Forces and FOCUS, and spouse certification and credentialing. In some states it is happening around certification and licensure of military
members based on their experience. For instance, in New York you can get a commercial driver’s license now if you have been an operator of heavy equipment or atruck driver during your military service. That is going to help people who want toremain in those positions.
But we still have not adequately addressed the issues regarding teacher licensor, or in the medical field for emergency medical technicians. We are beginning todo that now. We are also beginning to create some educational opportunities andprograms on a state by state basis, but we are still not telling people adequately
what those include.
We are not handling spouse transitions well, for example, career interruptions
resulting from geographic changes. Spouses often change careers because the licensure and certification requirements are onerous as they move across state lines. In
some cases people are separating physically when a spouse is transferred because
they cannot afford to take a new job in a new place that does not fully take advantage of their degree or their background. This is particularly the case with certified
professionals. For example, many people have onerous student loan debts. If we canprovide credentialing and licensure opportunities, whether they are temporary or
permanent, we can increase the quality of life and reduce stress on military families.
This will have implications for the future of the all-volunteer force.
There are also significant issues around civilian equivalency of military training
and education. That is an area where we can actually make a difference while people
are in the military. During the curriculum development and idea generation phases
we need to consider what to include in training curricula for military members while
they are learning their professions. In many cases the civilian requirements are met
but not documented. They are not coordinated with whatever civilian licensurebody is necessary.
Unfortunately, many states have state level certifications; therefore we need

Panel 5: Military Families and Transitional Stress: What Critical Information is Missing?

to better understand what those certifications are at the locations where we havemilitary members being trained. Can we offer the opportunity for them to become
licensed or certified in that civilian job market in a way that may be transferable
across jurisdictional boundaries? Those kinds of policy changes and those kinds ofpractice changes would reduce stress on families as they are thinking about what
to do post service.
We have some interesting examples to learn from. For example, California is
an interesting state when it comes to teacher licensure. My understanding is that if
you are a teacher in California and you are a military spouse, you can be licensed
in California as long as your spouse is on active duty. But as soon as your spouseleaves active duty, your teacher licensure is no longer valid. That is an example of astate-level policy that could be easily changed. If you are qualified on one day, you
should not be disqualified the next day by an action that has only to do with your
spouse and not with your professional qualifications.
Military members are able to contribute economically to an area as they areleaving military service and settling in those areas. We want to make it as easy as
possible for their spouses to settle and stay. These types of things will reduce transition stress. Focusing on issues at the policy and practice levels will make a difference.
Another issue that we have heard repeatedly from the veterans that we areworking with is that sequestration, budget issues and predictability are importantto them add a level of stress that is very difficult for families. There are a couple ofimportant examples of these issues. We saw tuition assistance change in reaction
to sequestration and then change back in many cases. We also are starting to see achange in the transferability of GI bill benefits to dependents, particularly with the
Army. Although this was definitely intended as a recruiting and retention tool when
it was begun, that reduction and ability to transition, or the requirement to give
additional service commitment in order to transfer GI bill benefits, is something thatis impacting the predictability of their service life. It also is impacting the predictability of what will happen for their spouses and dependents.
The predictability piece is as important as the policy change itself. People think
about retirement differently now. In the civilian sector for instance, we just saw
IBM take all of their military and healthcare recipients who were retired off of
their retirement plans. They just notified them that this was going to happen. In
the military we are seeing changes in the military retirement health benefits. We areseeing changes proposed for co-payments, changes in Tricare for dependents, andother kinds of issues. Again, these kinds of issues and policy changes and the way
they are projected to military people will potentially impact what they think about
their careers and will also impact retention.
We are now hearing from military veterans about their concerns regarding themilitary-civilian divide. The Pew Charitable Trust did a survey recently about the
military-civilian divide, and we have seen the results. Essentially what our researchers
have shown has happened in every country with an all-volunteer military. Civilians
not connected to military members or veterans begin to see military service as a
choice and not as an obligation. Because it is a choice, they feel that their obligation to those who serve and to veterans declines over time. We are not seeing thisyet in this country. We are still seeing a great swell of nationalism, patriotism, andsupport for our troops. This is very different than what we saw post-Vietnam andeven post-Gulf War I, but we are not seeing that same level of commitment in allof the civilian population. When surveyed, many civilians said that they have no89

We are now
hearing frommilitary veterans
about theirconcerns regarding
the military-civilian
divide.

90

One aspect thatreally impacts
people is related to
employment andhiring initiatives.

Military Families in Transition: Stress, Resilience, and Well-being

responsibility whatsoever to military service members and to veterans. Fortunately,
many communities have come together showing a responsibility to military service
members when they return from deployment, still welcoming them home withparades and celebrations. But eventually, the research shows, most countries have
had significant divergences between their military and civilian populations.
One aspect that really impacts people is related to employment and hiring
initiatives. In my work with the Institute for Veterans and Military Families, a big
focus is on employment initiatives related to hiring veterans. We work with the
U.S. Chamber of Commerce through Hiring Our Heroes. We work with the JP
Morgan Chase 100,000 Jobs Mission, which now includes 114 companies that arecommitted to hiring 100,000 veterans. Very large companies are involved in bothof these initiatives. We also work with Alcoa, Lockheed Martin, and Boeing on the
GE Get Skills to Work program, which is focused on opportunities for veterans totransfer their skills into advanced manufacturing careers in the 600,000 job openings
available there. What is interesting is the narrative in this area. Because we have anarrative that is largely in the public sense, we must do something because we owe
it to veterans, or we must do something because veterans need help.
We are trying to change the dialogue now while the country is still in the moodto help, and while they still see this as a corporate social responsibility. We havesupported about 10 propositions on why veterans are good for business, including
adaptability, trainability, education, and resiliency. We also provide information
about the strengths veterans develop while they are in military service, and how
those translate into the military and veteran environment. That message is not yet
getting out fully to the American public. They do not yet understand that, like thepost-World War II generation that Tom Brokaw called our greatest generation, thisgeneration of military veterans has incredible skills, education, and training. Theseassets can be applied in the civilian contest in business and industry, and in civilsociety and community leadership positions. Veterans have the ability to do community building in the same way that they did community building in other nations.
Taking advantage of that, and messaging around that, is very important.
There are two critical messages that get in the way of each other. First is that all
veterans have an unemployment rate that is nearly a percentage point lower than thatof their civilian peers. However, post 9/11 veterans, and particularly those who are
20 to 24 years old, have a much higher unemployment rate than their civilian peers.
We know the veteran experience can benefit their employment across their entire
life course. What we do not yet know is how to help transition veterans quickly,
particularly young veterans, from their military service into their civilian roles. We
need to work on these issues. They begin early and are an important part of the
discussion on transitions and stressors facing members of the military.

Panel 5: Military Families and Transitional Stress: What Critical Information is Missing?

91

Military Families andTransitional Stress: What
Critical Information is Missing?
Wanda L. Finch, LICSW, CAS
DR. URSANO: Our second speaker is Captain Wanda Finch. Wanda is fromthe Family of Community Resilience Program, the Defense Centers of Excellence(DCoE). DCoE is a long term friend and partner of the Center for the Study ofTraumatic Stress and of the University. It is a pleasure to have Wanda here to speak.
CAPT. FINCH: I am going to provide a brief overview of DCoE, and highlightstrategies to address psychological health and the needs of military families. I will
identify some of the ways the DCoE is employing strategies to increase researchknowledge and also identify some innovative ways to transfer that knowledge into
practice. Our mission is to improve the lives of our service members, families andveterans by advancing the excellence of psychological health and traumatic brain
injury (TBI) prevention and care. Our vision is to be the trusted source for the
Department of Defense (DOD) but also to serve as an advocate for psychologicalhealth and TBI knowledge, and to improve the system of care in the military healthsystem. The values that we exercise are excellence, integrity, and teamwork. We
recently reorganized and now have three centers rather than four. My particularteam is embedded in the Deployment Health Clinical Center (DHCC). Our primary
mission is to improve the deployment-related health care needs of military healthsystems, and to look at research program evaluation and program implementation
support for our partners within DOD and for our external federal stakeholders.
We also have the Defense Veteran Brain Injury Center (DVBIC). Their focus is toprovide state-of-the-art clinical care, including research and education programs as
they relate to traumatic brain injury.
Our third center is the National Center for Telehealth Technology (T2). This
Center is at the forefront of many health technology solutions. If you are a provider,
you may have the Resilience Provider App on your phone. You may also refer manyof your patients if you are doing clinical care using many of the applications that
our T2 center develops.
Who is our population of focus? We are all well aware of the basic stressors arethat our military families face across the employment cycle. What are some of theunique readiness concerns? One is financial, having a plan. What types of support

Our mission is toimprove the lives ofour service members,families and veteransby advancing
the excellence of
psychological healthand traumaticbrain injury (TBI)
prevention and care.

92

During the post
deployment phase,
we also want to becognizant of thelack of support andvarious changes that
our military families
encounter.

Military Families in Transition: Stress, Resilience, and Well-being

will family members need in the absence of the service member — whether it is a
deployment or the extended training that many of our service members face. Theseissues can often create stress for the family members. We also know that the current
conflicts in which the U.S. has been engaged over the last decade have led to anincrease in the operational tempo for our service members. We have relied heavily
on the guard and reserve as well, to be at the forefront of today’s wars.
With regard to the deployment cycle, we want to be aware of the ambiguous loss
and worries that many of our children and spouses face. They are concerned as towhen the service member may be coming home, and whether will they be coming
home injured. If they are not coming home injured, how will they be? Will we beable to reunite and be the family that we were prior to their separation? It also brings
about increased roles and responsibilities for spouses, when they may be missingthat extra pair of hands to drop off the kids in the morning, take one of the kids tothe doctor, or some of the other household duties that the spouse may be asked to
do in the absence of the service member.
During the post deployment phase, we also want to be cognizant of the lack ofsupport and various changes that our military families encounter. We need to consider how the roles differ, and that there may be other boundaries the family member
may have problems with, for example, managing care or addressing particular issues
such as financing. Or they may need other types of support to sustain themselves in
the absence of the service member.
There is also concern about the care of physical injuries and/or mental healthissues that our service members may come home with, and whether family members
are prepared to deal with those injuries. We are concerned about whether family
members know how to get assistance for the service member or for themselves, tohelp them cope with the challenges that they are facing. With the reintegration phase,often families are faced with the dual mission of preparing for another operational
mission, transitioning post service, or perhaps entering the veterans’ system.
We see that there is often a limited time to transition and/or address other issues,in order to support the families and help them make a successful transition. Looking
at what the U.S. Army has been doing, I identified the Army’s position regarding
support for military families. Some of you in the audience may be familiar with
the Army Family Covenant, which was signed by Secretary McHugh in 2007. The
covenant states that, as you are changing your life for the Army, a bond should beformed that lets you know this is not a commitment to be taken lightly. The Army
will look out for you, for your soldier, and for your entire family. We are all one
family in the Army and should act accordingly.
What came out of this covenant is a commitment by the Army to provide services
and support to make those services available and accessible to family members. The
Army has also enlisted a couple of other strategies to improve force readiness andsave lives and also to advance the health of service members and support militaryfamilies. One of those strategies is the Health Promotion Policy, which is designed
to maximize readiness, war fighting ability, work performance, and to enhancewell-being. This particular program is looking at readiness in terms of a number ofstrategies including policy, organizational, social, behavioral, spiritual and healthcare
activities. The Ready and Resilient Campaign is another such program. This campaign looks at enduring cultural change that recognizes the family as an essential
part of the strong foundations for Army readiness. This enduring cultural change isdesigned to differentiate the definitions of readiness and total soldier fitness, and toPanel 5: Military Families and Transitional Stress: What Critical Information is Missing?

address the way that the Army develops the soldiers and civilians in the future. Thischange integrates resilience into how soldiers and their families build their healthand fitness capacity, as well as strengthening and maintaining access to a variety ofresources.
One of the other key strategies is the Army 2020 Campaign. This programis designed to transform the healthcare system into a system of health that will
maintain, restore and improve the health readiness and resilience of soldiers, theirfamilies and communities. I want to highlight communities because the Instituteof Medicine recently released their follow-up report on the readjustment needsof service members, veterans and their families. It includes a chapter that looks atsome of the challenges that our communities face in view of the high Operational
Tempo (OPTEMPO), which has heavily relied on our guard and reserve troops inthe past conflict.
Finally there is the Comprehensive Soldier and Family Fitness Program (CSF2).
The CSF2 was also endorsed by the Secretary as a major component for Army readiness and the resilience campaign. The CSF2 teaches life skills intended to help people
face stressful events and confront future challenges in five major areas: physical,
emotional, social, spiritual, and family. There are also five additional componentsthat the CSF2 endorses as part of this program. One of them includes the Global
Assessment Tool (GAT), and the Comprehensive Resilience Modules. The GAT isan online survey designed to assess an individual’s social, emotional, spiritual, andfinancial status, as well as physical fitness. The GAT also encourages individuals toseek support at their area service centers.
The Comprehensive Resilience Modules (CRMs) are another web-based selfdevelopment tool that provides training to address aspects of strength and resilience.
There is also the Master Resilience Trainer Course (MRTC), which is a ten-day
course that teaches resilience fundamentals and follows the soldier throughout hisor her career. In addition, the Institutional Resilience Training, the Warrant Officer
Education System, and the Noncommissioned Officer Education System also support the officer throughout his or her career and professional military education.
And then, finally, there is Performance Enhancement training, which is designed tostrengthen the minds and the performance of service members.
I am going to take a moment to share with you some of the strategies that DCoE
has used. First, however, I want to make sure that we understand that the current
conflicts are not our fathers’ or our grandfathers’ wars. We have a different adversary. These conflicts have involved many unparalleled challenges. For example, theuse of guerrilla and terrorist attacks to identify the enemy combatant is much moredifficult. There are a growing number of invisible wounds in our returning service
members, and there is also a changing demographic. We have relied heavily on the
Guard and Reserve in this past decade of war. As frequent deployments are occurringin larger numbers, there is often little downtime for service members. Most recently
we have lifted the ban on women in combat. We need to have a discussion about
what this is going to mean for our service women.
We also have a different environment in terms of the military operation. Manyof the adversaries are non-state—they are unknown. They may not be an organized
government, which could be easily recognized. There are also stringent rules ofengagement which our service members have to follow to make sure that the mission
is successful. We have also increased coordination of operations with our joint bases,
to share information and provide access to all service members or their families who

93

Army 2020
Campaign…
is designed totransform thehealthcare system
into a system of
health that will
maintain, restore
and improve thehealth readiness andresilience of soldiers,
their families andcommunities.

94

Concerns fromspouses… included
the amount oftime that it took toreadjust the family
relationship oncethe service member
returned home.

Military Families in Transition: Stress, Resilience, and Well-being

are receiving support from joint services. There is also an increased flow or ambiguityof information about tasks because we do not know what our adversaries have instore for us. Finally, there is also the responsibility of what is happening to bootson the ground within the combat unit.
The 2010 Survey of Army Families recognized many of those issues. The Survey
also found that many families believe that they were resilient through these difficultand challenging times, which is wonderful. However, the Survey also found thatspouses identify concerns that we need to consider as we continue our researchaddenda. These included the redeployment of the service member, and whether or
not their loved one would be injured in battle. A number of emotional and nervous
experiences were described by family members on the Survey of Army Families, aswell as marital problems experienced in the last six months. There are also reports
from some spouses on dissatisfaction about deployments and the amount of timethat the service member is away from home. Spouses also reported having limited
knowledge about Army systems and questions regarding how to access the rightservice at the right time.
With regard to deployment, spouses identify a lack of knowledge on emergency
assistance generally, and, in particular, about where those supports were. For
example, they expressed questions about how to access documentation on entitlements and other types of services and concerns about the lengthy separations or theambiguous loss for children. That is, children may not clearly understand if theirparent is going to be returning home and if so, whether there will be changes. How
will the family renew their relationships? Finally, spouses also reported challenges
on the job, in terms of managing their roles as a caregiver and as a professional, or
having time to volunteer.
The Survey also identified a few other concerns from spouses. One of thoseincluded the amount of time that it took to readjust the family relationship oncethe service member returned home. Five weeks appeared to be the average, according to the 2010 Survey of Army Families. Spouses also identified some changes inthe service member’s mood or personality, and challenges with communicating or
reestablishing household roles and responsibilities. The reintegration phase was
identified as another difficult time. Older children may have had more challenges
fitting in with the returning parent and restoring that relationship, but also being
worried—are they going to leave again? Is it going to be next week? Is it going to
be next year? How long will they be away? The total number of months deployed
was also associated with challenges for many of the children.
A few other studies also looked at ways to support our service members. The
Army STARRS program hopes to apply health promotion and risk reduction strategies, as well as suicide prevention efforts, in order to support service members andincrease their protective mental health factors. The Military Life Project found that
improved communication between service members and families was a big plus.
Obviously social media played a big role in much of this. It also minimized theimpact of deployment on the home front but also enhanced support through theMilitary OneSource by encouraging families to access many of the supports thatwere available.
The Millennium Cohort Study found that the population was healthier than was
perhaps once perceived, in terms of mental and physical challenges. This was perceived to be very useful in the prospective evaluation of health and post-deployment
issues. Finally, the Blue Star Families Survey found that despite the high OPTEMPO,

Panel 5: Military Families and Transitional Stress: What Critical Information is Missing?

military families again found themselves to be very resilient. However, there wasalso some concern about a decrease in marital harmony in that particular survey.
Looking at the literature, I pulled together a short list of some key challenges.
One of the key things is caregiver issues. How does that impact spouses post deployment? Finally, yesterday we kept talking about service and access for our militaryfamilies from a treatment-only perspective. I want to remind us that families do notstay in treatment forever. There will come a point in time where they will be expected
to be on their own, to be able to exercise some type of self-help strategy, so that they
can sustain their own recovery and outlook for the future.
These are thought-provoking questions, which I hope you will be able to apply
in your research strategy as we move forward. If you have any questions about othercollaborations that DCoE is engaged in with our federal partners, please see me.

95

One of the key
things is caregiverissues. How doesthat impact spouses
post deployment?

96

Military Families in Transition: Stress, Resilience, and Well-being

Panel 5: Military Families and Transitional Stress: What Critical Information is Missing?

97

Points to consider in Judging
the Value of Interventions for
Military Families in Transition
Speaker: Stephen A. Maisto, PhD
DR. URSANO: Our next speaker, Dr. Stephen Maisto is Professor of Psychology at Syracuse University, and Executive Director of the Center of Integrated
Healthcare.
DR. MAISTO: Part of my research program is conducted as the Director of theCenter of Integrated Health Care, which is a VA Center of Excellence. What has been
discussed here during the last day and a half is important and related to the work
we do in the Center. The Center has a mission of advancing knowledge about the
integration of treatment for behavioral and mental health concerns in the primarycare setting, which is a non-traditional setting for those concerns.
Although military families in transition was not my area of expertise, working
in the VA in various capacities for the last 20 to 25 years, I acquired knowledge indelivering direct clinical services, both as a clinical psychologist serving veterans andas a program administrator. I am now a Director in the Center of Excellence andcontinue to do research within the VA context. The knowledge that I have accruedin these roles is closely related to the topics we are discussing at this conference.
In addition, I delved into the literature to determine the most important questions
being asked in the field. What is the state of knowledge on multiple dimensions? One
such question involves looking at both preventive and therapeutic interventions. My
research programs have been focused on the effectiveness of treatment for substanceuse and related disorders, including comorbid substance use disorders, in traditionaland non-traditional settings. My particular focus has been on the primary care setting. In fact, the DOD and the VA are leaders in that regard, pushing the treatmentof these disorders in the primary care setting.
A number of interventions have been developed to help spouses and childrenof military personnel. There are a lot of outstanding programs that have the potential to help the people that they are intended to help. If you look at what they aredesigned to do they all, in one way or another, distill down to those two points:
to help military families cope with stresses of deployment and its aftermath and toenhance their resilience in facing potential stressors. Research has shown the kinds

My research programs
have been focusedon the effectivenessof treatment for
substance use andrelated disorders,
including comorbid
substance use
disorders, intraditional and nontraditional settings.

98

It is important tonote that researchers
are always concerned
about the past andthe present, but the
DOD is concerned
about the future.

Military Families in Transition: Stress, Resilience, and Well-beingof stressors that military families experience, the problems they face in coping withthem, and the factors that facilitate their resilience.
It is important to note that researchers are always concerned about the pastand the present, but the DOD is concerned about the future. There is tension,
because researchers are conservative, they want to look at what is and how good
it is. Whereas if you have other priorities, for example, if a crisis is happening, thequestion becomes, how do I deal with it? You want to know what should we doright now. I hope to say a few things today that might help to resolve some of thistension. Whatever the future brings, if the DOD and the VA have any hope of copingwith what comes up, they will be looking at these three points to help families copewith stressors and to make them more resilient.
During the last day and a half, we have heard about empirically based interventions. That is, we have heard about interventions that are based on research. But are
the interventions themselves evidence-based? For example, how do we know thatthey actually improve the lives of individuals for whom they are designed, however
we might measure that. In the literature, the most common critique of interventions
is that they typically are not evidence-based. As we have heard in this conference,that critique does not apply to the interventions per se, but to the question, do
they work for military families? That is, there is a great deal of evidence, in somecontexts, that the interventions are effective and further, that when they have been
implemented widely, they have continued to prove effective. But there is less data
to support their effectiveness with military families.
What does “evidence-based” mean actually? It is a complex term, and usually
it refers to research that has been done to support the intervention. Not necessarily
what the intervention is based on, although most of the interventions are based onsolid research data. But rather, does the intervention hold up when tested?
The kinds of research evidence that have been published and discussed include
research designs that are clinically relevant and patient centered. In fact, these arebuzz words you hear in VA and DOD: clinically relevant and patient centered. If you
are looking at the clinical context, or if you are looking at prevention work, the samequestion applies. Does this actually apply to what the provider or the intervention
is trying to do? Does the intervention address the needs of the patients or clients?
These are important questions that we have to ask when we do this kind of research.
The design considerations that a researcher has to consider include whether
they will conduct quantitative research or qualitative research. Will they use agroup design or a single-subject design? Why not study one person? This is a tradition in biology, psychology, and psychiatry that went out of existence for about 30
years, since the 1970s, but it is slowly making its way back. This is important forpeople who do clinical practice or are actually on the line, working with clients or
patients. This is the kind of research they feel is most related to the work that they
are doing, as compared to research that focuses on group averages rather than on
the individual. They consider that this kind of research is related to what they aretrying to do with patients. That is, what should I do with this person right here andnow, given what kind of picture the person is presenting?
The next consideration is whether we should do a randomized controlled trial(RCT) or one that is not randomized? Both have a contribution to make.
Finally, is this an efficacy trial or an effectiveness trial? This is not really an either/or—it is actually more like the next stage of development. One does an efficacy trial
at the earliest stage and intervention evaluation where there is the most internalPanel 5: Military Families and Transitional Stress: What Critical Information is Missing?

control. It is like a controlled experiment, or as controlled an experiment as you
can get in this kind of context.
For an effectiveness trial, the context is more like real-life clinical activity. For
example, one of the features of that would be not screening out patients based on
various criteria that might create noise in your data. Rather, you are more likely to
accept patients who have all sorts of different issues, just as would be the case inclinical practice. Interventions have to pass this second test in order to go further. If
we are going to implement an intervention, it must pass the effectiveness test.
Researchers need to stop adhering to the RCT as the almighty gold standard,as the only way that we can evaluate interventions. This clearly is not true. Theseother research designs have a great deal to offer, and typically use fewer resources.
This is not to denigrate RCTs. The point is that they have a place; however, otherdesigns also have a place. One of the things that slows down the connection between
research and practice is that RCTs take a great deal of time and resources, and there
may be other types of data that we can consider, which may also help to address thequestion of whether an intervention is effective.
The second point is that given these different types of research designs, it isimportant that researchers now have an ability to look at all the research data
related to this intervention, not just those data accrued from controlled studies.
Can we integrate these various types of data and come up with a coherent pictureof whether this intervention has potential? If so, it should be disseminated andultimately implemented on a widespread basis.
It is problematic that many review articles consider only controlled trials. Thiskind of thinking has to stop if we are going to have any relevance to places like
DOD and the VA, who are looking for ways to act quickly and effectively. Because
there is far less data for us to use to answer their questions, which are often times
urgent questions. “What do I do now? Give me something that can work given mysituation.” Being able to draw on a wide array of sources of data will increase ourrelevance.
I also want to emphasize the value of a coordinated set of smaller types of studies
rather than larger studies. The former require fewer resources, and at the same time,evaluate the intervention across multiple sites and multiple places in multiple ways,
which is what you have to do in the final analysis. Integrating the data to make senseout of it can paint a picture that could be ready when a crisis comes up or when asituation arises in which this particular intervention might be of use.
Some methodological points to consider beyond simple or basic research design
involve intervention quality control. Is the intervention being delivered in theintended way? Is it being done in the way it is supposed to be? Do you know what
you are evaluating? In implementation science, we do not expect an intervention tostay intact. It will vary by clinical practice across multiple sites. You always have to
make adjustments, but does the core of intervention stay intact? Do the principles on
which it is based stay intact? These are important to consider in doing these studies.
We talked about following patients over time, and we asked how long do you
follow them? It is critical to follow patients over long periods of times in order tounderstand the course of their symptoms or problems, or the course of their outcomes over time, that is, how their symptoms and outcomes fluctuate. How can wecreate a knowledge base that will help us identify the most efficient and effective
time to deliver an intervention for these families?
Related to this is a statistical point. In psychology and other behavioral and99

For an effectivenesstrial, the context is
more like real-lifeclinical activity.

100

But we have tolobby for what we
believe in, because
people in Congress,
who actually holdthe purse strings, do
not all agree with us.

Military Families in Transition: Stress, Resilience, and Well-beingsocial sciences, we have been trained to use the linear model to analyze our data.
This simply means we accept a linear relationship between an independent and adependent variable. However, in reality these kinds of outcomes do not tend to belinear over time. They are often nonlinear and are often characterized by spikes in thedata. Why is that important? As an interventionist, understanding this is may help
you to identify the tipping point. When is the best time to deliver the intervention?
Do not expect straight lines over time; rather, expect many bumps in the data. That is
the way behavioral variables are best characterized. This basic fact has been known
for many years. However, we now have statistical models available that allow us tomodel these patterns of change.
Many of the points we have been discussing over the last two days stem fromthe biopsychosocial model. Anyone who has been trained in behavioral science orhealth psychology, or who has been studying health and treatments of health-related
problems, has heard of that model. George Engel, a psychiatrist, first published thatmodel in 1977. Unfortunately thinking in both research and practice has waxed andwaned over the years, often in favor of a biomedical approach. Over the years astrict biomedical approach often gets more attention than a biopsychosocial model.
However, in his article back in 1977, Engel had a picture of a series of concentric
circles representing what you have to consider when looking at health and treating
health-related problems, starting at the molecular level and building up to the levelof the community and culture. That kind of thinking is helpful in guiding research
design and in thinking about your research more generally. It is important to thinkat those multiple levels.
I would like to make one final point. We all agree with much of what has been
said during this conference. We value research. We value helping families, military
personnel and veterans, and we value the role of research in that. But we have tolobby for what we believe in, because people in Congress, who actually hold thepurse strings, do not all agree with us. We need to get better at this—we need to
improve our ability to lobby people in Congress to support the kinds of things we do.
DR. URSANO: I appreciate Stephen’s comments in particular, which weredirected towards science and the scientist. But let me translate for Mr. Stamilio andDelores Johnson Davis and for other policy people. What is the minimal actionable
evidence to institute a program? That question includes both a science question and apolitical question. What is the minimal evidence that allows science to move forward
and—as those of you that work in the world of policy and politics know—make adefensible case in front of a hundred senators? It is a very important question. Not
what is the best evidence, but what is the minimal acceptable evidence?
I would also like to draw a quick analogy. The biopsychosocial model, which wehave not explicitly mentioned, embeds all of our thinking. The Walter Reed Army
Institute of Research (WRAIR) is one of the homes of that model, with a tremendous
history including Mort Riser, John Mason, and now Paul Bliese and Paul Bartone, as
well as others who have carried that forward. George Engel is a wonderful name torecall in this context. The question is, how do we think across those multiple levels?

Panel 5: Military Families and Transitional Stress: What Critical Information is Missing?

101

Military Family Transitions in
the Next Decade
Speaker: Shelley M. MacDermid Wadsworth, PhD
DR. URSANO: I would like to introduce Shelley MacDermid Wadsworth.
Shelley is Professor of Human Development and Family Studies and Director of theCenter for Families and the Family Research Institute at Purdue University. Purdue
has been one of the most active places in the areas of family programs and family
research.
DR. WADSWORTH: I would like to thank Dr. Ursano, of course, and my goodfriends and colleagues at Syracuse University for inviting me to be here. I am goingto start by giving some background. By my estimation a good chunk of the militaryforce of 2025 today is about eight years old. You watch your eight-year-old kids ornieces and nephews teaching you how to work the remote in your house, knowing
how to do these sorts of things we do not know how to do. You watch all the ways
they move through the world. They are not fictional, theoretical people. They arereal people and they are already here. We can see how they are being trained andeducated and prepared for their military careers in the future.
The second overarching point I will make is that families have always been
diverse, and they have always been evolving. We like to think that there are moments
or periods where there is a certain kind of family, or a modal family, or a typicalfamily. In fact when you dig into the data, you find that the picture is rarely as clearcut as we would like to think. Stephanie Coontz has written persuasively on thisissue, and it is just as if the military is a pipe that is open at both ends, and so it is
not like there is a military force. There are people flowing through the military at all
times. That is true also with families. Families are flowing through different kinds
of forms and arrangements. There are always many more forms and arrangements
than we are thinking about.
Finally, war and warfare always also seem to be evolving. The decisions that we
make today to address the issues that we have learned about in the last ten years
will probably be relatively poor preparation for the next conflict, just as the templatethat was created in the early to mid- 1990s was an imperfect reflection of what weought to have been ready to expect in the 2000s. These guesses that we are making
are guesses, and they are difficult.
It is in the context of these three points that I have thought about what to say
today. I also want to be intentional and overt about levels of analysis and levels

Families havealways been
diverse, and they
have always been
evolving.

102

A third level isthat families areembedded in muchlarger systems,
including but not
only the military.

Military Families in Transition: Stress, Resilience, and Well-beingof thinking because much of our conversation here has been about one or two ormaybe three levels of analysis. I am aware that there are people who have to operate
at additional levels of analysis, or higher levels of analysis, which I personally findincredibly intimidating. But that is part of the reason that we were brought here. I
just want to recognize those.
There are individual programs, and that is where we have spent much of ourtime speaking. But there is also the notion of the configuration of programs. Thatis a level that Ms. McCollum and others frequently have to deal with. It is not amatter of which should it be, Program A or Program B. The question is what is thematrix of appropriate programs that need to be in place for the diverse elements ofthe population at the moments that they need them.
I confess I have a negative reaction to bubble diagrams that have 200 bubbles onthem, only because I have seen them used quite a bit in the last 5 years to describe
family programs. It is as though those bubble diagrams are somehow evidence inand of themselves of redundance or poor quality or other things. I will respectfully
suggest that you could do a similar diagram about training in the military or medical
services or educational programming for children. You can do it about many things.
But it is a simplistic way to understand the complex matrix of things that need to
be in place to address particular problems at particular times over the course of themilitary career or family’s life. It is not a nuanced way to understand things. I am notbeing critical because I know there for a reason for using this type of model. However, as we think about how to deal with these problems, there is a level of analysis
that goes far beyond which one program is better or which kind of evidence is best.
A third level is that families are embedded in much larger systems, including but
not only the military. There is healthcare, there is education, there is the economy,
and there is the political system. We cannot forget those things. The military is not
its own world, despite evidence to the contrary sometimes. Those other things areout there, and they are impactful.
Fourth is the issue of connectors, which others have recognized. But what I haveobserved over time is that we put far more energy into developing programs than todeveloping the pathways between programs. We spend far more time figuring out
what it is that people need to do that will fix this particular problem. But we spend
relatively little time figuring out how we are going to get families to those places, or
how we are going to make that work. The most common suggestion is probably casemanagement, and if you add together all of the voluntary, political and military, andmedical and VA programs that have created case managers, there are some people, it
seems, who might need a case manager for their case managers. We have not cracked
that nut yet. We have the question right, but we do not have the answers figured out.
In general we have to challenge ourselves. Every time we think about a program ora solution we have to figure out the pathways to and from that program. Where isthat going to live? How is it going to be embedded?
Finally, at the highest level there is the Army and the DOD stance on families,
per se. This frame affects not just research on particular programs, but also thepolicies and practices that shape everyday life in the military. This is the level atwhich Mr. Stamilio has to operate. He has to be thinking beyond just the family
programs stovepipe to a whole variety of portfolios of interventions. These could
be policies or other things that convey and create the environment within which
military families serve.
I thought about the question posed to that group earlier, what would you do ifPanel 5: Military Families and Transitional Stress: What Critical Information is Missing?

you had a dollar to spend, and being a very literal person I tried to take that very
literally. I’ve asked many of you, “What would you do if you had a dollar?” Asking others I would say the answers ranged from costing maybe a million dollars toa billion dollars. But what could I do for a dollar? I could write a memo to makesome recommendations.
Number one, before we become completely a peacetime Army once again, we
ought to record lessons about what needs to be done the next time a big conflict
emerges. As family researchers, it took us quite a while at the beginning of thisconflict to figure out that this was going to be a long, protracted, big deal and thata great deal was going to be required. Now is the time to think about what we did
not do that we should have done. What did we do that seemed to be good ideas?
What are the things that we never even thought of that we can now? Somewhere in
the Pentagon, there is a place for those manuals. When something big and bad happens, there are manuals for everything on the operation side. I propose a manual forfamily programs for the next big conflict. This is the moment to do that, because ten
years from now, when we have a peacetime force, we will not remember anymore.
There are many great lessons that we can learn from the past decade of conflicts.
Number two, the second item in my memo—I loved what Ann Masten said yesterday about harnessing the power of human adaptive systems. We are not yet fully
engaging families as powerful, adaptive systems around military service members. We
talk quite a bit about it but there are still places in which this idea has not become
fully embedded in how we act and what we do. Much of our talk is still about preventing, or solving, or addressing, or minimizing the problems that families cause.
We have not yet fully engaged the positive power of families as adaptive systems.
Evolving family diversity is also going to challenge us to figure out what thepolicy stance in the military needs to be regarding families, because, increasingly,
marriage is going to become an unworkable gateway for defining families. We
already see that we cannot use it for gay families in the way that we have used it
before. But if you cannot use it for gay families, then why would you try to do it
for straight families? And if you cannot do it for straight families, then why would
you use it for single service members whose parents and siblings are their primary
support systems?
This is something that is very difficult, but my fear is that the easy decision isgoing to be to decide that we are not going to have a gateway. We are not going to
try to harness the power of families as adaptive human systems. This is not a smart
decision for the long-term, given how every first sergeant will tell you that they spend
inordinate amounts of time dealing with family-related issues. This is a very thorny
problem, and I wish I had a simple answer.
My third recommendation is to take trajectories seriously. Understand that small
inflections early on can really change the future. Increasingly we are learning thatto a large extent, past is prologue. People who are having difficulties before they go
on deployment have a much greater likelihood of being messed up after they comeback from deployment. People who enter military service with a load of exposure toprior trauma and with other problems are at higher risk for having more problems
later. How good a job are we doing of understanding the prior experiences of accessions when they enter the military, so that we can take that into account as we plan
resilience training, as we allocate people to positions, and as we decide how muchtrauma we are going to expose them to?
What sorts of trajectories are we setting up for kids? New parent support is a

103

Before we becomecompletely apeacetime Armyonce again, we
ought to record
lessons about whatneeds to be done
the next time a big
conflict emerges.

104

Figure out
how to partner
productively and ina sustained way with
communities andunderstand that thisis not just a reserve
component issue.

Military Families in Transition: Stress, Resilience, and Well-being

good example. Trying to change a later trajectory is an early intervention. Some ofthe other prevention activities that we have discussed have that same sense. Female
service members have an abysmal experience, by all accounts, in trying to get andstay married, if they want to be in the military. Many women have to choose between
having a career and having a family. Is that a tenable pathway going forward, nowthat we have lifted the combat ban and are trying to make the military somethingthat is really open to women?
My fourth recommendation: Figure out how to partner productively and ina sustained way with communities and understand that this is not just a reserve
component issue. Active component service members and their families live in
civilian communities, attend civilian schools, receive their healthcare from civilian
providers, and, increasingly, live around civilian people. Civilian communities arepart and parcel of what we are trying to do with families, not just for the reserve
component. We are figuring out how to engage them and work with them. My fearis that it is all going to fall away now, and some of the lessons we are learning will
not be sustained. If this happens, the military then leaves resources on the tablebecause there is help out there that we should not be leaving alone. This includes
communities defined by both affiliation and by geography.
Finally—and this is self-serving for people in this room—stop wasting taxpayer
money and leaving money on the table by imposing unnecessary barriers to researchand data. Allow the use of data. Remove barriers from funded, credible projects andembed evaluation when programs are created. When researchers can get money fromother places to help the military answer important questions or deliver services tofamilies, let us not be so scared about it. When this happens, we waste money andfail to get the full value of the skills and resources that we are bringing to the table.
When researchers can use your existing data to help you answer important questions,
let them. Let us figure out how to make that more possible, not less. There have also
been a number of instances where there have been barriers posed to evaluation thatare not necessary. I am not suggesting that there are no necessary reasons for gatesand filters. However, more could be done with the resources available if unnecessary
barriers were eliminated.

Panel 5: Military Families and Transitional Stress: What Critical Information is Missing?

105

Army Science and Technology
Essential Core Competencies
Speaker: Mark N. Glauser, PhD
DR. URSANO: I am pleased to introduce Mark Glauser, Professor and Associate
Dean for Research and Doctoral Programs at the L.C. Smith College of Engineering and Computer Science at Syracuse University. For those of you who have notcaught my earlier allusions to engineers, there is both method and history to thoseallusions. There are engineers in our audience. Mark is one of those, as is Gina. We
have nearly always included engineers in these forums.
There is one engineering methodology—failure mode analysis—that I findparticularly useful. We do not use it enough when we think about things. My nonengineering description of that methodology is that you take a hammer and throw it
into the air conditioner, and then you try and understand how it broke. Not how it
runs, but how it broke. Understanding how things break requires a whole different
set of concepts than understanding how they operate. But these concepts inform us,
particularly during high operational times. When you are running your air conditioner intensely, you want to understand what is going to breakw, not necessarily
how it operates. These are very important questions as we think about identifying
what is coming over the horizon. How will we identify what will break first? Not
necessarily what is the new program to put in place, but what is going to break, how
it is going to break, and what band-aid is going to be available?
DR. GLAUSER: Thank you. It is indeed a pleasure and honor to be here with this
distinguished group of colleagues, working on a problem that is extremely importantand near and dear to my heart. I am a child of a veteran, and someone who has worked
closely with the defense industry and systems for most of my academic career. I want togive you some of my thoughts, and the first thing that you will notice is that everythingshould be tied to the warfighter mission. This is my view. When I spent three years at
the Air Force Office of Scientific Research as a program manager in my own field, thiswas always a driving principle behind our thinking. We were funding a 6-1 program,so we were funding basic research. But we wanted to make sure that that research,even though it was fundamental, was tied to the mission.
When I see all the wonderful programs that you are all working on, I have toencourage you to tie these things to the mission. I heard some of this qualitatively: We
all have a sense that if a soldier’s family issues are good, that soldier is probably going
to be more effective. The question is how do you quantify that?

We all have a sensethat if a soldier’s
family issues are
good, that soldier isprobably going to be
more effective. The
question is how doyou quantify that?

106

There is a realopportunity forfolks in the social
sciences to team withcomputer scientists,
engineers, and appliedmathematicians tolook at ways of using
modern tools to deal
with complex highdimensional nonlinear systems.

Military Families in Transition: Stress, Resilience, and Well-being

In an all-volunteer service, a high percentage of the next generation of service
personnel is going to come from current military families. From my perspective, that issomething that can be quantified and utilized, to convince Congress of the importanceof these programs. CAPT Finch mentioned some of the programs the Secretary of
the Army has put in place that are along this line as well. There is recognition of theimportance of tying the health of the family back to the mission.
We heard in Dr. Maisto’s and Dr. MacDermid’s talks about systems as a way tothink about this. My area of expertise is turbulent flows and steady aerodynamics andnoise. Think uncertainty. Think lack of predictability. The reason we cannot predict
weather as well as we would like is because of our uncertainty in understanding turbulence. That is at the core. But what do we do? We do not stop trying to predict it.
Rather, we send data. We build models. We correct those models on the fly. There isan adaptability component to this.
There is a real opportunity for folks in the social sciences to team with computerscientists, engineers, and applied mathematicians to look at ways of using modern
tools to deal with complex high-dimensional non-linear systems. When I am sitting in
the audience and hearing the questions you are dealing with, I feel I am dealing withturbulence because of the complexity and the high dimensionality of those questions.
However, there are tools out there.
You want models for understanding. You want to know what is happening. You
want to be able to predict and then control. This gets to the issue of when somethingis going to happen. Can I change something before it happens? Can I find predictorsthat will tell me when something is going to happen? Because applied mathematics,
computer science, and engineering are driven by physical systems that are highly
complex and nonlinear, we have a marvelous set of modern tools to use in addressingthese challenges.
Those are two high-level things. What are the Order 1 issues? I hear the manythings that you are dealing with, but I am thinking like an engineer now. What is themost important problem? And what does that mean? From my perspective—and again
this is an engineer’s perspective—I might argue that this should be linked to the following question: How do we impact in a positive way the greatest number of people?
Because we deal in our business, in engineering and science, with things that vary inspace and time, that is how I am thinking about this question. From my perspective,
this would be a high-level goal of your programs. Now, can we provide a framework
to move forward with this challenge? I am going to propose that a core competency
framework might make sense for sorting out some of these issues.
I serve on the Army Science Board and was brought on as an aviation expert. We
were asked by the Secretary of the Army to go through a process, to give the Army, inparticular the Science and Technology (S&T) community, guidance on core competencies that they need in order to make sure that they keep within the Army labs. I havesome idea as to how this might map onto dealing with military families.
Essentially we were to determine what the Army must develop as S&T corecompetencies. Of those core competencies you want to identify and recommend whatmust be formed in-house, onsite, and why this is the case. This gets to the issue ofwhat is unique to military families, and those should be the things that the militarywould focus on. This is the key. Then you want to identify some sort of a model thatwould strengthen the performance of these core competencies and provide appropriate
justification for that model. That is a framework.
The first thing I want you to know is that to do something like this took a greatPanel 5: Military Families and Transitional Stress: What Critical Information is Missing?

deal of work. If you are going to try to implement something like this as a community,
you must get a handle on what the Order 1 problems are, what part of the solution
needs to stay within the military, and what you can get from the outside. You are goingto have to do a great deal of work. As to the core competency discussions, this is basedon an idea proposed by Harvard business professor, Professor Hamel, and one of hisformer students (see Prahalad, C.K. and Hamel, G., 1990, The core competence ofthe corporation, Harvard Business Review, 68: 79-91). We took Hamel’s definitions,which were driven by a corporate view of the world, and we mapped them onto the
Army S&T infrastructure. The idea is that you have core competencies that are yourroots, then you have your core products, and finally you have your end products.
Hamel’s model was initially a business model, and one can see how it might apply
to United Technologies or General Electric. But how does it map onto Army S&T?
Figuring this out took a great deal of effort.
We worked at Fort Carson for about 12 days back in July adapting Hamel’s modelto the Army S&T. I was in charge of putting the chart together for the mapping tovertical lift. Within the DOD infrastructure, the Army is responsible for vertical lift,i.e., helicopters. Basically we identified the core competencies. The military rotorcraft
was our core product and the end products were the various types of helicopters.
Over the past day and a half I attempted to apply the Hamel model to the issues
that have been discussed at this conference. First, what is the end product that you
are interested in? My feeling is that you are looking to deliver great things to militaryfamilies, particularly when they are in transition. I would argue that the end productis providing good stuff to military families that are in transitions. I would consider
separation, reunion, and deployment as one transition, and then transition to veteranstatus.
Then I asked, what are the core products? I would argue that the core products
would be the DOD-VA family support programs—the trunk in the Hamel model. Next
we get into the core competencies. Which of these are more important than others? I
do not know. That is for you to figure out. I can tell you what they are for the verticallift for the helicopter problem. I have taken Hamel’s model and projected it onto theissues of military families in transition. While this needs some work, it is an interesting
framework.
There is also another question, and it was Tony’s first question. What about the
dollars? A second question is how do I deal with the large numbers of suicides andwith aggression? This was a question that the Secretary of the Army was very interested
in from the point of view of S&T. Here is the basic idea. I would argue that in-houseresearch would be that work which needs to be done on issues unique to militaryfamilies in transition. That body of research must be done by the military.
Next, when you are transitioning someone to veteran status, you would be working with, for example, the Department of Labor. At that point, you might work withstate agencies or with other federal agencies. You could work with not-for-profits,
universities, and everything else out there that you can leverage, whatever that mightbe. Maybe we can learn something by studying other countries.
This is a framework, and it needs to be filled in. Many of us on the Army Science
Board were not ready at first to drink the Hamel Kool-Aid, and I still do not. We had
to modify it. We conferred with Hamel, and he worked with us to modify the modelfor the Army S&T. My thinking is that if you go back to this model, it gives you anidea of how to start thinking about the issues. The model provides a framework to

107

The idea is thatyou have corecompetencies thatare your roots, thenyou have your coreproducts, and finally
you have your end
products.

108

For each of the six
areas that we had afocus on within Army
S&T, we went throughand basically did ananalysis of every oneof them.

Military Families in Transition: Stress, Resilience, and Well-being

think about your core product and the end products. That is one step, and then you
need to support that interpretation.
The model also provides a way to filter one of the most important things. As partof the exercise we had for the Army S&T, we were asking some very tough questionsin an era when there could be reduced budgets. How are you going to make the best
decisions? For each of the six areas that we had a focus on within Army S&T, wewent through and basically did an analysis of every one of them. It was interesting.
We argued that with some of them, there were things that could be captured from theoutside community and did not need to be funded in-house. There were others, I am
happy to say, in aviation that basically were already applying a model like this anddoing a good job at it. This is an interesting framework, but whether it is the rightframework, I do not know.
DR. URSANO: At the next forum I am not only going to mention failure mode
analysis, I am going to mention the Hamel model. Very nice dovetailing of Shelley’scomments about capturing lessons learned with the Hamel model, which is very compatible with what we have been talking about today. Needless to say, this is a big pieceof budget modeling. The question of what things must be sustained in-house versus
purchased out-of-house, which is a traditional way and which the WRAIR folks willrecognize. In fact this is the way we think of research activities in general within DOD.
Where should its research dollars be versus where should Pfizer’s research dollars be?
In general research dollars from the federal government are spent in two areas.
The first is the absolute innovation area, which no company will take on because it is
too expensive and because there is no evidence there will be product. The other area
includes critical things related to the military population, which no one else is goingto do but which are necessary for national security. For example, making sure we cantreat malaria does not generate a great deal of interest in the United States; however, it
is of tremendous interest to the military. Similarly, the whole area of PTSD generated
little interest within the United States until it became a critical national security issue
for the nation. This is a wonderful perspective for us to think through these challenges.

Research and Military Policy: Thinking Forward — Closing Discussion

109

6

Research and Military Policy:
Thinking Forward
Closing Discussion
Moderator: Robert J. Ursano, MD
DR. URSANO: We are open for discussion, comment, and observation. In particular, we would welcome thoughts about what constitutes core competencies. Or
what constitutes critical issues that must be resolved in-house versus out-of-house?
Or what are the issues of continuity that Captain Finch brought up? Or what are
the levels of investigation that DOD looked at as Dr. Maisto brought up? Or as
Mr. Schmeling began with, where is the role of considering opportunities, what areopportunities as an aspect of implementation science, and how does the provisionof opportunities for families and service members maintain mental health during
the last year of a tour and the beginning of the next year of a tour?
DR. LESTER: The tree model, the Hamel model, would be interesting to think
about when trying to integrate the diversity of programming that Dr. MacDermid
pointed out. It is not just an array of many different programs, but programs thatare there by design to touch people at different points. If there were an opportunity
to think across the DOD systematically, what are the core competencies across all
those interventions as they relate to military families? And then think systematically
about training and technical support, and about data collection.
DR. GEWIRTZ: I have been thinking about quality control and trade-offs. I
would like to comment on the randomized control trial (RCT) because I think it
has become a hot button. The idea of a RCT as a gold standard is not my opinion;
obviously it is a general scientific consensus. I will defer to my colleagues at the
National Institutes of Health on that. It is sort of a gold standard and that is not
an opinion, it is a scientific consensus. That doesn’t mean that that is feasible ordesirable in every circumstance.
It would be easy for a high level administrator to say, “Well these are the programs I have now. I have an inherent interest in keeping up these programs. So let
us keep going with that, and let us add some evaluation after the fact.” Just like
it would be easy for a researcher whose running a RCT to say, “I am not going toreport any of my data until a year beyond the end of my trial so I can know exactly
what’s happened.” This would lead to a 20-year cycle between research and practice.
Clearly what we have to do is find the balance. There are some great contri-

It is not just an arrayof many different
programs, but programs
that are there by design
to touch people atdifferent points.

110

But we have had theopportunity in thelast year to hold focus
groups with spouses,
who say the biggest
problem is that they
do not know anything
about the services.

Military Families in Transition: Stress, Resilience, and Well-being

butions that the civilian sector can provide. That is the whole area of prevention
research. It is an area that has 20 years of solid evidence. The military sector cancontribute because of the immediacy and the urgency of families who need help now.
You cannot operate in an ivory tower. The crux for me, in terms of quality control
and what we are willing to give, is the intersection between those two challenges.
DR. URSANO: One of the pieces that dovetails with this is the earlier comments
on lessons learned about competencies. How does one carry on a ramp-up? What
are the ramp-ups for now? What have we learned about ramping up to respondgiven the present war? This was our major challenge for 5 years in this war — tomeet the current need.
DR. COOPER: What I consider interesting is that there actually could be a
failure analysis. We have talked about what works. But we have not talked about
what has not worked. There have to be things that have not worked because there
have been many programs that have been rapidly deployed. There have been many
delivery mechanisms that have been rapidly developed and deployed. I imagine thatsome of them do not work. Being a biomedical engineer, I have to ask if there has
been any harm done, or have there been any missed opportunities?
DR. URSANO: Well said. Earlier in the conference Dr. MacMillan mentioned
the importance of the question of harm.
DR. SLEP: What Dr. MacDermid said really resonated with me — thinking about
how to engage families, and about further enhancing and supporting resilience ofthe soldier in addition to that of the family. If we think more deeply about that, it
will help address one of the biggest challenges of family programs, which is that wehave no way of mandating things to family members and ,in fact, we do not want
to do that.
But we have had the opportunity in the last year to hold focus groups withspouses, who say the biggest problem is that they do not know anything about theservices. That is fine but there are systems to try to educate those folks about thoseservices. That may be because people have a problem meshing well with the services
that are provided in the traditional ways. But if you are not at the end of the continuum, it is harder to think about how to engage people. It could be that thinking
about how to enlist families as a resource might lead to novel ways of engaging andpartnering with families.
DR. URSANO: Great point. Families as a resource to involve in the solution
to the problem dovetails with Dr. MacDermid’s comments about the pathways andgateways, and how people move between programs, as we have case managers ofcase managers of case managers. Great observation and absolutely true.
DR. BARTONE: Every panelist in one way or another touched on policy issues.
I want to raise a policy issue that does not get enough attention in our business, andthat is the length of deployment. What is the right deployment length? Is it 6 months,
8 months, 12 months, 18 months, or 24 months? This is an important issue because
it affects transitional stress in that it can add substantially to the problems faced bymilitary families as they transition to civilian life.
Captain Finch presented data from the Survey of Army Families indicatingthat the families are very concerned about the length of deployments. There are a
few studies that have looked at the impact of deployment length on soldiers andtroops, but also on family members. One was a study in the New England Journal of
Medicine a couple of years ago by Alyssa Mansfield and colleagues. This was quite acomprehensive study. It looked at medical records for over 250,000 wives of active

Research and Military Policy: Thinking Forward — Closing Discussion

duty Army soldiers and found that wives of soldiers deployed for more than elevenmonths had significantly more mental health diagnoses, as determined from medical
records. These were depressive disorders, sleep disorders, anxiety problems, acutestress reaction and adjustment disorders. This is an issue that merits more research.
Captain Finch, do the Defense Centers of Excellence (DCoE) have a role to playin gathering relevant evidence on issues like this, and then advocating for policychanges specifically within DOD, because this is DOD policy, or Army policy?
CAPT. FINCH: The Army commissioned The Deployment Life Study in 2009 tospecifically look at the impact of deployment on service members and their families.
In 2010, DCoE was able to provide additional funding to expand that study to theother services. We just completed the baseline data collection for multiple waves ofthe study. It is a 36-month baseline collection. The Navy part of the study is going
to continue until the spring, but what we are finding right now is that there is no
direct impact of deployment on the particular service members and their spouses
that were interviewed in terms of some of the outcomes that were being reported.
One of the other questions that I have posed is whether we are seeing any differences in the services that are accessed. Do we know any information about thesefamilies anecdotally before deployment, in terms of whether there are some readinessactivities or resources that they were accessing prior to deployment that may haveminimized the impact of deployment? That will give us a little bit more information.
I have not come across anything that definitively states a time frame, whether
there is a difference in the effects of a 3 month or 6 month or 18 month deployment. What I am picking up is that the separation period in and of itself creates a
disruption to the family system.
DR. URSANO: Good discussion that echoes some of our comments earlier about
the question of family function. What is the decay curve of family function related to
deployment? How long does family function remain altered rather than impaired?
How long does it take for family function to be restored? What are the different
family functions that are affected? Which ones are critical family functions? Howlong before capability is restored in a redundant fashion, so that one can have asecond deployment that does not add to the impact of the first deployment? One canpicture hazard curves related to the question of family function over time. Severalof those must be critical capabilities from which a family cannot recover, or fromwhich a family cannot recover quickly. This is a very important policy question, as
well as research question.
CAPT. FINCH: The Deployment Life Study examined traditional married families where the service member is typically a male with a female spouse. We have notlooked at single service members with children in this study, which is another areaof concern, particularly as we bring more women into combat roles.
DR. URSANO: Dr. MacDermid made an excellent point about the different
definitions of family, and whether or not our present definitions are sufficient as we
think forward. I will remind those of you who have been through this war, one ofthe perfect examples of that is the question of wounded warriors. We found thatour definition of family provided no funds for moving parents of single soldiers tocome to visit their warrior when they were wounded. Clearly the definition of family
never covered that. We need a different definition.
DR. MACMILLAN: I really like the idea of core competencies, and if we applythat to the intervention research area, some of the essential competencies have to dowith knowledge about the use of mixed methods. We hear about quantitative versus

111

What is the decay
curve of family
function related to
deployment? Howlong does family
function remainaltered rather than
impaired? Howlong does it take forfamily function to berestored? What are
the different family
functions that are
affected? Which ones
are critical family
functions?

112

For those of you
familiar with themilitary literature,
there is the question of
frequent deployments
in combat. The otherrisk time is boredom.

Military Families in Transition: Stress, Resilience, and Well-being

qualitative methods. There is some creative work going on right now with mixed
methods. There is a whole literature on the evaluation of complex interventions. We
heard yesterday about the idea of system navigation, and we know so much more
about how to evaluate not just complex interventions but complex systems.
I would like to comment on RCTs which do get a bad rap; however, they do
not have to take a long time and increasingly there have been a variety of articles
on them. There was one recently in the New England Journal of Medicine about
strategic ways to be more nimble in conducting RCTs. RCTs are not good or bad.
What it really comes down to is what the question is, and what is the best approachto answer the question. We want to see research methods used that control otherfactors as much as possible, and many times that is the RCT.
DR. ROBICHAUX: As the Family Advocacy program manager at the U.S. Army
Medical Command, I would like to make two points. One is that we talked a great
deal about PTSD and the stress of 10 years of war, but I would submit that what islooming on the horizon, with sequestration and budget concerns that cut training
dollars, is the increased risk for a wide range of misconduct, including domestic
violence and child abuse. We had this experience in the 1990s in Europe when wedrew down. Those units that had no purpose sat around and played video games
all day, basically acted out and showed up in all of our programs with higher levelsof problems.
The other point I would like to make is that the recent VA study indicated thatabout 10% of that cohort had engaged in severe domestic violence. In contrast, thecurrent numbers among the active duty population, indicate that close to one quarterof the cases of domestic violence fall into the severe category. We have tracked thisand the numbers have risen since 2009, and we think part of the reason for thisincrease centers around the increased use of Army combatives. Soldiers are routinely
taught techniques associated with Brazilian jujitsu wrestling moves, the old handto-hand combat, and they tend to be inclined to use that training when things turn
physical in their marital discussions. Parenthetically, when you read the literature on
the evolution of Army combatives, the colonel who is given credit for proliferating
the doctrine outside of the Ranger battalions is Colonel Michael Ferriter who is now
Lieutenant General Ferriter, the Assistant Chief for Staffer Installation Management,
under which family advocacy falls. It is kind of a circular process.
DR. URSANO: Very interesting observations, particularly the comment about
increased risk time. For those of you familiar with the military literature, there is
the question of frequent deployments in combat. The other risk time is boredom. In
Vietnam the rates of substance abuse increased as boredom increased; boredom—
because of a lack of things to do—creates risks. Also the issue of actual rates ofseverity versus the change in rates of severity of events is very important. In addition,
approximately 20% of the Army in any given year has had some type of mental or
behavioral health intervention in the medical system — either counseling or assistance for sleep or actual treatment of a disorder. That is the good news; however,even if those who have insurance and the capability and ability to get there receive
health care, we still know that not everybody who needs it receives health care.
DR. COX: I would like to make two comments about the issue of core competency. One of them is an observation, and the other one might be slightly controversial. From my perspective, the Army did a very good job in the 1990s maintaining
a core competency of individuals who could look at soldier issues. Even though wewere not at war, we were sending teams into Bosnia and Haiti, and similar places,Research and Military Policy: Thinking Forward — Closing Discussion

so that when the war occurred, we had that core competence and the ability to bevery effective. We had the Hoge, et al., article in 2004 in the New England Journalof
Medicine and then followed up, supporting the National Health and Aging Trends
Study. But that did not happen just by magic. That happened because we had
maintained a core competency, and somebody had strategically decided that it was
important to keep teams around with those skills.
A more controversial part of this is that in my over 20 years of experience withthe military, I am still not 100% sure who has the core competency for the executionof research when it comes to families. There is a great deal of excellent research that
we are funding extramurally. There are many individuals and different institutions
doing research. However, I do not know whether we can really define core competency or groups within DOD that maintain that core competency. For example, theMillennium Cohort Study now has a huge family component. But when did they
start this—about 4 or 5 years ago? Tt is a relatively new DOD initiative. Dr. Riviere
has some good studies; however, I do not know that we would define ourselves as
being the group with the core competency.
DR. URSANO: That is an excellent organizational observation about WRAIR.
Seems to me WRAIR has always had great interest in this area, but only occasionallyis able to build a cell around it. The Uniformed Services University has some good
activities, somewhat limited, but supported because of this office, with the supportof Delores Johnson Davis and Mr. Stamilio. But the issue of sustained combat andwar-related operations is a whole other concept. Clearly it is one of the things wehave been talking about today, let alone core competencies and basic research to corecompetencies, and program evaluation, implementation and sustainability, which
also has a whole set core skills related to it.
DR. LUNDQUIST: I wanted to point out that although only about a third toa fourth of families experience war deployment, this is not an insignificant number. However, something that every active duty family experiences is a permanentchange of duty station (PCS). In looking to the future, I hope we can assume thatthe wartime will not be a constant. However, thinking about the effect of an averageof 3 year intervals between permanent changes of duty station, it is important tounderstand that while there are many advantages to the mobility, there is also a kindof trauma in moving constantly, changing school systems, and changing employment
trajectory for spouses, etc.
To go back to the original question, that if I had one dollar to spend, how would
I spend it. I would go back to the homesteading policies that were talked about andbrought out for certain sub-populations, maybe a decade ago. The idea is that, atleast for first-time enlistments, families spend 5 to 7 years in one garrison, in one
place. This could be very cost effective, as has been talked about in the past. Goodin terms of reduced stress. It is important to think about the life course of families
at that point in time. Many families have very young children during that first enlistment, and at the youngest stage of development, these children are most vulnerable
to their parent stressors. If they were to stay in one place for 5 to 6 years, many ofthe problems we have been talking about would be eliminated.
Second, to go back to Martha’s point about very early marriages occurring in the
military. This is a period of time when many of those early marriages do occur upon
the first PCS, maybe leading someone to make a hasty decision to marry in orderto stay together and move on. If people were able to stay in place for 6 to 7 years,
this could also have an impact on the early marriage issues that have been discussed.

113

A more controversial
part of this is that in
my over 20 years ofexperience with themilitary, I am still not
100% sure who has
the core competency
for the execution ofresearch when it comesto families.

114

We need to think about
the family as a networkof relationships,
and that resources
for resilience can befound throughout
the network. Thatis especially true for
African-American and
Latino families.

Military Families in Transition: Stress, Resilience, and Well-being

DR. WALSH: I would like to address the important point that Dr. MacDermid
made about families being diverse and evolving. What does that mean for us in our
research and in our programs and services? We are talking about couples and aboutparenting; however, if we have a systems view of the family, we need to be asking
each family about who their resources are, who is important in their family network,
and who could be an important resource for resilience. An example of that would be
for a parent when the spouse is deployed, the grandparent may be a critical resource,whether living in the home or not. For post-divorce or separated couples, what is
the role of the non-residential parent in the child’s life? That is a significant factor
in that child’s well-being or possible dysfunction.
In addition, we need to think about the family as a network of relationships,
and that resources for resilience can be found throughout the network. That is
especially true for African-American and Latino families, as well as many others.
As we think about transitions, an important factor that demographers are finding isthat families are changing and evolving more fluidly over the life course. This means
that, if we are thinking 10 or 15 years out, the family that we are working withtoday may be going through disruptive transitions including divorce or separation
into single parent households, into re-partnering, or into step-family configurations.
Although the complexity may be something we do not want to see, if we can draw
on considerable research over the last 2 decades about varied family forms, we havevery good evidence about what works well, and what works poorly for family andchild adaptation.
DR. BRISTER: At the National Alliance on Mental Illness (NAMI), we rely heavily on research for our advocacy and education. One of our signature programs, theFamily to Family Program, was recently designated as an evidence-based practice.
We are in the process of developing a similar program for military families. Our
niche—and this is going back to the previous presentation on core competencies—isknowing the community, and knowing where people live. Most of our programs
are taught by peers. We have 50 state organizations and 1,100 chapters across thecountry.
I want to encourage the folks in the room, both the academicians as well as
individuals with the VA and the DOD, to think outside the box and look at where
things are already happening. Somebody mentioned that we are only as good as thepeople to whom we can deliver the programs. How do we get families engaged?
I frequently refer to myself as a recovering mental health professional. I ran community mental health centers prior to coming to NAMI about 8 years ago. If I had
known then what I know now about families and individuals, I would have run
better mental health centers.
We cannot all know everything. In reference to the circle figure that Dr. Glauser
presented, I would encourage folks to think about what is shrinking and what is
growing? What do we do in-house? What do we outsource? Look at people thatare already out there. NAMI has a memo of understanding (MOU) with the VA. We
are in our third year of our second three-year MOU, where we offer our family tofamily programs on the VA campuses and engage families so partnerships can work.
DR. CONNER: I was intrigued by Richard Himmons’ intervention study, inwhich they showed effects on partner physical abuse, suicidality, and prescription
drug misuse. The impact of an intervention on multiple outcomes is encouraging.
It reminds me of a large-scale Air Force intervention trial for suicide prevention
that showed effects on multiple death outcomes including suicide. I am a suicideResearch and Military Policy: Thinking Forward — Closing Discussion

researcher so I am always thinking about that as a primary outcome. However,
perhaps that gets in the way of thinking about the most important interventions—those that can have widespread impacts. It will be very useful for us to consider
intervention or prevention activities that are most likely to have multiple impacts
across these sorts of endpoints. One could even think about family-based interventions as being nested in a larger intervention strategy, as one component rather thana singular component.
DR. URSANO: Excellent comment. This echoes back to Dr. MacDermid’s comments and to Mr. Stamilio’s and Ms. Davis’s challenge of the portfolio of portfolios.
How does one choose a program that, in fact, may have multiple impacts acrossmultiple bad outcomes? Yet our research strategies are not quickly aligned with
that, as we tend to want a nice clean outcome to assess. There are advantages togrouping outcomes when one wants to affect many people and there is a cost benefit
associated with it.
DR. LEE-GLAUSER: That gets to my point as a systems engineer. I see people
optimizing for an event, whether it is a suicide prevention or a special needs family
or other things. When you have integrated assistance, you have a different dynamic.
When you are talking about failure mode in engineering, sometimes when you
optimize for an individual event, optimization integration could be a failure mode
when you are evaluating at the level of the system. For example, if you think in termsof your vehicle, you are balancing your tires, and you have a vibration problem inyour car. If you do the static balancing of your tires, and they fit with little weights
around your rims, when you are driving, that adjustment could make the vibration
worse than anything else.
You have to look at an integration systems view of dynamics. Not only does thiscommunity have to think about the family dynamic situations. How could mathematicians and computer scientists with a variety of artificial intelligence and data
mining use their expertise to help look at the integrated system model? Inflection
points have the sensors and actuators. Where do you put that? Where do you put
the interventions, and what are those inflection points?
DR. URSANO: Excellent thoughts. I especially like the wheel analogy. Optimizing for one thing may actually create substantial problems so that as one goes up
the system, there is the question of optimization at the system level. This questionof sensors is a great term within DOD. What are sensors? Where do we place them
if they are placed in the wrong spot? We get information that will actually increase
the problem rather than decrease it.
DR. BLOW: I would like to comment on Dr. MacDermid’s outstanding memo.
One of the things she talked about was the need to figure out how to partner with
communities in productive and sustained ways. That is a critical point. In my stateof Michigan, we know that communities really want to help, and we have had great
responses in our Star Behavioral Health Provider training there. We have reached out
to communities in multiple ways, and they are eager to help. But community members do not always know how to help. The military is often this big machine withwhom community members do not know how to work. The military in Michigan,
and the National Guard in particular, has reached out to communities but sometimes
these are not sustained outreach efforts.
My last point is that there are many resources aimed at the military, for example,
the VA. Many resources are given to the military but not enough resources are given
to community members who want to work with the military. Figuring out how

115

How does one choose
a program that,in fact, may havemultiple impacts
across multiple badoutcomes?

116

We have a master
resiliency training
program, andapproximately 18,000
soldiers have gone
through it. It is basedon a University ofPennsylvania model ofpositive psychology.

Military Families in Transition: Stress, Resilience, and Well-being

to provide resources in communities who want to work with the military is a bigquestion.
DR. URSANO: Excellent observation, particularly the question of lessons
learned and capturing them. If part of our challenge is how to ramp up, ramping
up requires rapid bridging to the civilian community. One of the core elements ofbeing able to do that is knowledge of the military in the civilian community. How
do we keep that activity available, sustained over time, when we expect it will go
down? As the war goes away, knowledge of the Army or DOD within the civilian
community will decrease dramatically. It is already fading off the front page. Butthat is a critical function of being able to ramp up.
DR. THOMAS: I wanted to address something that was said several times yesterday. We all like to collect our own data because it is our data, and we know how
to do it in the best way possible. I would like to make a plea that people not forgetthat the Army, and particularly family programs, collects a great deal of process
and implementation data across what Dr. MacDermid described as this matrix ofprograms. One of the things to think about is that, when a family is having problems
and getting services, they may very well be using a number of these services. There
are data available to look at who is using what at critical times. Please consider that,
especially in this time of constrained resources, not everybody is going to be able tocollect new data. It is important to think about leveraging the tremendous amountof data that already exists.
DR. RIVIERE: I have two main thoughts. First, what lessons will we have learned
from this process for the next efforts that some of us may be involved in? Defining
the problem that we are trying to fix is important, because I have seen proposals inwhich it is unclear exactly what the problem is. Part of the problem is that we do notknow exactly how many families are experiencing stress. In addition, you have thisambiguous, unclear definition of military families under stress. What exactly is the
problem that you are trying to fix in this whole universe of stress? Without a clear
definition of how your program affects a very specific problem, we are throwing
money at a particular issue, and it is not necessarily solving the problem. Defining
the problem is also useful for the concept of everything is tied to mission, which is
not necessarily comfortable. You do not want to think all of your work is tied to theeffectiveness of war fighters on the field. But if you have to justify why your project
should be funded, it has to have some relevance to the military, and if senior leaders
have to approve your project, they need to understand how it affects war fighter
effectiveness. So in the fighting the problem is very specific to the problem you aretrying to solve because we know that 10% of military families don’t have access toservices. Then we can also address the question of military relevance.
The second point has to do with reflection and competencies. I am thinking of
our own center and branch, and what we do at WRAIR. I am referring to The Center
for Military Psychiatry and Neuroscience, Colonel Bliese, Director, and my branch,
the Military Psychiatry Branch. Reflecting on what do we do and whether we aredoing what we should be doing, the point of understanding what the competencies
are is for you to understand. For example, this is what we do and this is what we
do not do. If I know who else is competent in an area in which I am not competent,
then I can share my research findings, and we can estimate the prevalence of aproblem. I can tell you this is the nature of the problem, and you will be the one tocreate an intervention or program to solve it. That way we can actually have theResearch and Military Policy: Thinking Forward — Closing Discussion

flow of information from one competent cell to another competent cell, each withdifferent competencies.
DR. DRETSCH: We are in the business of trying to build resilience for soldiers
as well as family members, knowing that there is a huge link there. We have a master
resiliency training program, and approximately 18,000 soldiers have gone throughit. It is based on a University of Pennsylvania model of positive psychology. There isa great deal of room for improvement. We have performance experts who ork withthe troops to ensure that they are able to try and improve their performance, whether
it is on the marksmanship range, or another operation. It is important to categorize
what this resilience is, whether it is operational, and whether it is offsetting what
happens when soldiers return from deployment.
Again, the outcome measures are extremely important. We are looking at how
to enhance performance, knowing that if you enhance performance, if you increase
job satisfaction, if you help soldiers feel they have reached some level of competence,
this affects the family too. It is bidirectional. What do we do to address issues within
the family so that we can have a bigger impact overall on the force? But it goes inboth directions. What purpose can we serve during down time, when soldiers are
re-deploying, and re-integrating and asking again? There needs to be activities orsome level of interaction in which the war fighter returns and feels like they are stillpart of something other than maintaining some level of readiness and training. All
soldiers, all humans, need some level of arousal, especially when they are younger.
You need to be engaged. You need to be active. When you come back and you
experience the stress of down time and not serving a purpose, and this emptiness,while you are being directed to attend various formations and do online trainings,
etc. That is a stress. How can we address that? It may not be an easy answer or thesolutions may involve a great deal of trial by error.
DR. URSANO: Those were excellent observations, in particular, the importance of defining resilience. If one is going to use that term referring to policy or toresearch, one needs to specify, resilient to what, from what. Resilience is not a newterm in the military, nor is it a new term in science. It has been used in relation tochildren for a long time. It has been used in the area of the military since prisonersof war. For example, how are soldiers resilient to the prisoner of war experience?
Although it is not a new concept or term, it needs to be defined carefully.
DR. COZZA: A couple of thoughts, one related to Dr. MacDermid’s commentson perspective. Gaining a perspective on what the issue is and recognizing how
fluid the experience of military families is, and her metaphors with the open-sided
pipe and the eight-year old child were incredibly helpful. It also made me think
about when we discuss core competencies, and also core issues. How do we define
what the core or the continuous issues are for military families versus what aretransitional or situational issues? We are not always entirely clear about that. When
we are in the midst of the experience, we may assume that certain things are coreand continuous, however this might not be the case. It makes me think of disastermodels of examining populations over time and the particular experiences thatthey have had. Also it speaks to research methodology. There are certain researchmethodologies that would better identify what the core issues are versus more
nimble methodologies that might be required in terms of situational or transitional
issues. One of our core competencies then as researchers needs to be this capacityfor vigilant observation, so that we can determine when there is a shift within the
population. We need to maintain our awareness, and be prepared to understand,117

How do we define
what the core or thecontinuous issues
are for militaryfamilies versus what
are transitional orsituational issues?

118

Sometimes
strengthening
communities isa much more
effective wayof keeping
people resilient
at a number ofdifferent levels.

Military Families in Transition: Stress, Resilience, and Well-being

address, and study the changes that we see. One example I have relates to the shiftof the population over time. Whether we are talking about the VA or the DOD community, what is the experience going to be for military families as we begin to havethe co-existence of combat experienced versus combat-naive populations living inthe same military communities as well as the VA? When combat veterans from thiswar are engaged with Vietnam veterans, there are multiple ways that could go. It
could lead to opportunities for successful mentorship or it could lead to competitive
or conflictual relationships within the population. What mechanisms can we think
about or study or be aware of that could impact or contribute to those outcomesin a more successful way?
DR. URSANO: That is an excellent allusion to the disaster literature. I am
reminded of a study that was done here in DC around the time of the anthrax
attacks. What was looked at was the question of who received vaccinations for
influenza and who did not. They found a substantial generational gap as to who
felt at risk and who did not feel at risk. The way that was resolved with a positive
outcome was to bring the generations together. Older people were much more likely
to get influenza vaccinations than younger people. They created town hall meetings
that brought together the cohorts to exchange information. They could hear fromeach other what the challenges were, and, in fact, there was a positive outcome inthat there were increased rates of influenza vaccinations in the younger generation.
It is important to keep track of our cohorts, how they had different experiences, andhow they can be used as a tool. We have a whole new cohort that we have created.
DR. COOPER: A question I have is how do we define family? I know that has
been a challenge because in some cases the traditional definition of family is notgoing to apply. In the wounded warrior population as well as the generation population, maybe it is parents, maybe it is a sibling, or maybe it is a boyfriend, a girlfriend,or fiancée. In some ways you have to realize that there are certain restrictions due
to family. If you are trying to build resiliency and coping strategies, then we need tolook at casting a wider net for the definition of family.
DR. URSANO: Excellent point. It would be very helpful at the policy level togo after a couple of the low hanging fruits. I could see all kinds of challenges, butthere are some that we could solidify easily, for example, the question of parents or
grandparents of single family members. Are there laws that may assist us to implement those kinds of family definitions more rapidly in the future as we need them?
Maybe such laws already exist, but clearly they are challenged.
DR. ALDWIN: Over the past day and a half I have been struck by how top
down all of this is. We are going to develop programs and deliver them to people to
make them more resilient. But I was very glad to hear, and I really want to reinforce,that sometimes strengthening communities is a much more effective way of keeping
people resilient at a number of different levels. We need to understand that people’s
networks are broader, and remember that there may be social networks within basecommunities, and between base communities and other surrounding communities
that are important resources. Understanding that, for example, an individual’s contributions to communities may be the best way to maintain their own mental health. If
you bring soldiers coming back with down time into community service projects andidentify barriers that the military itself may be making to the enhancement of natural
existing support communities, this might be a different way of looking at things.
DR. URSANO: I am reminded of a brief conversation I had with Paul Bliese justa few moments ago. Maybe one of our questions is not to define what the family

Research and Military Policy: Thinking Forward — Closing Discussion

is but to ask the question what is the soldier’s network that creates impact on theoutcome of interest. That is, first define where we are seeing an impact and thenfigure out how to describe that in a way that would include things like buddies,units, etc. There may also be ways to use research tools to define the impact of family
other than the generational family, and there will be substantial overlap between
the two definitions.
DR. SPOTH: I have three general points pertaining to the Hamel model, about
what might be characterized as strategic multi-level system thinking. In addition, I
would like to make an illustrative point, and a point about standards of evidence.
The first general point goes back to the question about how to spend a dollar. There
have been many references to future scarce resources. In light of many competing
demands in this area, there seems to be a need to be clear about what that means,
especially in light of anticipating future issues to address. Another point is getting
clear about the resources and demands, which relates directly to what Dr. Glauser
was saying about Order 1 issues or priorities. He referenced how difficult that isand, indeed, in this context it seems immensely difficult to be clear about what is
unique to the military and what has to be the highest priority. Second, how do you
operationalize these? The third point is the importance of getting specific about
how you identify core competencies. How do you operationalize something that isa more systems oriented, strategic kind of approach?
That brings me to a more specific point about standards of evidence. There havebeen many hints about how to think about this strategically. This is not black andwhite. It is not either/or. It is not RCT or not RCT. There is a great deal of creative
thinking about research designs and methods. One of the things Tony Biglan, Brian
Flay, and other people have developed is this idea of hierarchical decision-making,which starts with clarifying the question but then addresses how you can maximize
scientific rigor within specific practical constraints. There you get into many kindsof interesting designs, for example, multi-factorial or roll-out designs, that are in
the randomized family. Then you get into many kinds of other qualitative methods
that have a great deal of value, for instance, observational studies. It is a systematic,
higher-archival decision-making process that starts with the question and then carefully considers how you can you maximize rigor within obvious practical constraints,
in way that is specific to the question.
DR. KLEYKAMP: Given the nature of this conference, the focus is on militaryand military-specific core competencies and specific programs, areas, and domainsof expertise. But as a citizen and not just as a member connected to the militaryfamily, I want to go back to James Schmeling’s point of thinking about not building a higher, thicker, more fortified wall between what is military specific and what
is civilian specific, but thinking about moving into the future and bridging thosemilitary-civilian divides.
One thing that is connected to this is the continuing notion and complacency
with the idea that our military families today are breeding the military families oftomorrow. From a citizen perspective, I find that incredibly problematic that we
think about how to treat military families today as a means of recruiting the next
generation. It is something that I find concerning. I understand from a policy andpragmatic perspective the need to divide and conquer, to be nimble and effective.
But there is a much higher-order societal level concern about the tendency to divide
rather than integrate military and civilian communities.
DR. MONAHAN: I am thinking along the same lines. What is resonating for119…one of our questions
is not to define what
the family is but to ask
the question what is
the soldier’s networkthat creates impact
on the outcome ofinterest.

120

The reason we want
to help families intransition to themilitary is that more
supportive families
lead to better soldiers.
That rationale will
not work for soldiersleaving the military,
but their children aregoing to be our next
generation of soldiers.

Military Families in Transition: Stress, Resilience, and Well-being

me is the point that Dr. MacDermid made with respect to eight-year-olds being thesoldiers in the future in 2025. I am thinking about civil society and the issue of athird of children being raised in impoverished households and impoverished neighborhoods. What are we doing about healthcare and mental healthcare for children
today? What are we doing to improve the educational institutions, to incentivize
them to become productive citizens and to engage in military service and so forth?
I am thinking of the obligation that we have to get out of our own silo with respect
to the field of study and think more broadly about the individual who becomes partof an organization, who is part of a family, maybe part of the military, and so forth.
That challenges us a great deal with respect to our civic responsibility.
DR. URSANO: Of course the military in the biggest picture has always been oneof the boot strap operations of our society. It is one of the ways to move up. Thatbecomes an important component to sustain in the future.
DR. ELBOGEN: We have talked about definitions of military families and trying to refine the definitions resilience. One of the things that struck me over the last
2 days is that the transitions into the military and from the military have different
rationales. The reason we want to help families in transition to the military is that
more supportive families lead to better soldiers. That rationale will not work forsoldiers leaving the military, but their children are going to be our next generationof soldiers.
Those contexts need to be considered with respect to all the interventions thatare available. What are the top 5 needs and problems of families transitioning to themilitary? It is going to be different than the top 5 needs and problems of militaryfamilies transitioning away from the military and into civilian life. I did not know
about many of the surveys available. It seems like there might be data pertinent tothese questions. We have listed at least 30 different problems that military families
are having. There are limited resources. I am going to bring up the dollar again. I
would say 50 cents should go to looking at what are the problems associated withthe transition to and from the military. Then you could prioritize 10 cents for eachof the 5 top problems. You can probably gather that information from data acrossall those great data sets.
DR. SPIRO: I am from the evidence, not the policy-based, community. I like todabble in what I think of as facts. Dr. Elbogen just made a great lead into somethingthat has been striking me through much of the discussion over the past day and ahalf, and that is, what is the evidence base for the decisions we are making? Whatis the evidence base for what is a family? What is a transition? What is stress? Twopeople have shown the survey of Army families that is done every five years. Those
data might have been quite worthy at the time that they were collected. But to makedecisions on data that are now three or four or five years old seems rather ineffective.
I want to ask 2 questions. How many soldiers over the past 5 years have decided
to make the military a career? Is there an answer for that? What is the marital rategoing to be of people who are 8 years old now and who will be in the military in
the future? It seems that it is declining among Millennials from some of the things
I am reading. Perhaps the issue of families in the military will be rather different in
20 years than it is now.
Those are rhetorical questions but I want to come back to Dr. MacDermid’scomment about trajectories. How do people get into the military, and what leads
them to come in as a family or to become a family once they are in? How and why

Research and Military Policy: Thinking Forward — Closing Discussion

did they stay? How and why did they transition out? How will these things changeover time? Where can you get the evidence to answer these sorts of questions?
Part of that can come from “big data.” Another way is transferring from thehealth care system a learning healthcare system. Most healthcare systems, most large
businesses, Google, Amazon, etc., are using data in real time to inform them and to
make decisions and predictions. Based on the 3 movies I have watched, Netflix willtell me 10 that I should watch. Now they may be predictions based on past behavior.
They are not going to tell me about the new genre of movies that I have never heard
of. Would it be worth thinking about the military, which has the advantage of being
in many ways a total institution, managing to collect data on real-time basis andusing it to guide, at least in the short term, future actions?
I want to go back to the Hamel model and the core competency idea. There arecertain competencies that the military should retain. Focusing on what, if anything,is different about a military family versus a non-military family can do a great deal
to help us decide whether intervention programs can be simply lifted, transported,
and worked for military families. Alternatively, why are we unique, what is different,and how do we have to adapt these programs and evaluate and modify them on thefly, as we begin to implement them?
DR. URSANO: I would like to capture a few of those important comments: How
many soldiers decide to stay in? Of course that information is known. The marital
rate of eight-year-olds is a little more challenging, but we can speculate and it is agreat question as to how that will go forward.
The broader issue of trajectory, a term that I actually thought would come up
much more often in this conference than it has, is clearly a powerful and important
issue. I remember discussions in 2001 or 2002, when Dr. Chu was the Deputy
Secretary of Defense. At that point he had great interest in, and a major initiativearound, identifying trajectories of careers into and out of the service. This remains
an important issue as a target to help understand families as well as soldiers.
Last, the comment about Google, Facebook, Twitter, which are certainly important data sources that influence our folks as well as everyone else. You may recall
an article in Science this past year, which showed that the influences of one’s friends
are substantially greater than other influences on Facebook. How that influencesfamily and how we can better use those are important questions.
DR. PARIS: I am reacting today to things that were said yesterday and today,from my position as researcher and clinician, having worked with families for 30
plus years in many different venues. I support the idea of core competencies andsynthesizing basic ideas to inform the ways we move forward. Part of the reason I
support that is because the more things change, the more they stay the same. That is,
we have some core ideas and people are struggling to define family. The definition offamily has changed over the last 50 years and it will change over the next 50 years.
But the function that families serve and who is in those families, what is important
about relationships, what human beings need to grow and live out their life cycle—I
am not going to say throughout history but let us say the last 100 years—has stayed
relatively the same, although the formations have looked different.
If we have some common understanding that we can agree on, the way it actually looks is going to change. Some of that we may be able to predict and probably
much of it we are not going to be able to predict. To go with Dr. MacDermid’s ideas
about the 8 year-old, it is important to look and see how he or she is growing and

121

Focusing on what, if
anything, is different
about a militaryfamily versus a nonmilitary family can doa great deal to help
us decide whether
intervention programs
can be simply lifted,
transported, andworked for militaryfamilies.

122

We want to introduce
the idea of militaryculture diversity, that
not every installation
nor branch nor
sub-groups withinbranches at the
military are the same.
In fact, they are quite
diverse.

Military Families in Transition: Stress, Resilience, and Well-beingchanging. I look at my 23 year-old students and the way I am trying to teach themis different than I taught 10 years ago or 10 years before that.
But I do not think we can throw out all we know about families, human relationships, core ideas about growth development, and the biopsychosocial model. If you
have some basic tenets that you can hold onto, it allows for a great deal of flexibility
in how people and things and needs are going to change. That may be kind of simple
but I do think it is true based on my observations over 30 years.
DR. WADSWORTH: Thank you, Dr. Paris, for mentioning that because I realize
I was not as clear as I should have been. I should have said that family structures arealways evolving. But I completely agree with you that family functions really havebeen remarkably consistent across cultures and throughout history. In this society
we do tend to spend far more time worrying about structures than we do aboutworrying about functions. We assume that one is a function of the other—that if you
ensure a particular structure then function will surely follow. Yet we have so many
examples that show that that is not true. Certainly the very creative solutions thatmany step and blended families come up with to deal with completely unprecedented
complexities in family structure are a very good lesson about that.
DR. LESTER: I wanted to respond to the comment that these all seem top-down.
I appreciated the community partner research efforts that were presented yesterday
and know that there is a great deal in the civilian literature about working closelywith communities.
We want to introduce the idea of military culture diversity, that not every
installation nor branch nor sub-groups within branches at the military are thesame. In fact, they are quite diverse. Any implementation like yours, where the sites
just ignored the intervention, required this kind of community partnering at the
ground level. Even though there may be the advantage of some systemic, top-downorganizational decision, change is not going to occur unless that kind of partnering
happens on the ground.
I also wanted to advocate again for the use of some of the real-time data collection processes that could help us guide intervention delivery, not only at the familylevel but to make those kinds of real-time modifications around specific installation
culture and also follow a dynamic trajectory. If we could enlist the assistance of thebusiness world and the computer engineers who can help us do that kind of thinking,it would be easier to think about the delivery of core competencies, whether thoseare in the research or intervention realm or even in the implementation realm. We
have not talked much about training. That is such a critical component of integrating
any of these into the system.
DR. URSANO: Excellent comment and I am reminded I want to ask Ms. Davisand Mr. Stamilio whether we have a cell at the Command and General Staff College
and at the War College that is directed towards teaching about family structure andfamily support. It is support for the longitudinal picture of how we integrate that
into the thinking going forward?
DR. ZATZICK: It is important to have an on-the-ground sense of what is goingon. I cannot tell you how much we have learned with Steve Cozza at the head, andwith the UCLA focus team, just hearing a series of cases. From an engineering perspective, if I understand, as in hydraulics, you are going to create a model and you
are going to break it down. You take your hammer and throw it against the damn
and it breaks. There are points—inflection points—at which you cannot optimize
everything.

Research and Military Policy: Thinking Forward — Closing Discussion

That is really what we are seeing in these incredibly complex military systems,case by case. FOCUS depends on two parents communicating. Dad comes in with
TBI and PTSD, and he cannot communicate. We go back to the medication clinic.
The TBI clinic is giving 3 meds. The psychiatry clinic is giving another 3 meds. We
need to build an organizational intervention to get the dad on the right medication
regime so that we can go back and do FOCUS.
I am going to suggest something that does not cost Mr. Stamilio any money—
basically, you want to redesign jobs. You want Dr. Ursano to have a clinic or maybe
a little more feasibly, you want Dr. Cozza or Dr. Bliese to have a team early on in thenext conflict that is fielded, an expert team that is saturating on cases. Even before
you have a research network and data coming in, you want to taste the diversity of
the cases. That way, the engineers can pick up on this and these kind of higher-levelengineering models can come through, which would not be feasible if you do nothave the team on the ground. Dr. Glauser was just saying that the engineering models
rely on good field information.
DR. URSANO: One piece of that would be the importance of ecologicalobservation early on and having teams that can carry those out so that one has asensor that one has ready to work and can deploy with the core skills of accurate
observation.
DR. GEWIRTZ: One point I would like to make is just a reminder that close tohalf of our forces are civilian soldiers. I have heard a great deal of discussion about
installations and culture and separation from the service. But the family dilemmasof the civilian soldiers and the resources that are available to them within the military structures are vastly different and much harder to access. They are much lesscentralized. They are often highly isolated and some of the data on the vulnerability
for PTSD and other disorders shows that is a risk factor for those disorders. Let us
not forget those military personnel.
A second point is about methodologies and real-time methodologies. These
exist and are being tested now in highly innovative ways of capturing just-in-time
data. DCoE’s National Center for Telehealth Technology (T2) provides an excellent
example of that. But also, civilian researchers around the country are experimenting
with smart phones and respondent report or observational data that are gathered
immediately, wherever participants are. This can really inform this kind of work.
DR. SALTZMAN: One of the themes that also emerges is the difficulty withengaging families to participate in programs. For many projects I am working on,
it is hard to get the families in, and then difficult to go where they are, in terms ofdealing with some of their immediate needs so that they feel they want to participate
in the program.
One of the things we are doing in Dr. Cozza’s program, and with Dr. Zatzick
as well, is designing the program so that it is nimble up front. We adjust what weneed to do so that families see an early win and get pulled into the program. We do
not just follow a manualized approach in which we have our checklist and we aregoing to do these things no matter what. This goes to the design of programs or
the modular agile approach we are talking about, and also speaks to the process ofdeveloping the programs.
We are talking about an iterative approach that feeds into the ecological fit thatyou mentioned. This approach has points along the way so that we can re-evaluate.
We build in degrees of freedom so that the programs can be adjusted in ways thatare faithful to the original, core components of the program. We plan up front that123

But the family
dilemmas of thecivilian soldiersand the resourcesthat are available
to them within the
military structuresare vastly different
and much harderto access.

124

Our military changes
constantly becauseof the people thatcome into themilitary. Therefore,
it is constantly being
represented by a newcohort of people thatbring with them theirown sets of ideas andways of doing things.

Military Families in Transition: Stress, Resilience, and Well-being

we need to adapt the program, and we have dimensions for adaptation built into
the program so that we can hold on to those core components going forward.
MS. BARRON: As a military family member whom you might study, I have acouple of comments. I like what Dr. MacDermid said about adaptive human systems.
Our military changes constantly because of the people that come into the military.
They are young, and they do not stay in very long or if they do, a long time is only
20 years. I would venture that some of you have been in your career for a much
longer time than just 20 years. Therefore, it is constantly being represented by a newcohort of people that bring with them their own sets of ideas and ways of doing
things. What I like about what Dr. MacDermid said is that if we could just look atwhat is working and continue to look at that because it is going to change. Whatworks will change all the time. Then we can inform those programs that we havein place, programs that I hope will not go away because of the basics of financial
stability and behavioral health, etc. But we can make those programs even stronger
by informing what is working for that particular group of people.
I mentioned that the young lieutenants and captains today are going to be yourbattalion and brigade commanders in 2025. When I ask my daughter who is an
Army captain, what she wanted me to tell the group, she said tell them that young
leaders, both NCO and officer, do not trust their leadership. Right now there isvery little trust in leadership for many different reasons. Families carry with theman enormous amount of anger. And that is the cohort that, in 2025, is going to beleading those eight-year-olds that Dr. MacDermid talked about earlier. Again, I
am one of those family members whose daughter decided to follow in her father’sfootsteps for many different reasons.
DR. COX: I really hear what Ms. Barron says about the trust in leadership. The
thing we need to understand—there was an article written in the mid-1960s called,“The Art of Muddling Through.” Some of you may remember it. It is an old policy
article we had to read eons ago. The bottom line is, for example, who would haveguessed that December, January, and February, Mr. Stamilio would have spent his
lifetime looking at childcare checks, out of the blue.
As policy people, we like to think, and I am talking strategic now. I am nottalking about which studies do we do and how do we do them. But at the strategiclevel, we have this issue that we really do live on a day-to-day edge of what did theCongress say yesterday or what does the President want to do tomorrow. Thereis a constant going on that is interplayed between congressional interest and thepress. What is the hot topic in the news? We are in reaction mode way too often
unfortunately.
Then there is this other effect. A few years ago, we celebrated the 60th anniversary of our being in the war in Korea. Of course we have had garrisons there for avery long time. I like the expression, “Korea: 60 years, one year at a time.” The idea
being that nothing really ever gets better in Korea because by the time you get there,
you spend 3 months figuring things out. You have 3 months of actively working on
things. Then you have the rest of the time packing to come home. This has gone on
for 60 years. Nothing ever really gets better because I, personally, am going to behere only for a year.
The same is true with the command levels. Most commanders are in place for18 months to 2 years. They cannot wait for a command. They cannot wait 6 years
for an outcome study to show how great it is that they have made a splash on theorganization. They need something to go on their Officer Evaluation Report thisResearch and Military Policy: Thinking Forward — Closing Discussion

year, about how well things are going. We get this effect of immediate kinds of issues
that at the strategic level end up influencing how we do long-term studies, if there
is money to do these studies.
For example, about 30 minutes ago I got an e-mail from DOD that says, “Whatwould happen if we cut your budget by 13.7%?” What bothers me about that is, if
you had asked me how much would I take at a 10% or a 15% cut, I would not be
nervous. But when you say 13.7%, I wonder whether this a done deal? Do I have areal say in this? What is going to happen? These are the realities. Most likely, I justlost millions of dollars in the last 30 minutes.
We live on-the-edge, wondering what is going to happen next. Mr. Stamilio, theseguys are living it every day up in the Pentagon, trying to defend our basic resources.
Having lived through the 1990s, the young kids have problems with the leadershipnow, however, wait until the Army starts discharging them in large numbers.
To give you an example, I was a young social worker at Fort Sill. I was an artillery officer. Luckily, I was in the very top of my advanced course in artillery. The 3
top guys—I was number 2 in my advanced course—were given an option to do any
job in the military they wanted. I went to the general, and said, “Sir I want to be asocial work officer. I have my master’s degree in social work.” He was not happy,
but he granted my wish and I remained at Fort Sill. Over the next 3 of the 4 years,
43% of my class was eliminated. The Gulf War seemed like nothing compared tothe stress and trauma that was put on those families when they got out.
We are facing that again. This is the short term. It is not going to last forever. We
are going to get through this, and life is going to go on. But the next two to three orfour years is going to be pretty traumatic on the Army. In ways, it will be more traumatic than the war has been. For families it is going to be more traumatic, because
it is one thing to have your soldier deployed back and forth. It is another thing not
to have a job, not have a career. It is outstanding that you were a gunner during thewar, however, when you get out that will, maybe, get you a job at Walmart.
This is going to be very traumatic for families. We are going to have to workthrough this. I do not know what that means for long-term programs but in the
short term, this is going to be a traumatic and devastating kind of experience. That
is what we are up against.
DR. URSANO: Excellent comments. They keep us current about what is anticipated, and the 13.7% budget cut rule applies. It means that someone has actually
thought about it. Someone has at least taken the average of several numbers to comeup with a percent of the budget to cut. It makes it more real.
MS. LEWIS: That brings us back to transitions. We know that this cycle repeats
itself. Our job near-term is dealing with these guys. They are going to be going out
and not necessarily willingly leaving a career they were planning on being in for 20
years, and it has only been 5 or 7 or worse. But how do we also then take care ofthem through this transition, so that when we need them again—and we will needthem again—they will be ready to step up and volunteer?
DR. URSANO: Excellent point. No one has mentioned much about the Reserve
and Guard as one of the opportunities. It seems appropriate to talk about this issueof opportunities as a part of the planning, and to ask how those opportunities affectthe people that are in service, as well as the people getting out.
MR. SCHMELING: I would like to comment on 2 issues that occurred to me.
The first is the comment that was made earlier about how we are, as a society, putting the burden on military families to produce that next generation of soldiers. The

125

For families it is going
to be more traumatic,
because it is one thing
to have your soldier
deployed back andforth. It is anotherthing not to have ajob, not have a career.

126

For the Guard andReserve members,that is also thechallenge. They
do not know how
long they are going
to be back in theircommunities.

Military Families in Transition: Stress, Resilience, and Well-being

reality is that the percentage of people who are serving is declining. We have justless than 1% of the population serving on active duty at the moment, and overall
about 9% of our population has served in the military. Those percentages weresignificantly higher in World War II. Thus, we are drawing from an ever-smaller
pool for a variety of reasons, and that contributes to the military-civilian divide andlack of understanding.
This is amplified in the Guard and Reserve components in that they are backin their communities. They were deployed and now they are back home. They aredemobilized very quickly. They are reintegrated into their communities in manycases. Some of the challenges that we have are with business and industry and community leaders, and their reluctance to hire and rely on these folks because they do
not trust that their workforce will be there. They do not know whether or not they
can reintegrate into their lives.
For the Guard and Reserve members, that is also the challenge. They do notknow how long they are going to be back in their communities. They do not feelthat they can put down permanent roots, and that is a stressor and a transition issue.
Further, the family members who are not going to deploy have to deal with theirlife as it changes, when people move in and out, when their employment situation
changes. They are employed and unemployed. When they are receiving pay, there aredifferences in their pay when they are activated versus when they are not activated,
and that has implications for their life cycle and their transition.
This relates to the leadership issue that we just talked about. While I understandthe comment about trust in senior leadership, it goes back to our military-civilian
divide. Fundamentally, our elected leaders, perhaps, may not fully understand theramifications of the decisions that they are making, or the changes in decisions thatthey are making, and the ebb and flow of money and politics and how that impacts
our soldiers and decreases the predictability of their lives.
DR. URSANO: There is also the impact of reductions in Guard and Reserve
where people may have expected a particular retirement plan up ahead or a supplement to their income that may not be present as well.
DR. KLEYKAMP: I have a factual question as we are talking about this notionof downsizing as the context in which many of these transitions—family transitions,strategic tactical transitions—may be taking place. In the 1990s when we drew
down, I understood best from the research that that actually took place, it was lessby pushing people out who had been in, and more by closing the front door a bit
more tightly and not letting as many people join up. Are we changing how we aredownsizing versus an earlier time? If so, that would change the nature of the trust
between your junior members and your leadership. If it is that you are tightening
standards and not letting people in, that changes people’s sense of connection to
the institution versus if it seems to be systematic that you are pushing people out.
DR. URSANO: Before I invite Mr. Stamilio to share a couple of last comments,
I want to thank you all for being here and remind you of the marvelous road that
we have traveled together. We began with a picture of what is the Army. We thenaddressed some of the stressors and challenges of the Army. We then discussed
some of the programs and approaches that the Army has had for dealing with thesestressors and challenges. Next, we addressed the questions of how to build and foster
resilience. Finally, we had an outstanding panel to address what we had forgotten,
what we did not think of, and to examine the systems issue.
The group has been marvelous moving across levels, from the individual to theResearch and Military Policy: Thinking Forward — Closing Discussion

family to the larger system in which things have been embedded. It has been a very
successful conference, and I thank all of you for your participation.
MR. STAMILIO: Allow me to give you a couple of reflections before I give you
my truly heartfelt thanks. First, I had to go back to the Pentagon yesterday. I met
with a sector of the Army. I said, “Boss, would you loan me a dollar?” He said, “Stamilio, what is it you want to use it for?” I said I am looking to make an investment
at family programs, working on resilience and the family. He asked, How would
you define resilience?” I said that the conference has not decided that yet. He thenasked, “How would you define family?” I said the conference has not decided that
yet, either. He put the dollar back in his pocket.
As I reviewed about 15 pages of notes from this forum, I have been struck by
a couple of things. One of these is that we are looking at a systems engineering
approach as one possible way to look at this. It is incredibly insightful. I was struck
by a couple of other things, including the notion of core competencies. Sitting in the
middle of my desk is that Army Science Board briefing. It is there because the otherside of my portfolio is to manage the civilian human resources for the Army, and I
am working with the science and technology community on these core competencies.
In the matter of one short presentation by Dr. Glauser, I have reduced my problem
set from two to one. All I have to do is figure out how to make these trees grow that
represent core competencies, and I will be in great shape.
My granddaughter is 8 years old. She has not joined the Army yet, but she is on
the delayed entry program. Dr. Kleykamp, I would like to make one very serious
comment, which gets exactly to the point you mentioned: if we are only breeding
the next generation of soldiers by way of taking care of families, then we have asignificant societal problem. I could not agree more, and I can tell you that is not
the intention of the United States Army. That is really not what we are trying to do.
The facts are, though, that the sons and daughters of our soldiers become soldiers,
and we like to think it is because of the way that we take care of families.
To the point that many of you have made, communities are absolutely vital anda fact that needs to be addressed is that we now have approximately 70% of ourmilitary families that do not live on military bases. They live in communities, and so
the Army has a charge—to reach out to our communities more effectively.
One of the last comments was about using facts. If you are familiar with how
things work around the Potomac River, the facts are just the color commentaryaround which positions are built. They are marginally relevant. We do dabble in facts
from time to time, but only when it comes to our advantage. Colonel Cox mentioned
the art of muddling through. I have been muddling through on this, working withthis institution for nearly 40 years now, and it is a day at a time, a year at a time.
What this body has taught me and reinforced for me is that we owe much more to
the institution and to the nation than merely to muddle through. The charge that
I have taken away is, given all of the ideas that have been presented and all of thechallenging questions and all of the notions that are not fleshed out yet, the charge
is to do something more than just muddle through. The charge is to figure out some
way to make a strategic difference.
Such strategic differences happen over a long period of time, but they have tohappen. They happen because people like you keep poking and prodding and asking
hard questions of people like me, to force us to do something strategic to fix what isgoing on. Not that we are broken, but we are challenged, and we face ever-increasing
challenges. It is not a matter of throwing up your hands. It is a matter of taking the127

If you are familiar
with how things
work around the
Potomac River, thefacts are just thecolor commentaryaround which
positions are built.
They are marginally
relevant.

128…we are looking
at a systems
engineering
approach as one
possible way tolook at this. It is
incredibly insightful.

Military Families in Transition: Stress, Resilience, and Well-being

great work that you all are doing and trying to make some sense out of it, trying
to move the organization forward in a very meaningful way. You have given me, anonpaying customer, a great deal to think about and a great deal to work with. I
cannot thank you enough for your investment of your time here.