**Transcript of Cyberseminar**

**Spotlight on Women’s Health**

**FOCUS Family Resilience Training**

**Presenter: Dr. Patrick Link**

**September 17, 2012**

**FOCUS Family Resilience Training**

**September 17, 2012**

Moderator:And as we are just about at the top of the hour I now would like to introduce our speaker for today. We are lucky enough to have Doctor Patrick Link presenting for us. He is a clinical instructor at UCLA’s Semel Institute for Neuroscience and Human Behavior. And we would like to thank him for taking the time to present to our VA audience. So at this time I would like to turn it over to you. Are you ready to show your screen Dr. Link?

Patrick Link:I am. 

Moderator:Great. You should see a pop-up now. Go ahead and accept. Great, thanks. 

Patrick Link:All right. Thank you for having me today. It is really an honor to speak to this group. It is good to be back with a VA group. I did a research fellowship at the VA and it is a nice home to be back in. Today I am going to present on FOCUS family resilience training. And if you can not hear me or if there are problems with audio please let Molly know. As she said my name is Patrick Link. I work at the UCLA Semel Institute with the Nathanson Family Resilience Center. And unfortunately my slides are not advancing. 

Moderator:Patrick, go ahead and click on the slide and then you can press – there you go. 

Patrick Link:All right. So no disclosures, I do not have any financial interest in the material being presented today. And some acknowledgements, a lot of our work has been funded by the US Navy Bureau of Medicine and Surgery or BUMED. And we have also done a lot of our work in coordination with the US Marine Corps Combat Operational Stress Control Program, or COST. And we have also been supported by the – Office of the Secretary of Defense, Office of Military Community and Family Policy. This is the UCLA FOCUS leadership team. Dr. Lester is our leader. Lee Klosinski is the associate director and this is the rest of our staff here. 

To start off with, the impact of military family stressors, particularly parental deployment on military children is a national public health concern. I think we would all agree with that. In the active component, about 39 percent are married with children and about 5.4 percent are single parents. And in the National Guard and Reserves component of the military, 34 percent are married with children and 9.3 percent are single parents. And these families face a lot of life challenges: frequent family relocations, the deployment of a family member to a combat theater, and fears that this family member will be injured or killed. Military children move on average six to nine times during their school career. So this has a big impact on these kids. And the wars in Afghanistan and Iraq have significantly impacted these families. Outside of their usual military stressors they have had to deal with these combat deployments. 

Over 2.1 million troops have been deployed to OEF, OIF, or OND and roughly 44 percent of these folks who have deployed have been parents. It shows you that the folks who deploy are more likely to be parents than the folks who do not deploy. Roughly two million children have been impacted by a parent going to OEF, OIF, and OND. If you look at the children who have been in the military of the last – or have been affected by a parent in the military over the last ten years or so it is about four million. But at least two million of these have been affected by deployments to OEF, OIF, or OND. These conflicts have had unique features: multiple prolonged deployments an all volunteer military, heavy reliance on Guard and Reserves, a higher proportion of female troops, a higher survival rate among injured troops, and then continuous family communication during deployment. This is not news to any of you. 

We know that deployment to OEF, OIF, and OND is associated with elevated rates of behavioral problems and emotional distress among the service members, the non-deployed spouses, and their children. So everyone in the family is affected by deployment. Parental deployment has been associated in research studies with increased rates of mental health visits or among military children an increased number of mental health diagnoses among military children. A dose-response relationship between the length of parent deployment and mental health diagnoses among children and elevated child depression and externalizing behaviors. So we have really been able to demonstrate that parent deployment really dose affect these kids and affects their mental health in a demonstrable quantifiable way. 

We believe at our center that families really must be involved in any effort to significantly ameliorate these adverse effects of military associated stressors on children. Of course that is a challenge for the VA because only recently have families really been incorporated into the care of veterans and it has really been a step by step process. During deployment social, academic, and emotional outcomes in military children are significantly impacted by the emotional and behavioral health of the non-deployed parent. So if you can help the non-deployed parent the kids do a whole lot better. Non-deployed caregiver status, his or her psychological distress is associated with child internalizing and externalizing symptoms. Internalizing symptoms would be things like stomach aches, anxiety. Externalizing symptoms things like acting out, behavioral problems. And the non-deployed caregiver’s depression has been associated with child depression symptoms. So you can really see that mental health problems reverberate across the family. 

And the active duty parent status has been shown in studies; their post traumatic stress symptoms are associated with child depression and internalizing/externalizing behaviors. And the active duty parent’s depression and anxiety symptoms are associated with child internalizing behaviors. So again you see the reverberation of stress across the family. So FOCUS was brought in to deal with exactly this problem. It was a rapid response to a public health crisis. In 2004 UCLA partnered with the US Marine Corps, the Naval Medical Center, and the Madigan Army Medical Center to develop FOCUS. And FOCUS was developed from some foundational interventions that had been developed at UCLA and at Harvard and some other locations and it was adapted to Marine Corps families at Camp Pendleton. And in 2007 when Congress really got wind of just how much our military families were struggling through the Walter Reed problems and through some difficulties that were filtering up through the ranks for military families and also military schools, Congress provided a lot of money to BUMED and to other folks to improve the psychological health of our military families. And project FOCUS was created through this funding stream. It was initially intended for naval special warfare and Marine Corps bases but it has been able to expand beyond that initial start. 

In 2008 also the National Military Family Association and UCLA partnered to develop the FOCUS curriculum, make it manualized, make it structured and rigorous. In 09 the Department of Defense Office of Military Community and Family Policy provided funds to expand it to Army and Air Force installations so moved beyond Navy and Marine Corps. And in 2009 we partnered with the Military Family Research Institute of Purdue University to create the FOCUS couples adaptation. Previously it had been just for families but we realized a lot of these couples were struggling also. So we manualized a couples version of this. 

Here is all that went into creating FOCUS: so there was traumatic stress research that brought it – it was brought to bear, family resilience models, some foundational evidence based preventive interventions that I mentioned before. We implemented FOCUS across the prevention continuum and it was a rapid implementation of scale up. So it was a pretty big effort. I will go through these one by one. So traumatic stress research. So again some things that are familiar to this audience: the sequelae of trauma includes reexperiencing, avoidance, hyperarousal, inaccurate assimilation, inaccurate over-accommodation, so assimilation over-accommodation are the problem of how do you make sense of a trauma? Do you incorporate the trauma into your previous worldview and thereby distort its meaning? Or do you suddenly see the world only through the eyes of the trauma? So for example if someone has been carjacked for example, then if they assimilate that into their previous worldview that only people who do foolish things get carjacked then they just start blaming themselves and say well, I must have been foolish because only foolish people get carjacked. 

Or if they over-accommodate they will say well, now I can not drive anywhere because anywhere I drive I could get carjacked. So the goal of course is to make sure the person is able to incorporate the trauma into their worldview and alter it enough to still be functional but just see things realistically. In trauma informed interventions they provide education about the effects of trauma, they manage trauma reminders, discourage avoidance, they provide help with management of anxiety, and they address these cognitive distortions. So we incorporated some of these things into FOCUS. 

Family resilience models. So what is family resilience? In our view it is coping with and overcoming adversity through open and effective communication, collaboration and problem solving, the development of a shared sense of meaning, and this is really critical for families because a lot of folks will go through the same experience like a family deployment and give a very different meaning for each person. If you can not develop a common family sense of meaning then it threatens to tear the family apart. And also effective mobilization of support. We also believe the family resilience model should be strengths based and family centered. Strength based meaning focus on what the family does well and encourage them to strengthen those things, to rely on those things, and not to take a deficits based approach which can be stigmatizing. And particularly for the military we have found that if we took a deficits based approach then it really turned them off. These are folks who are trained to be superior and to excel. And if you come at them with a model that says we are going to add to your toolkit, we are going to improve what you can do and help your family be stronger than it already is then it is much more easily received. 

The other thing about it being family centered is that a lot of these folks will come for their kids but they will not come for themselves. So making it a family centered model really helps decrease stigma and improve access. All right. Foundational evidence based preventive interventions. So FOCUS is based on three different interventions. Models of how to help a family be resilient in the face of a depressed parent, a medically ill parent, and children affected by war. The children affected by war was some work we did in Bosnia, not me personally, but our group did in Bosnia with children who had been affected by that conflict. And how do we help them become more resilient and deal with that conflict? All right, FOCUS core components. So these are the core components that we took from those evidence based interventions. We do a family real time checkup. So the first thing that we do with the family is we do a series of standardized assessments to get a sense of where are they at. And we flag areas that they might need help with their resilience. 

We feed that back to our resiliency trainers so it is a real time process where the trainers see where the family is struggling and they can target it with particular interventions. Next we provide the family with education: the effects of trauma on a family and on child development. And this is really where I think that a lot of these families lack knowledge. They are aware of trauma. They are aware of stress. But they never have been taught about how this can affect their kids, how it affects child development, how to put it in the proper context of the child’s development at that particular age for that particular child. So it is a big help. We do a family deployment timeline and this is where we have the family develop its shared meaning. Every member of the family does a timeline and then they come together to create a joint family timeline. It helps them deal with inaccuracies and how each other sees what the other person has been through. And then we focus on some family level resiliency skills. So we teach the family some skills that we believe will help them function at a maximal level in the face of stress. 

The real time checkup, as I said, it customizes a service to the family’s needs and that has been very helpful. The family level education focuses on the Marine Corps Combat Operational Stress Continuum which I will show you in a minute and we provide developmental guidance. Here are the resiliency skills so emotional regulation, how to recognize feeling states, how to them verbally, how to understand their body manifestations. And this can be really helpful for kids. If you have ever seen those things that everyone always has stuck on a file cabinet with all the faces of angry, sad, emotional, happy, shy, that is pretty much what we do. Problem solving: this is family level problem solving. So what are our family’s problems and how can we come together to solve them. Communication skills, establishing readiness, and goal setting. Establishing readiness is the idea of are you ready for deployment, can you face this coming, and what are your family goals. And then also managing deployment trauma and loss reminders. 

In the timeline as I mentioned, it links these skills to the family and the child experience so they develop a shared family meaning, they bridge estrangements, it encourages co-parenting. And this has been a really – a big benefit of the program for a lot of these parents. They go back and forth where when a service member is not deployed there is often some co-parenting that takes place. Then the service member deploys and you rely on the stay at home caregiver to do all the parenting. But during the reintegration process we have to reestablish co-parenting. And if you do not do that then you do not really have a great sense of family leadership. So co-parenting really, we believe, is the foundation for family leadership. We encourage an appreciation of the child’s experience. A lot of times these kids are not heard. They understand that their role is to not cause trouble while their parent is deployed and unfortunately that causes them to internalize a lot of their experience. So we encourage them to open up and we encourage the family to appreciate what that child has been through. We clarify confusion and misunderstanding. And we try to maintain the parent/child relationship. 

All righ,t so implementation across the prevention continuum. So many of you are familiar with the universal, selective, and indicated continuum that the IOM came out with in 1994 for mental health prevention. We wanted to not just bring the resiliency skills and the family narrative and the education to individual families. We wanted to have many different delivery systems to get these principles into a military installation. And I will show you that in a minute. And we also focused on the Marine Corps cost model which is a preventive public health orientation to combat stress. So here is the IOM prevention continuum. Universal intervention should be available for everyone in a population. Selective interventions are for subgroups at risk and then indicated interventions are for folks suffering subclinical distress or impairment. So we designed interventions within the FOCUS model to address each of these levels. Those same principles, it is the same resilience skills but delivered to different audiences. 

This is the cost model. So on the left side when it is green the Marine is ready. In the yellow reacting, in the orange injured and on the right side it is ill. And it really helps frontline folks meaning non-clinical folks assess how someone in their Marine Corps unit is doing. Do they need clinical help or will they respond to self-help or to educational or preventive interventions like FOCUS? Or do they need professional help? So we wanted to make sure that FOCUS fit into a Marine Corps installation or frankly any military installation. On the left side of the continuum but then we had referral pathways to the right side of the continuum to clinical services. And here is our suite of services. So at the core is our individual family resiliency training. This is an eight session model. This is really our most evidence based version of FOCUS. It is eight sessions and it does the whole kit and caboodle. It does the family narrative. It does the education. It does the family check-in with the standardized assessment. And we do a lot of skills work. But a lot of families are not going to come for eight sessions and a lot of families are not going to need eight sessions. So we do skill building groups and this can be groups of individuals or groups of families. We have done groups in schools, deployment clubs. We have done family groups where you get three or four families in a group. We have done parenting groups. So pretty much any group of folks that want to come together and learn these resiliency skills, that is what we will do. And this has also been highly manualized and structured. 

Consultations are one time interventions with either service providers or with families to discuss their particular situation, speak about some of the ways that we think they could help that situation, and often that is all that is required. Although sometimes we do funnel folks in those consultations either into clinical services or into family resiliency training or the skill building groups. We also have educational workshops. This is where we train other staff like with fleet and family services or Marine Corps family services in resiliency principles. That has been really well received. It has been a great way for us to develop partnerships with other organizations. And we also do community and leadership briefs. And this has been very important on installations: making sure that the leadership is informed about what we are doing, and also helping the community understand why we are there and what we are up to. So you can see that we try to span the entire IOM prevention continuum with different levels of interventions to try to have a maximal impact in an installation. 

This is the individual family resilience training, again, our core most intensive intervention. The first two sessions are with parents only and this is to get their timelines, to do a lot of education, and frankly to prepare them for what is coming. We do two sessions with the kids. Again, for them to do their timelines and to talk about some of these skills. We bring the parents back for one more session to tell them what some of the things are that the kids brought up, prepare them to hear what the kids are going to say, and really to make sure that the parents are ready to establish themselves as the co-parenting leaders of the family. And in the last sessions, six through eight, are where we bring the narratives together, create a common family narrative, and work on our skills. This is an example of a parent timeline. So you can see our feelings thermometer on the left. And this is – if you have ever done any PTSD work it is basically a subscale. And you have the family rate, zero to a hundred how distressed they are at different time points. 

So you can see here that both had a high stress level during the painful good-bye. And during deployment they really stayed in the red and orange level. With delayed homecoming the burgundy or the purple, whatever color that is on your screen, that is the stay at home spouse. They had a much harder time with the delayed homecoming than the service member did. And then the service member comes home. You have some wildfires at home that create a little spike in stress but in general things are going well. And there was a departure delay and you can see that the service member really had a much higher stress level waiting on deployment to start than the stay at home spouse did. So you can see this is how it plays out. You really help people understand that they did have different experiences at different time points. And that they do not have to take it personally but they can communicate together and create shared meaning. 

This is an example of a kid’s timeline. So with our younger kids, they really can not – they are not able to do these kinds of more abstract charting. This is really more for our middle school aged kids and up. So our younger kids we make it look like Candyland. We have little timelines on the Candyland board: deployment, wildfires and what not. And then we have the kids do drawings and it helps them communicate what they are going through at different time points. And we do have the feeling thermometer which they know how to use. So here on the left, this girl did drawings of the wildfire and worrying about her home burning down. You have a picture of her surfing with her dad. That is a high point for her. Mood, you see her feelings thermometer on the right and it says what should she do when she gets a five out of ten. So it helps the kids really communicate their experience. 

All right. So rapid implementation and scale up. So FOCUS is pretty centrally controlled by UCLA in partnership with our military partners. It was centrally implemented from UCLA in partnership with the military branches. We did have defined implementation stages and that allowed us to rapidly scale up and to track our implementation. We broke it into discrete step by step phases of implementation. We placed a local team on each installation. And having an on installation team was really, really critical. A lot of organizations that try to come into the military community and provide high quality services struggle because they are not located on the installation. So having this sponsored directly by the military was really helpful to us. We identified a FOCUS point of contact on each installation. And this person really helped problem solve and helped our local team navigate the bureaucracy of the Department of Defense. It was an outcomes based management system. We did focus on process but we really had set goals. I mean, our local teams knew that they had to see a certain number of families, do a certain number of outreach programs, do a certain number of workshops, and that there were expectations. And that was partially because we were contracting with the military. So the military expected us to carry out a certain level of service for that contract. 

And we also used a cloud computing system that our technology folks developed themselves. We modified the sales force system, if you are familiar with that, and the cloud computing system allows our local teams to input clinical data and tracking data into the system and it is immediately available to our headquarters team. We grew from eight initial sites in 2008 to over 20 installations by 2011 using this system. These are our current sites. So we are concentrated in California, Hawaii, Okinawa, Mississippi, North Carolina, Virginia, and Washington. Some of this is the history of our preliminary partnerships or excuse me; our primary partnerships have been with Marine Corps and Navy. 

All right FOCUS evaluation. First of all take some time; I just appreciate how cute this little boy is. I love this picture. So FOCUS evaluation, we do pre and post evaluations from project FOCUS. The take-home from that very brief phrase is that this is not a randomized controlled trial. It was a service intervention. So the best we could do in terms of evaluation of our primary outcomes was more pre and post assessments that we would evaluate the family up front. We would do the intervention then we do a post test and that really gives us how we think the family changed over time. Now there is no comparison group so it is not controlled data but because some of the impacts were pretty large we felt like that we could show the focus was affected. We do have an ongoing RCT currently with veterans and National Guard and Reserves in the Los Angeles area. So we are trying to get you might say more rigorous data and quantify, I should say, the impact of FOCUS. And we also did implementation evaluations. 

This is our project FOCUS evaluation plan. We did a program evaluation with a real time family assessment. So we do entry, we do exit, and we do follow up. We also assess family member satisfaction and we get a perception of change. And these were scales we invented ourselves. How satisfied are you with the FOCUS service? How do you think it changed your family’s ability to do this or that? But we also did use standardized assessments: the strength and difficulties questionnaire which gets a sense of how a child is doing. The parent does the rating and it is what are your child’s strengths? Do they have difficulties in internalizing/externalizing peer problems, those kinds of things? Hyperactivity. We do the PTSD checklist which I am sure you guys are all familiar with. The BSI is a brief symptom inventory. It is a depression and anxiety inventory very similar to the PHQ. The Kid Cope which assesses child coping skills, the McMaster family assessment device which assesses how well a family is doing. And then the GAF or the GAF score, the standard mental health psychiatric assessment scale zero to a hundred. 

We use multiple reporters so we have the kids do a reporting, we have the parents do a reporting, and we have our trainer, our resiliency trainer, do a reporting. We measure impact over time with the entry, exit, and follow up assessments. We do have a flagging system for suicide risk so if someone on one of these assessments indicates that they have suicidal thoughts it immediately sends a red flag to our headquarters staff and we implement our suicide safety protocol. And the intervention is tailored to the assessment results as I mentioned earlier. All right, FOCUS’ impact on family psychological health. So in our pre and post assessments children do report increased use of positive coping skills in dealing with stressful events including significant increases in problem solving and emotional regulation. So it did have an impact on the kids as we had hoped. 

Parents report reductions in child conduct problems also, reductions in emotional symptoms such as anxiety and depression and improvement in child pro-social behaviors. So how social are they? How empathic are they? Those kinds of things. Parents also report decreased levels of their own depression and anxiety and those – all these results are statistically significant. And family functioning does improve according to the McMaster family assessment device: problem solving, communication, roles, affective responsiveness, how much does the family respond to each other emotionally in a positive and helpful way, and also behavioral control. And you can see the citation there if you guys want to read our outcomes data. All right. So here is some of that data. So mean parent distress at intake and post intervention. So this is from the BSI. Again, very similar to the PHQ if you are familiar with that scale. So for the non active duty parent before the FOCUS intervention you could see that the global severity was a 10.19, anxiety around four and depression again around four. And you could see that the norms for females in the gray box. So almost all of our non active duty parents our stay at home takers were women because again we were primarily on Marine Corps bases, Naval Special Warfare, so a lot of infantry which is primarily male deployers. So we normed it to community female norms. 

This is a pretty distressed population coming in the door. But at the post evaluation after FOCUS they had fallen below community norms for global severity for anxiety and depression. So I think that shows that the program likely had a significant impact even without a control group. Again with the active duty parent: so before deployment again a pretty distressed group. So 8.5 on this global severity index. The norm is five, 3.19 where the norm is three and again 3.63 where the norm is three. And again after FOCUS they fall to levels below community norms. So we feel like that was a pretty significant impact. Here is the prevalence of clinically significant anxiety and depression. So this is taking the same BSI data but doing the standard research protocol cutoffs for clinically significant symptoms. So the non active duty caregiver, again, mostly these were stay at home moms, anxiety levels around 20 percent had clinically significant anxiety before the evalua – before the FOCUS intervention. And after the intervention around eight percent. So a pretty big drop. 

With depression again about 20 percent down to about ten percent. With the active duty caregiver it was a more significant drop. They were more distressed when they came in the door but less distressed than even the stay at home caregiver at the end of the intervention. And all again statistically significant. This is the prevalence of unhealthy family adjustment. So this is taking the family assessment device and McMaster data and this is percentage in the unhealthy range. So how many families came in the door met standard research cutoffs for unhealthy family functioning? You can see according to the non active duty caregiver’s opinion this was about 44 percent of families in the unhealthy range at intake. And at a post intervention that had fallen to 29 percent. And for the active duty caregiver in their opinion about 54 percent were in an unhealthy range and had fallen to 39 percent. 

We feel like this is a clinically significant impact. It was not quite as powerful as for individual mood symptoms but we think it was a significant impact. And this is how it affected the kids. So prevalence of children with significant difficulties. And this is from the strengths and difficulties questionnaire again using standard research cutoffs. So at intake about 36 percent of boys had significant difficulty according to these cutoffs. And after the intervention that had fallen to 14 percent and that was statistically significant. For the girls, again, at intake 25 percent falling to about ten percent. All right and these were our family satisfaction ratings. And again this was our own scale. It is just a simple Likert scale so for the individual family resilience training these are adults reporting that their mean satisfaction scores are between 6.5 and 6.7 on this one to seven Likert scale so that is pretty high satisfaction. And then for the group family resiliency skill building, again they provided strong positive feedback on our Likert scale, one to five, their responses were in 1.3 to 1.6 range for the means. 

Now one thing that is important to point out is that all the data up to this point, up to this last bullet point, has been for the individual family resilience training. So these – the research data I just showed you was the impact of our most intensive intervention, the FRT. And then this last bullet point is for our skill building groups. As you can imagine outside of a controlled trial setting it has been difficult to evaluate the impact of things like workshops and outreach consultations although we do some sort of – we do a lot of satisfaction ratings and the person’s assessment of their own efficacy and how that has changed pre and post. I do not have that data here to show you but it has been easier to evaluate the more intensive intervention more as a clinical service. 

All right couple that – or FOCUS adaptations. So as I mentioned before FOCUS was originally intended to be a family centered intervention. We originally had the cutoffs be for children ages five to 18 and it was originally meant for your run of the mill military family but particular the infantry families who were going to be facing a lot of combat. But as we got on the installations we got a lot of feedback that there were other kinds of service members and family structures that really could benefit from this. We also heard there were specific populations that needed a specific approach. So again we partnered with Purdue University to develop the couples adaptation. We also developed an early childhood adaptation for children as young as three years old. We partnered with uniformed services, University of Health Sciences to do a wounded warriors adaptation. And that was also a partnership with NICO. And we specifically adapted intervention to the wounded warrior battalions and the Marine Corps. We also have done the purple expansion with the Office of Secretary of Defense, so this is to a handful of Army and Air Force installations. Usually where we already had a site. 

So for example – can everybody hear me OK? I am getting a little bullet here that says you are –

Moderator:You are coming through just fine. 

Patrick Link:Great. I will speak up a little bit. I get into my psychiatrist voice. I do not want to lull you to sleep. We did our purple expansion where we expanded to Army installations usually nearby one of our Navy installations so Hawaii is a good example. We were initially at Kaneohe Bay, the Marine Corps base on Hawaii but we got a lot of interest from Pearl Harbor and Hickam Air Force base and also from Scoffield Barracks. So with some of this funding we were able to expand to Pearl Harbor, Hickam and to Scoffield. We also got push back that a lot of folks do not live near the installation. And if we ever wanted to use this in veteran and guard populations we needed to get to folks who are not near our services. So we developed an online version of FOCUS called FOCUS World and I will show you a screen shot from that. But FOCUS World allows folks to practice the same family resilience skills but in an online format. And then we have also been working to move FOCUS to veterans, National Guard, and Reserves. This is a screen shot from FOCUS World. So you can go to our website, focusproject.org, and you can link to this. Anyone is welcome to use it. You can see that there is a little girl avatar and this little purple guy and a football. You go inside the house and each room has a different resiliency building task. We are currently trying to take some of the lessons we learned from FOCUS World and build a phone app as well that will have the same resiliency principles. 

All right, veterans, National Guard, and Reserves. So we believe FOCUS has been a success on military installations but obviously a lot of these folks are moving out into – out of the military service. We also have Guard and Reserves that come in and out of active service so we want to really adapt this to the future and the future are the veterans that come back from these conflicts and reintegrate into civilian society. So we got funding from the Welcome Back Veterans program. You can go to WelcomeBackVeterans.org to learn about this initiative but it is an initiative funded by Major League Baseball Charities, the McCormick Foundation, and the Entertainment Industry Foundation. And they funded several universities to improve outreach and services to veterans, National Guard, and Reserves. And the funding we received was for two purposes. One was to do a randomized controlled trial of our core FOCUS intervention, again the family resiliency training versus the waitlist control, also to test couples counseling for combat veterans which is a couples intervention for PTSD that came out of VA and out of Louisiana versus the waitlist control. Shirley Glynn at the Los Angeles VA is helping us with that as the PI on that project. 

We have already been partnering with the Greater Los Angeles VA to do this project and the Los Angeles area. The second thing we received funding from WBV for was community capacity building, partnering with local agencies to bring these resiliency principles to those agencies. We have developed some partnerships with the Department of Mental Health and Los Angeles County with our local National Guard and Reserves unit. So to go out into agencies that are seeing a lot of veterans and Guard and to bring family centered resiliency principles to these organizations. We believe it is really important to bring this perspective because I think that it is very easy for all of us who are clinically trained to take the clinical perspective particularly if we have got a particular individual in front of us like a veteran, a guard member, or reservist, and to not think about the family system. Particularly if they are not great structures for supporting a family centered approach. So we are trying to bring that family centered approach to these systems so they can support clinicians that want to work with the entire family. 

We were able to leverage some of the WBV money to get additional funds from Operation Mend. So Operation Mend is a UCLA program that is funded by private donations to provide free reconstructive surgery to catastrophically injured service members and veterans. It became apparent through their work that a lot of the families of these catastrophically injured service members were struggling. So they brought us in to provide family resiliency services to their wounded warriors but also to do some community capacity building in the Los Angeles area. So they have been a helpful donor to us as well. I will put in a plug for Operation Mend: if anyone on the call knows of a wounded warrior program that could utilize the UCLA plastic surgery service in partnership with VA clinicians or military clinicians it really is a partnership. We have the military expertise, their clinical expertise brought to bear as well as our clinical expertise partner in helping the patient. You can go to their website operationmend.ucla.edu. 

Veterans, National Guard, and Reserves: so outside of the WBV and Operation Mend initiatives –

Moderator:Dr. Link I apologize for interrupting. We are no longer seeing your slides. Do you have a screen shot on or –?

Patrick Link:I do have a screen shot on. Let me – it says on air showing screen. 

Moderator:Let me take control back really quick and we will switch back to you. All right, let us get this back to you now. Actually you are no longer connected to the meeting. Go ahead and click on the link again and I apologize to our attendees for this delay, should not take very long. In the mean time just please stand by.

Patrick Link:While we are getting this up, if anybody has the slides printed out in front of them I can go through some of the things. There are only a couple more slides left so I want to save time for our questions. And if we can get the slides back up I will show you what is here. 

Moderator:Feel free to – I can also put up the slides for you but that is a great idea to feel free to keep talking through them as we near the top of the hour. 

Patrick Link:I apologize to everybody for the technical difficulty. Only a couple more slides left. So with veterans, National Guard, and Reserves outside of WBV and Operation Mend we have partnered with the VA Long Beach Healthcare System to do a FOCUS couples pilot. So as we moved into the VA it became apparent that the policy restrictions on how children could be incorporated into preventive services was going to be a challenge. But we did not want to not have FOCUS available. So our initial effort was to do the FOCUS couples program with veterans in the Long Beach area and that has been successful. We partnered with the MIRECC in our area to do that project. We have also been working with Susan McCutchen’s office in the VA to do a VA FOCUS parenting pilot. This will be kind of the next generation out. This is for families with kids and we are going to work with the veteran and the spouse on using resiliency principles in their parenting. We may not be able to work directly with the child on VA property but we can bring the same principles to bear. 

It is not ideal in a sense because the child is not there to share their version of the story but we think that it still would be an effective intervention and we hope to bring that service to the VA. And then we also in the Los Angeles area partnered with the LA Unified School District and the LA County Department of Mental Health who has funded a pilot of FOCUS services in Department of Mental Health Clinics and also in schools that have a high prevalence of military connected and veteran families. That pilot is underway and has been successful. We have a couple of proposals for FOCUS. We have – we proposed home visiting early childhood model in the Los Angeles area with veterans, National Guard, and Reserves. And we have proposed also a school based model where we would bring some of the FOCUS interventions, not the individual family work but the skill building groups, the consultations, and the training workshops for teachers and school personnel into schools that have been affected by military populations. Only about ten percent of military connected children attend DOD run schools. The other 90 percent attend public schools. So it is very important, we feel, to make sure those public schools are equipped to handle this population from a resiliency perspective. So we have proposed that as well. We hope that that is where FOCUS will take us in the future. 

That was my last text slide. I have a thank you slide that shows some service numbers on it and a kid with a really cute sign that says, “Welcome home, troops.” You guys can probably all imagine it in your head. And our website, www.focusproject.org. My email also: P-L-I-N-K, plink@ucla.edu so that is pretty easy. And just to give a summary of the presentation: this presentation is really about giving you guys the full span of what FOCUS has been and where we hope it to go, the fact that it is a public health program that spans the prevention continuum that is centered around a core set of principles, resiliency skills, family narratives, education, and evidence based standardized assessments to do a family check-in and to monitor progress over time. We primarily have implemented it on military installations but it can be rapidly scaled up. And we do hope to bring this to the VA in some form. We select you all, our really critical partners, for the future of FOCUS because the future of FOCUS has got to be with veterans, Guard, and Reserves. Then I would just say I really appreciate your time. I hope that you guys were able to hear me OK and I apologize for the technical difficulties but we would be happy to take whatever questions you have. PAUSE...... I am going to try to connect to the meeting in case there are chat questions that I need to address. 

Moderator:Thank you very much. Sorry for that delay. A couple of you have written in saying – asking if your screen is stuck. No, what you are seeing is the introductory slide with Dr. Link’s picture and his credentials and he will be pulling his slides back up momentarily. We do have a couple questions pending so we will go ahead and jump right in. The first one: were all the active duty caregivers males or were there any females as well? 

Patrick Link:No, there were females as well and we do have female data. As I said initially our charge was to help a very specific population. We were asked initially by the Navy to help Naval Special Warfare, so Navy Seals and EOD, the hurt locker folks, the explosive ordinance device folks, the CBs which is the Naval Construction Battalions, and to help Marines. And so those three medical – or military occupational specialties or MOSes are overwhelmingly male. As we have been able to move into other populations, to Army installations, to serve other populations on Marine Corps bases besides infantry we have had a lot of female active duty parents who have been deployed. They obviously have unique challenges that we have had to address. But in the end the resiliency principles are the same. I think that the idea that the family needs to be able to communicate in an effective way, there must be co-parenting, that we have to handle deployment reminders, and stress, and that everyone has to bring their own particular experience to bear, there has to be a common family shared narrative, have been the same. 

Some of the traumas and stresses obviously have been different and we have had to adapt it to military sexual traumas and the other traumas that some of the – that the female populations has addressed. But that is not to say that male service members also do not deal with military sexual trauma. So we have adapted it. I wish that I could present to you specific data on the female service members that have been active duty. We do have a PhD candidate that is working with us that is specifically looking at that question. And we hope to be able to present that to you guys maybe at a later date. 

Moderator:Thank you for that reply. 

Patrick Link:And my computer appears to be connected to the internet so I do not know if you want to try to take over and it will just be the last slide. 

Moderator:Great, all right, I see you are up here so I will go ahead and make you the presenter again. Excellent, thank you very much, perfect. Having the contact information is very helpful. 

Patrick Link: Yes. 

Moderator:We do have a couple more questions pending. For those of you that joined after the top of the hour we do need you to submit your questions and comments in writing and you can do so by using the question function on the go to webinar dashboard on the right hand side of your screen. The next question that came in, “Have you attempted to work with veterans through the readjustment counseling services at the vet centers?” 

Patrick Link:We have partnered with some of the local vet centers to recruit into our local randomized controlled trials. With the Welcome Back Veterans funding, and these are the slides you guys did not get to see, so I think we lost – you guys lost me on this one. So with the Welcome Back Veterans funding we have the family resiliency training versus the waitlist control as a randomized controlled trial. And we have the couples counseling for combat veterans. Again, the couples PTSD intervention. We have recruited from vet centers for those studies and they have been a good partner for us. Bringing this intervention to the vet centers, I think, would be really logical and I think it would be a lovely home for FOCUS within the VA system or within a system that serves veterans. I think that we would have to negotiate that obviously with that center’s leadership and it would have to be something they would be interested in. But we would really welcome that partnership. I know that some of the leadership of some of the vet centers here in California know about us and have been very supportive. So that certainly would be a future venue for us to investigate a partnership. 

Moderator:Thank you for that reply. The next question we have pending is, let us see, I lost it really quick. “What does RCT stand for?”

Patrick Link:Randomized controlled trial. So randomizing one group to receive the intervention, so the family resilience training, and the other group to receive a waitlist. So basically with both of our studies you either get the intervention right away or you get it three or four months later. We did not want the folks in the control condition to get nothing. The advantage of doing the randomized controlled trial is that it really allows us to very specifically quantify the impact of FOCUS. The problem with the service project is that you get data before – as they come into the intervention you get data after they have done the intervention so you can say, “Well, they’ve changed over time.” But it is hard to say if that change was exclusively due to the intervention or because they just simply got better over time. I mean, people tend to come to these kinds of services when they are the most distressed. So naturally over time they are probably going to get a little bit better even if you have not intervened. So it is very hard to disassociate the impact of the intervention from how they just got better over time now. FOCUS on the installations had a big impact we believe so it is not all going to be because they got better over time. The intervention clearly had a significant impact but the randomized controlled trial allows us to add more rigorous data to the exact quantification of that impact. These trials also allowed us to adapt our intervention to veterans. 

Moderator:Thank you for that reply. We do have a couple more questions. The first one: “What changes do you anticipate the military will make as a result of this data relative to new recruits with families?”

Patrick Link:That is a really, really good question. I probably should preface the answer with the fact that we are – our team is contracting with the Navy to provide this service but I do not want anyone to in any way, shape, or form, to assume that I am speaking for the US Navy, the Marine Corps, the Department of Defense, the Veterans Affairs, or frankly even my boss as I say this next comment which is that I think that the military has struggled a lot with how to deal with families. And part of what I have done with this team is an implementation review where we visited – we did six site visits to early FOCUS sites. We tried to get a sense of what factors were critical to the implementation of FOCUS. Why was it able to grow to 20 sites over just three or four years? Why was it received so positively when a lot of other programs are not? And what were the challenges and how were – what about the installations where it was not received successfully? Because there were installations where it was not well received and there was a lot of competition and we had a lot of struggle. So it was not all roses. We went out and visited these installations and a constant theme that we heard in our data was that the old way, and I have no idea how old we are talking about, but the old way was that the military approached families was that if you – if the military wanted you to have a wife and kids they would have issued you one. And people say that tongue in cheek but I think that it had some element of truth. I think that the military the last at least ten years if not longer has really taken that issue of family seriously. And I think that Admiral Mullen was a big help with this in saying that no, we have got to take care of these families. And I do not think it is lost on the military that the next generation’s military are currently the kids of the current military. Military runs in families anymore particularly with all volunteer military force. So we have got to take care of these kids. 

I think that the challenge is what to do with resilience. I think that resilience can be an incredible advantage because it decreases stigma, it is a strengths based approach. People get things out of it. They understand that they are working on tools to make them stronger and better able to handle their emotions. But it has to be trauma informed. And that is where I think that our expertise as psychiatrists and psychologists has come to bear is that you can not just pretend that you can train someone – train the PTSD out of somebody. You can not take the approach that if you just train someone up enough they will not get PTSD because inevitably they end up getting PTSD or suicidal thoughts. And if they have been taught that they should have been trained not to get this well, then they feel like not only are they traumatized and suicidal but they feel like a bad marine or a bad sailor or a bad soldier. And that is a tough burden to bear. So I think resilience has to be done with the right approach which is a strengths based family centered approach, one that also acknowledges that there is real trauma and that there are real consequences to war and that is where the Marine Corps cost continuum is so brilliant. It says yes, there are going to be people who get injured and we have to deal with those injuries. 

That is a long winded way to say that I think they are going to – that they are going to address families. I think that they are trying to understand this concept of resilience. I think that one of the positive things about some of the challenges FOCUS has faced is that our presence creates a bit of competitive pressure to make sure we are really helping some of these families. We have seen on some of the installations for fleet and family services and Marine family services that said hey, let us partner with these guys and really do a great job. And we built partnerships with them where they handle some of the family resilience in clinical services and we do the family resiliency training. It has been a great partnership. So I think that that is a really long winded way of saying that the military gets it, I believe. They are putting a lot of energy into this and a lot of resources into this. They are not forgetting about these families. I think that they really care about these families. They are trying to strike the right balance between resilience and clinical services. And frankly I think the best thing that we could do to help these service members and their families is make sure that the mental health services and the services like FOCUS are fully staffed. I mean, if you – we all know that the biggest problem in mental healthcare is there is never enough mental health clinicians to go around particularly in remote and rural areas. 

Moderator:Thank you for that reply. We do have two more questions pending. The first is, “Can you please give again the link for the online self-directed FOCUS program that the vets can do themselves without going to a therapist?”

Patrick Link:Absolutely. And I would say that I am happy to do that and I want to clarify one piece of this which is when we implemented FOCUS we were very clear to not call our staff therapists and I want to – I did not mention this in the slide presentation and the question is giving me a great opportunity to address it. We call them resiliency trainers. We really see this not as a clinical service but as a preventive service. That allowed us to do a lot of things. It allowed us to approach families with a prevention, resilience oriented approach but it also allowed us to navigate swim lanes. We left the clinical work to clinicians and did the resiliency training ourselves. So I do not want to sell FOCUS World as a clinical intervention particularly for folks who have depression and PTSD even if it may have ameliorative effects on those conditions. But if people are wanting to look at preventing resilience oriented intervention they can go to focusproject.org. It is up on the screen there. And they want to click the link to FOCUS World. 

Moderator:Thank you. And we have a couple comments and a question in this last one. “Thank you for all you are doing from the chaplain’s daughter, a former Army brat who moved 13 times before the age of 18 during the Vietnam era. I am so happy to see families have assistance with this now. I saw a great need for this during the 1960s and 70s. Do you address the families that move off of the military installation while one spouse is deployed? For example, a mother moving the family to her hometown for the year while the father is deployed. 

Patrick Link:That is a really great question and I appreciate that comment also. I appreciate you bringing that historical perspective to this and your own family’s perspective. And thanks for your service as a military kid. I think we do not thank the kids enough for their military service. It is a great question and one of the challenges that we deal with and that the military deals with is that problem. The service member gets deployed and a lot of times the stay at home spouse says I am not going to stick around here. I am going to go home to mom and dad. And then they leave all the resources that are on the installation. And that, I think, can be a mistake because you are not around the services that are there to support you. And frankly it is very hard to get resources to all parts of the United States where people move to. So it has been a real challenge. Now that being said the support of a parent can not be underestimated. Sometimes it is the right decision for these folks to leave the area. But I know that a lot of the rear guard battalion and these other folks who are responsible for families that stay behind really encourage them to stick around. And I think that this has been where the professionalization of family services in the military has had pros and cons. 

I think that by professionalizing family services you get folks like us and Marine and family services and fleet and family services that are there, very organized and professional and rigorous way for families. At the same time I think that it has led to less of a feeling that the families all come together and help each other out. I mean, even ten, 12 years ago you did not have as many of these professionalized services so the families that stayed behind were organized by a couple of senior spouses into family readiness groups and family groups. And they really came together to support each other. I think the professionalization of services has brought clinicians to help these families but maybe has led to not as much pressure for families to stick together. I do not know. I think it is a bigger question than I can answer. We have not been all that successful at reaching the families that move far away from the installation. Now if they move – if they live off base but they are still living near the installation we do a lot of work to set up our services for those families and even though we are on installation we have often set up satellite shops for FOCUS at local schools or local YMCAs. And we try to get families that live off base. We have tried to be extremely flexible in how we get services out into the community because that is where most of the families are going to live. 

Moderator:Thank you for that reply. That is the last question we have pending so at this time I would like to let you make any concluding comments you would like to our audience. 

Patrick Link:I just really appreciate your guys’ time. I think is a fantastic group. One of my mentors during my fellowship was Becky Yano who I absolutely love and adore – I know she is affiliated with this group in a big way. So I have always really admired the work this group does. And I hope that this is something that you guys found useful and it was not a waste of your time. And I appreciate all your thoughtful questions and everything you are doing for women veterans which I think is such a critical population. Insofar as we can bring a family centered or family oriented preventive approach to our veterans and particularly to our women veterans we would be happy to do that service. And I hope we can partner with you guys in doing so. Just really appreciate your time today, thank you very much. 

Moderator:Well, we would also like to thank you for sharing your expertise and your time with our group. And Becky very much did want to be here today to provide your introduction but alas, her busy schedule got the best of her. [laughter] But we do thank you, Patrick, and we also thank our attendees for coming and for the great questions. And as I said please look in your inbox tomorrow. There will be a link to this archived video which you can forward along to anyone you might feel will be interested. And also as you exit today’s presentation please allow just a moment or two for our feedback survey to load on your web browser and please do provide us your feedback. It helps us to continuously improve our program and make sure we are providing the informational sessions you all need. Thanks again everyone and this does conclude today’s HSR&D cyber seminar. 

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