Family-Centered Care to Promote Successful Community Reintegration After War: It Takes a Nation

The papers in this section focus on public health responses and implementation considerations in addressing the challenges military families confront when parents go to war. While many military families show resilience, the challenges resulting from a decade of war with multiple deployments are detailed, as are innovative military and civilian programs designed to help service members and their families reintegrate successfully into the community. As more and more service members leave active duty, the burden of meeting military families’ psychological needs will transition from the Department of Defense (DoD) and into the Veterans Administration (VA) and civilian arenas. While many strategies to support successful readjustment are offered, in this time of dwindling mental health resources and competing needs, it is unclear what priority the broader society places on meeting the needs of returning service members and their families. A growing emphasis on family-centered care in the Veterans Administration may help meet this gap.     

Confidentiality and Mental Health/Chaplaincy Collaboration

Confidentiality can both facilitate and inhibit working relationships of chaplains and mental health professionals addressing the needs of service members and veterans in the United States. Researchers conducted this study to examine opportunities for improving integration of care within the Department of Defense (DoD) and Department of Veterans Affairs (VA). Interviews were conducted with 198 chaplains and 201 mental health professionals in 33 DoD and VA facilities. Using a blended qualitative research approach, researchers identified several themes from the interviews, including recognition that integration can improve services; chaplaincy confidentiality can facilitate help seeking behavior; and mental health and chaplain confidentiality can inhibit information sharing and active participation on interdisciplinary teams. Cross-disciplinary training on confidentiality requirements and developing policies for sharing information across disciplines is recommended to address barriers to integrated service delivery.     

An empirical examination of stigma toward mental health problems and psychotherapy use in Veterans and active duty service members

Although many Veterans and active duty service members experience mental health problems, most do not seek out any sort of mental health help. Stigma (a significant predictor of treatment-seeking) has been documented among Veterans and active duty service members; however, previous research on stigma in these groups has primarily utilized correlational and qualitative designs. The purpose of this study was to gain a better understanding of stigma toward mental health problems in Veterans and active duty service members using an experimental design. One hundred sixty-five Veterans and active duty service members were randomized to read a vignette that described a Veteran who either did or did not experience a mental health problem and did or did not seek psychotherapy. Results indicated that the participants held more stigmatizing attitudes toward the Veteran who was described as having a mental health problem, but not toward the Veteran who was described as seeking psychotherapy. Additionally, participants held more positive attitudes toward the Veteran, compared to the attitudes that they believed other military members would hold. Last, with this sample of Veterans and active duty service members, self-stigma toward seeking psychotherapy was found to partially mediate the relationship between perceived public stigma and attitudes. Implications for addressing stigma in military service members and Veterans are discussed.     

“I’m Not Sure I Trust the System Yet”: Lesbian Service Member Experiences With Mental Health Care

The purpose of this research was to understand lesbian service member experiences with mental health care. Individual and organizational factors were explored, including the influence of military policy (e.g., “Don’t Ask, Don’t Tell”) on service member utilization of mental health services. Thirty-seven participants responded to a survey containing 16 open-ended items regarding the impact of “Don’t Ask, Don’t Tell” on one’s professional life, relational life, identity, and willingness to access mental health services. Data were analyzed through an open- and axial-coding and constant comparative method. The findings indicated a lesbian service woman’s likelihood of accessing mental health services was impacted by confidentiality concerns, fear of repercussions, and a sense that military culture lags behind policy changes. Recommendations for therapists included renewed focus on safety through affirmative practices, need for competency in military and lesbian/gay culture, and sensitivity to the effects of systemic oppression on self-esteem. Implications and future research are discussed.     

Evaluating the effectiveness of REBOOT Combat Recovery: A faith-based combat trauma resiliency program

Evidence-based intervention programs attuned to the spiritual needs of service members, Veterans, and their families are needed to help them deal with the potentially debilitating consequences of combat trauma. This study evaluated the effectiveness of a faith-based, peer-led combat trauma resiliency program called REBOOT Combat Recovery. Participants were 254 adults who reported on 8 aspects of physical, mental, and social well-being during the 3rd week and the 12th week of the program. Findings indicated improvement for pain interference, fatigue, sleep disturbance, anxiety and depressive symptoms, and social participation. Improvement was uniform except that Veterans benefited more than currently serving military personnel with respect to anxiety symptoms. These results suggest the program may be effective for coping with the aftermath of combat trauma.     

Ethical Challenges for Military Psychologists: When Worlds Collide

Despite the mental health needs in the military and improved access to military psychologists, many in need do not seek psychological services. The military policies, culture, and environment pose considerable barriers to help seeking. In turn, military practices often conflict with the psychologist’s professional ethics, leading to a range of ethical dilemmas including multiple relationships, multiple agencies, and limited confidentiality. To address ethical concerns and encourage service members to seek mental health services, this article proposes maintaining an understanding of military rules, law, and professional ethics; identifying multiple relationships and establishing boundaries up front; and collaborating with the patient in disclosures of information.     

Moral Injury: A Mechanism for War-Related Psychological Trauma in Military Family Members

Recent research has provided compelling evidence of mental health problems in military spouses and children, including post-traumatic stress disorder (PTSD), related to the war-zone deployments, combat exposures, and post-deployment mental health symptoms experienced by military service members in the family. One obstacle to further research and federal programs targeting the psychological health of military family members has been the lack of a clear, compelling, and testable model to explain how war-zone events can result in psychological trauma in military spouses and children. In this article, we propose a possible mechanism for deployment-related psychological trauma in military spouses and children based on the concept of moral injury, a model that has been developed to better understand how service members and veterans may develop PTSD and other serious mental and behavioral problems in the wake of war-zone events that inflict damage to moral belief systems rather by threatening personal life and safety. After describing means of adapting the moral injury model to family systems, we discuss the clinical implications of moral injury, and describe a model for its psychological treatment.     

Task-shifting to improve the reach of mental health interventions for trauma patients: findings from a pilot study of trauma nurse training in patient-centered activity scheduling for PTSD and depression

ABSTRACT

Despite high rates of posttraumatic stress disorder (PTSD) and depression among traumatically injured patients, engagement in session-based psychotherapy early after trauma is limited due to various service utilization and readiness barriers. Task-shifting brief mental health interventions to routine trauma center providers is an understudied but potentially critical part of the continuum of care. This pilot study assessed the feasibility of training trauma nurses to engage patients in patient-centered activity scheduling based on a Behavioral Activation paradigm, which is designed to counteract dysfunctional avoidance/withdrawal behavior common among patients after injury. Nurses (N = 4) and patients (N = 40) were recruited from two level II trauma centers. A portion of a one day in-person workshop included didactics, demonstrations, and experiential activities to teach brief intervention delivery. Nurses completed pre- and posttraining standardized patient role-plays prior to and two months after training, which were coded for adherence to the intervention. Nurses also completed exit interviews to assess their perspectives on the training and addressing patient mental health concerns. Findings support the feasibility of training trauma nurses in a brief mental health intervention. Task-shifting brief interventions holds promise for reaching more of the population in need of posttrauma mental health care.     

Editorial

This study examined the psychometric properties of the Outcome Questionnaire-30.2 (OQ-30.2; designed to measure patient progress throughout mental health treatment) in a sample of United States Air Force active duty basic military trainees who were evaluated for mental health concerns during the course of basic training. Findings indicate that the OQ-30.2 was internally consistent and Total scores decreased with more contact with mental health professionals. Previously reported 1- and 3-factor structures were not replicated; rather, results suggested the use of a broad 27-item general psychological distress subscale and a separate subscale of 3 critical items assessing substance use concerns. Present findings support the utility of the OQ-30.2 as a tool for repeated monitoring of patient progress in military mental health settings. Recommendations for future directions in the development of alternate calculations of the clinical cut score and reliable change index are discussed.     

Characteristics of Traumatic Experience and Survivor Perceptions of Mental Health Services: The 2004–2005 Erie County Community Trauma Survey

Trauma is associated with severe mental illness and substance abuse problems, yet it typically is not addressed sufficiently in treatment. This article reports on an assessment of mental health service recipients and their experience of traumatic events and perceptions of service providers' sensitivity, helpfulness, and knowledge regarding their trauma and service needs using a community-based participatory research model. Demographic characteristics and status of co-occurring disorders were measured. Participants perceived that individual therapists and peer service providers were sensitive to and knowledgeable about their trauma. Group treatment and peer programs were seen as being most helpful. Psychiatric services were seen as being the least sensitive to trauma issues. Implications for practice and research are discussed.     

Implementation and Dissemination of Military Informed and Evidence-Based Interventions for Community Dwelling Military Families

Community dwelling military families from the National Guard and Reserve contend with deployment-related stressors in relative isolation, living in communities where mental health providers may have little knowledge of military culture. When they are community residents, active duty service members and families tend to live in close proximity to their military installations. This article will focus primarily on the challenges to quality mental health care for reserve component (RC) families. Where studies of RC families are absent, those of active component (AC) families will be highlighted as relevant. Upon completion of a deployment, reintegration for RC families is complicated by high rates of symptomatology, low service utilization, and greater barriers to care relative to AC families. A paucity of providers skilled in evidence-based treatments (EBTs) limits community mental health capacity to serve RC military families. Several emergent programs illustrate the potential for better serving community dwelling military families. Approaches include behavioral health homes, EBTs and treatment components, structured resiliency and parent training, military informed schools, outreach methods, and technology-based coping, and psychoeducation. Methods from implementation science to improve clinical skill acquisition and spread and sustainability of EBTs may advance access to and quality of mental health treatment and are reviewed herein. Recommendations related to research methods, military knowledge and treatment competencies, and transition to a public health model of service delivery are discussed.     

Special Issues in Psychotherapy with Minority Deaf Women

Abstract

Minority Deaf women have been traditionally underserved by mental health professionals, and specifically, therapists are unaware of issues unique to this population. It would be highly unlikely for a minority Deaf woman to have a therapist who matches her in racial background, hearing status, and communication mode. Therefore, the therapy process will be completely cross-cultural. Therapists who provide psychotherapy services to minority Deaf women need to be aware that their clients are members of a community where deafness is a culture and not a disability. Minority Deaf women are also likely to report feeling forced to choose between competing identities in order to get important needs met. In the following article, case examples are provided which illustrate some of the major issues that are likely to arise in therapy with minority Deaf women. These issues include: access to important information; communication, support and level of involvement with biological families; competing cultural demands; health concerns; and coping with chronic mental illness.     

Play Therapy in a Natural Setting: A Case Example

Play therapy is commonly used when working with children in counseling. Play therapists work at a developmentally appropriate level to assist children with a variety of mental health and behavioral concerns. Traditionally, play therapy and many counseling methods occur in office settings. We propose that play therapists and other mental health professionals working with children integrate nature and natural settings into their work. The use of nature has been shown to be effective in helping people cope with mental health and physical ailments. In this article, we explore the benefits of the use of nature in mental health and provide a case example of the use of nature and natural settings in counseling.     

Community Participation Needs of Families With Children With Behavioral Disorders: A Systems of Care Approach

The purpose of the current study was to convey findings regarding the community participation needs of families who have children with behavioral disorders. The changing focus of community-based service provision to the systems of care approach for children with mental health needs requires family input to identify and better address their needs. This study identified characteristics of community participation in families of children with mental health needs through a survey, using mixed methods design and purposeful sampling. Evolved themes supported challenges for policymakers to make changes in professional, school, and community supports. Occupational therapists have a strong skill set to offer these families and must work collaboratively with family organizations, provide support for successful engagement in desired social activities, and build adaptive behaviors in children with mental health needs.     

Pragmatic Screening of Anxiety,Depression, Suicidal Ideation,and Substance Misuse in Older Adults

Older adults’ mental health needs are often unmet across care settings (e.g., primary or residential care) for a variety of reasons, such as mental health stigma and mental health care professionals’ lack of awareness of age-related changes in mental disorders. Screening, when coupled with access to evidence-based interventions, is effective at identifying and reducing anxiety, depression, suicidal ideation, and substance misuse in older adults across care settings. Unfortunately, due to lack of training many mental health care professionals may be unsure about what or how to screen, as well as which screening measures are available for use with older adults. Following professional guidelines recommended for older adults, we provide an overview of screening measures for anxiety, depression, suicidal ideation, and substance misuse that are evidence-based and meet pragmatic criteria identified by stakeholder research. Specific pragmatic criteria include screening measures developed with older adults (unless unavailable) as well as brief in length (items ≤30), time for administration (≤15 minutes), scoring (<5 minutes), and interpretation (<5 minutes). Other pragmatic criteria include screening measures readily available on the internet at no cost and usable across diverse settings (e.g., community, primary care, and/or residential care). For each measure, we also review relevant psychometric properties (e.g., reliability, cut-scores, sensitivity, specificity, and construct validity). Lastly, we discuss strategies to facilitate screening with older adults and direct mental health care providers to internet resources that can be used to learn more about assessment with older adults.     

Mental Health Risk and Social Ecological Variables Associated with Educational Attainment for Gulf War Veterans: Implications for Veterans Returning to Civilian Life

This study examines how post-secondary educational attainment among young veterans of the first gulf war affects their mental health status. The all-volunteer military attracts recruits by offering them veterans’ educational benefits. Education should help veterans adjust to civilian life. Few studies have shown whether education following military service helps improve veterans’ mental health, however. Viewing resiliency, life span and life course, and social geography theories through the lens of social ecology, it is hypothesized that selected contextual factors in the personal, interpersonal, and organizational domains could mediate or moderate the relationship between education and veterans’ mental health. Informational social networks showed an association with obtaining mental illness treatment. Recent treatment for post-traumatic stress disorder (PTSD) showed an association with use of veterans’ educational benefits. Residing with a small nuclear family in conjunction with having higher levels of health and educational benefits and a higher family income was associated with higher educational attainment.     

An Intensive Outpatient Program for Veterans With Posttraumatic Stress Disorder and Traumatic Brain Injury

Post-9/11 service members may return from military service with a complicated set of symptoms and conditions, such as posttraumatic stress disorder (PTSD), depression, substance misuse, and traumatic brain injury (TBI), that interfere with reintegration and impair functioning. Although evidence-based treatments that facilitate recovery exist, their successful delivery at a sufficient dose is limited. Barriers to accessing treatment combined with challenges compiling a comprehensive treatment team further delay delivery of effective evidence-based care for PTSD, TBI, and co-occurring mental health conditions. This paper describes the development of a comprehensive, multidisciplinary, 2-week intensive day program for post-9/11 veterans with complex mental health concerns. The treatment program combines skill building groups, family education, and integrative health approaches with evidence-based individual PTSD or TBI care. Initial results from the first 132 participants were notable for a 97% completion rate, as well as statistically significant and clinically meaningful reductions in PTSD, neurobehavioral, and depression symptom severity for the 107 veterans who completed the PTSD track and the 21 who completed the TBI track. These data suggest the intensive program approach is an effective, well-tolerated model of treatment for post-9/11 veterans with PTSD and/or TBI. Future controlled studies should examine the effectiveness of this intensive model compared to standard evidence-based therapy delivery, as well as longitudinal outcomes.     

The Coping Self-Efficacy Scale: Psychometric properties in an outpatient sample of active duty military personnel

ABSTRACT

Active duty military service members endure a unique constellation of stressors while deployed or at home. Yet, assessment of protective factors against these stressors among active duty service members represents an under studied area. The present study advances the assessment of protective factors through the psychometric evaluation of the Coping Self-Efficacy Scale (CSES) in a clinical sample of military service members in mental health or substance abuse treatment (n = 200). Cross-sectional data were drawn from military medical records and a supplemental self-report questionnaire. Data extracted included demographic (e.g., sex, age), military characteristics (e.g., rank, years in service), physical health and mental health (e.g., anxiety, depression), and coping self-efficacy. Findings suggest a 3-factor (i.e., problem-focused coping, thought-stopping, and getting social support) CSES structure with acceptable internal consistency. Further, there were small-to-moderate associations with physical and mental health outcomes, providing evidence of construct validity. There were few significant associations with military-related characteristics. Finally, controlling for covariates, thought-stopping beliefs explained unique variance in suicide-related behaviors. Together, findings support the use of the CSES to measure coping-related beliefs in military service members. Recommendations are offered for future research and practice with active duty service members.     

Collaborative Home-Based Therapy (CHBT): A Culturally Responsive Model for Treating Children and Adolescents Involved in Child Protective Service Systems

Mental Health professionals are challenged with utilizing innovative treatment models to meet the needs of diverse communities. Enhancements in interventions have led to a reconceptualization of the role of mental health professionals, specifically, family therapists. This paper presents a collaborative, home-based model for working with children and adolescents involved in foster care. We begin by examining literature on home-based therapy. This review provides a framework to understand the need for a culturally responsive approach. A collaborative, home-based approach is presented along with unique issues and guidelines for practice. A clinical case is presented to illustrate implications for treatment.