Military Marital and Family Therapy Policies and Practices

Military Marital and Family Therapy

Policies and Practices

Colonel Anthony L. Cox

Deputy Chief, Behavioral Health Division

USA MEDCOM

UNCLASSIFIED

19 November 2011

Commander Brenda Gearhart

Marital & Family Therapy Program Manager

BH Division, USA MEDCOM

Select SLIDE MASTER to Insert Briefing Title Here

13-Feb-12 Name/Office Symbol/(703) XXX-XXX (DSN XXX) / email address

Disclaimer / Disclosure / Classification

Disclaimer

The views expressed in this presentation (oral and written) are those

of the author and do not necessarily reflect the official policy or

position of the United States Army Medical Command, the

Department of the Army, the Department of Defense, or the U.S.

Government.

Disclosure

This education activity received no commercial support. No

reference to unlabeled or unapproved use of drug(s) or device(s) will

be made during this presentation.

Classification

All data sources and referenced materials are unclassified.

Slide 2 of 41 – UNCLASSIFIED – COL Cox/ MCHO-CL / (210) 381-6544 / [email protected] 19 Nov 2011



BRIEFING OUTLINE

1. DoD – The Basics

2. DoD Marriage & Family Demographics

3. DoD Marriage & Family Programs

4. Issues on the Horizon

5. The Military MFT Alliance

PURPOSE: Provide an update on military marriage and family therapy programs

and to discuss some of the current issues involved.




Objectives

• Explain the demographics of the military population

• Outline Navy/Marines, Air Force and Coast Guard current

marriage and family-related programs/services

• Describe the Army MFT program policies and practices and

outcomes of the program

• Describe objectives of the Alliance of Military and Veteran

Family Behavioral Health Providers




Department of Defense OUR MISSION: “To provide the military forces needed to deter war and to protect the

security of our country. We are war-fighters first and as such, have no peers.

We engage in: War-fighting, Humanitarian Aid, Peacekeeping, Disaster Relief,

Homeland Security”.1

• We are America's oldest and largest government agency, with our military tracing its

roots back to pre-Revolutionary times.1

• Our FY10 base budget was $531 Billion2; about three times larger than the largest

state budget (California).3

• We are the nation's largest employer:1

– Over 1.4 million men and women on active duty

– 718,000 full-time civilian personnel

– 1.1 million serve in the National Guard and Reserve forces.

– More than 2 million military retirees

– Approximately 9.6 million total beneficiaries4

1. DOD. DOD101: An introductory overview of the Department of Defense. Online at http://www.defense.gov/pubs/dod101/index.html#evolved.

2. ASD(Comptroller). DOD Fiscal Year 2011 budget request. Online at http://comptroller.defense.gov/defbudget/fy2011/FY2011_Budget_Request_Overview_Book.pdf.

3. Gov of California. Governor’s budget 2010-11: Enacted budget summary. Online at http://www.ebudget.ca.gov/pdf/Enacted/BudgetSummary/SummaryCharts.pdf.

4. DOD(Health Affairs). What is the MHS? Online at http://www.health.mil/About_MHS/index.aspx..




Department of Defense (2)

• We operate in every time zone and in every climate with more than 450,000

“employees” overseas1 – including 103,000 afloat.2

• We control a lot of real estate – in urban and remote locations:1

– Over 5000 individual installations/sites world-wide

– More that 30 million acres (the size of Mississippi or the 32nd largest “State”)

• We run our own school system (DOD Education Activity):3

– 194 schools in 12 foreign countries, 7 states (16 bases), and 2 territories

– 8,700 teachers serving 84,000 students (K-12)

– 39th largest “school district” in the U.S.4

– Consistently ranked in top ten states for student performance

– Annual 1/3 student population turnover

1. DOD. DOD101: An introductory overview of the Department of Defense. Online at http://www.defense.gov/pubs/dod101/index.html#evolved.

2. DMDC. Active duty military personnel strengths by regional area, 30 Sep 2010. Online at http://siadapp.dmdc.osd.mil/personnel/MILITARY/history/hst1009.pdf.

3. DODEA. DODEA begins school year 2010-2011. Online at http://www.dodea.edu/pressroom/releasesDisplay.cfm?prId=20100812-1.

4. National Center for Education Statistics. (2009). Digest of education statistics, 2008. Online at http://nces.ed.gov/pubs2009/2009020.pdf.




Department of Defense (3) • We operate our own healthcare system and healthcare training programs:

– 59 hospitals, 364 health clinics1

– An insurance program with HMO and PPO options (“TRICARE”)2

– An accredited medical school & university (USUHS)

– Train over 25,000 officers and enlisted technicians annually in medically-related

fields (to include mental healthcare)3

• The Army is nearly doubling it’s numbers of uniformed social work and clinical

psychology officers over the next six years. It has also started an MSW program:

– Collocated with the enlisted mental health tech training school

– Currently training its third class of ~30 MSWs increasing to 40/cycle

– Results in Commissioned or DOD Civilian social workers

– Free training + full pay and benefits as an O-1 (~$49,800/yr) or GS-9

• The Army recently started a two-year post-MSW Internship program:

– Places new MSWs at major military medical centers for the first 2 years

– Prepares them clinically and academically for independent clinical licensure

– Trains them across all major military practice modalities

1. DOD(Health Affairs). What is the MHS? Online at http://www.health.mil/About_MHS/index.aspx.

2. Institute of Medicine. (2010). Provision of mental health counseling services under TRICARE. Online at: http://www.nap.edu/openbook.php?record_id=12813&page=R1.

3. AMEDDC&S. (2009). Course catalog. Online at http://www.cs.amedd.army.mil/courses/SCHOOL_CAT_FY09_9_jan_09.pdf.




Department of Defense (4) • We care for a broad range of age groups (48.5% female)1:

– 36% of Active Duty report minority or ethnicity other than White/Caucasian2

– 56% married; 44% have children; 5% are single parents2

– Many reservists, retirees, and their spouses and children

1. Institute of Medicine. (2010). Provision of mental health counseling services under TRICARE. Online at:

http://www.nap.edu/openbook.php?record_id=12813&page=R48.

2. USD(MC&FP). (2010). Demographics 2009: Profile of the military community. Online at: http://www.militaryhomefront.dod.mil.

Age distribution of the TRICARE beneficiary population.1

NOTE: Percentages shown are percentages for each sex, not the whole beneficiary population.




DoD. (2010). Demographics 2009: Profile of the Military Community. Available at:

http://www.militaryhomefront.dod.mil/12038/Project%20Documents/MilitaryHOMEFRONT/QOL%20Resources/Reports/2009_Demographics_Report.pdf

Components of the Armed Forces




DOD

MARRIAGE AND FAMILY

DEMOGRAPHICS






Service “Drawdowns”

• All Services cut force strength significantly following the first Persian Gulf War (1990-

1991).

• Involvement in Iraq and Afghanistan necessitated an increase in ground forces.

• With personnel (pay and benefits) one of the highest costs, DoD is looking to reduce

force structure and/or trim pay and benefits in order to meet budget limitations.






DoD Active Duty Family Status






Marriage Trends by Service






DoD Marital Status by Gender by Service




Marital Status of Active Duty Males

• Males on active duty in FY 2009 were more likely

to be married than their male civilian counterparts.

• Age 18+, military males more likely to be married:

Likelihood of marriage increases with age

Difference greatest at age 27

65.3% enlisted AC males married

33.3% male civilians married






Marital Status of Active Duty Enlisted Women

• From age 17 through their twenties, active enlisted

women are more likely to be married than their civilian

counterparts.

• From age 33 on, enlisted active duty females are less

likely to be married than female civilians.

• By age 44, 69.9% of civilians were married versus

51.5% of active enlisted females.








DoD Annual Divorce Rates by Service




Pollard, et al. (2008). Comparing Rates of Marriage and Divorce in Civilian, Military, and Veteran Populations (Extended Abstract). Available at:

http://paa2008.princeton.edu/download.aspx?submissionId=81696

Military Marriage and Divorce

• Using longitudinal data from the NLSY-79, Pollard, et al.

found:

• Compared to comparable civilians, military men and women are

more likely to get married.

• Military men are less likely to get divorced while serving in the

military.

• Military women are more likely to get divorced.

• Upon exiting the military, both veteran men and women have

higher rates of divorce than comparable civilians






Dual-Military Marriages by Gender and Service

• While 12% of service members are married to other service members, 48% of

service women are married to other service members.

• Further, it is likely that a much higher percentage of current service women are

married to former service men.

• What does this mean about a service woman’s access to marriageable mates?

• Does the “double stress” of military service contribute to the higher divorce rates for

service women?






Single Parenthood

• As of 2009, about 5.3% of service members were single parents – 4.2% of male and

11.9% of females service members.

• US Census (2008) estimated that 17.1% of US households were single-parent led.

• In general, the percentage of male single parent service members peaked in 2000,

however, the percentage of female single parent service members has continued to

increase.

% SINGLE PARENT

Year 1990 1995 2000 2005 2006 2007 2008 2009

Gender Male Female Male Female Male Female Male Female Male Female Male Female Male Female Male Female

Army 3.5% 11.1% 5.4% 13.9% 6.4% 13.7% 5.7% 13.8% 5.3% 13.8% 5.3% 14.0% 5.4% 14.3% 5.5% 14.7%

Navy 3.4% 10.2% 4.1% 11.0% 6.5% 12.1% 4.2% 12.0% 4.0% 11.8% 3.8% 11.7% 3.9% 11.6% 3.9% 11.5%

Marines 2.6% 8.5% 2.7% 9.1% 2.8% 9.1% 2.3% 8.3% 2.3% 8.1% 2.3% 8.0% 2.3% 8.6% 2.5% 9.1%

Air Force 3.3% 7.9% 3.4% 8.5% 4.1% 8.7% 3.7% 9.3% 3.6% 9.3% 3.5% 9.5% 3.6% 9.7% 3.6% 9.7%

Total DoD 3.3% 9.7% 4.2% 11.1% 5.4% 11.4% 4.3% 11.5% 4.2% 11.4% 4.1% 11.6% 4.2% 11.8% 4.2% 11.9%




Spouse Maltreatment (DoD Family Advocacy Program FY 2010 Data)

• Rate of reported spouse abuse per 1,000 couples

increased 1.2% from FY09 but declined 9.7% since FY01.

– Military prevention and early intervention programs?

– Decline in spouses reporting incidents?

– Ongoing impact of deployment?

• Rate of spouse abuse incidents that met FAP criteria per

1,000 couples increased 9.9% from FY09 but declined

32.1% since FY01.

– New FAP incident determination algorithm across installations.




• Rate of reported child abuse/neglect per 1,000 increased

by 15.2% from FY09 but has fallen 8.5% from FY01.

– Effectiveness of prevention programs?

– Family members returning to home of record during service

member’s deployment?

– Ongoing impact of deployment?

• Rate of suspected child abuse and neglect incidents that

met FAP criteria per 1,000 children increased 4.8% in FY09

to 5.7% in FY10 but has fallen 17% since FY01.

Child Maltreatment (DoD Family Advocacy Program FY 2010 Data)




Service Members and Infidelity (“Jody”)

“Service Members Twice as Likely to Have Affairs”:

– Based on National Health and Social Life Survey (NHSLS) that

started in 1992 (3,121 participants aged 18-59).

– 32% of current or former U.S. military service members who

were ever married have had affairs, compared with 16.8% of

other ever-married people.

– Not enough data to track deployment effects or male/female

service member differences.

– Findings suggest that service members, veterans and their

spouses may need special care and counseling

London, et al. (2011, Aug 29). Veteran Status, Marital Infidelity, and Divorce. Paper presented at the American Sociological Association Meeting, Las Vegas, NV.




Deployment and the Use of Mental Health Services

among U.S. Army Wives

• Frequency and the length of deployment were associated

with mental health diagnoses in military spouses.

• Deployment for more than 11 months was associated with:

o 39.3% depressive disorders

o 23.5% sleep disorders

o 18.7% anxiety

o 16.4% acute stress reaction and adjustment disorders

Mansfield, et al. (2010, Jan 14). Deployment and the use of mental health services among U.S. Army wives. The New England Journal of Medicine.




DOD

MARRIAGE AND FAMILY THERAPY

PROGRAMS




DoD Programs

• TRICARE:

BUT benefits do not include M&FT services, unless it relates to

another medical or MH condition.

• Military Family Life Consultants (MFLCs):

– DoD funded for ALL Services; licensed providers

– Non-medical, short term, situational, problem-solving

counseling; No medical records

– Contract managed by the Office of the Deputy Under Secretary

of Defense for Military Community and Family Policy




DoD Programs (Con’t)

• Military OneSource:

– 24/7 Call center for information and referral.

– On-line crisis counseling.

– Will make referral to local licensed counselor/therapist and

will pay for the cost of up to 12 sessions per person, per

issue, per counselor (that is, a lot of sessions).

– Have a duty to report family maltreatment, threats of harm to

self or others, substance abuse, and illegal activities to

appropriate military and civilian authorities.

• inTransition Program:

– Telephonic “coaching” from licensed MH providers during

relocation moves, or transitioning out of the military.

– For those engaged in MH care and referred by MH provider.





• New Parent Support Programs:

– Funded for each Service, though implemented slightly

differently by each Service

– Licensed nurses and/or social workers who provide early

screening and intervention programs to new and expecting

military parents (children up to age 3).

• Exceptional Family Member Programs:

– Mandatory enrollment program that works with other military

and civilian agencies to provide comprehensive support,

housing, educational, medical, and personnel services to

Families with special needs.

– Enrollment is considered in the military personnel assignment

process to ensure family members can access needed

services – particularly in overseas locations. Slide 28 of 41 – UNCLASSIFIED – COL Cox/ MCHO-CL / (210) 381-6544 / [email protected] 19 Nov 2011




• Family Advocacy Programs:

– Funded for each Service, though implemented slightly

differently by each Service

– Licensed social workers who provide early intervention,

assessment, case management and treatment services to

victims and perpetrators of intra-familial maltreatment (partner

abuse, child abuse/neglect).

• Chaplaincy Programs:

– All chaplains in DoD provide spiritual, individual, and marriage

and family counseling services based upon their individual

skills, education and availability.

– Some chaplains are specifically trained in marriage and family

counseling (“Family Life Chaplains”).

– Chaplains have total confidentiality.




Marriage and Family Therapy Services

• Army Marriage and Family Therapy Program:

– Initiated in 2001 as a direct result of the Army Family Action

Plan Issue #474, Shortage of Marriage and Family

Counselors (CONUS).

– Provide evidence-based relationship therapies for individuals,

couples and Families.

– Currently have 68 licensed MH providers (to include LMFTs),

46 at 18 installations in the US and 22 at overseas locations.

– Placed primarily at the larger bases and those with units that

deploy regularly to combat locations.

– Generally collocated in and are a part of MH clinics or Family

Advocacy Program clinics.




Marriage and Family Therapy Services

• Navy Clinical Counseling at Fleet and Family Support

Centers (FFSC) (54 sites) and Marine Corps Community

Counseling (16 sites):

– Staffed with licensed clinicians based on the size of the

installation.

– Provide short term clinical counseling to assist sailors with

problems in daily living that can have a negative effect upon

military readiness.

– Brief solution focused therapy for individuals, couples,

families and groups.

– A wide scope of educational, preventive, and therapeutic

services to promote an improved quality of life and increased

resilience in individuals/families.

– Crisis and disaster services.




Military MFT In Summary

• Marriage and family counseling programs are plentiful –

funded by both DoD and each Service.

• MFT services are implemented somewhat differently by

each Service:

– Some are part of the medical system (with HIPAA protections,

etc.); some are chaplain based (total confidentiality); some

are part of the non-medical family support systems (limited

confidentiality).

– Some utilize LMFTs, some utilize other MH or Chaplain

professionals trained in counseling, and some (regular

chaplains) may have minimal training in counseling/therapy.

– Some locate their services in hospitals, some in chapels, and

others in family service centers.




ISSUES ON THE HORIZON




Issues on The Horizon

• The “long tail of war” – which includes family problems – will continue to

require additional resources for 5-10 years beyond the end of the war.

• The repeal of Don’t Ask Don’t Tell paves the way for a redefinition of

the military family. Future research, problems, and programs will need

to address this newly “outted” sub-population.

• The poor economy, the end of the wars, and the need to cut military

funding will impact the willingness of service members to seek MFT.

↓ Economy

↓ OPTEMPO

↑ Recruiting

Ease

↓ BH Problems ↑ Recruit

BH Quality

↓ Size of Army

(Downsizing)

↑ Perfection

(Zero Deficit)

↑ Stress

↑ Fear of BH

Stigma




Issues on The Horizon (Con’t)

• As women become a larger percentage of the force, issues that

impact them will become more important:

– Lower rates of marriage than male counterparts.

– Much higher rates of dual-military marriages.

– Higher rates of divorce.

– Much higher rates of single parenthood – and physical custody

• The needs of male spouses will also become more important.




Issues on The Horizon (Con’t)

• As minority populations grow disproportionally in the US, they will

likewise grow in the military – perhaps leading to different family

needs

• Although the President, the SECDEF and others have stated they do

not plan to cut military family programs, they may have no choice.

• MFT programs will have to demonstrate positive outcome metrics

related to military and/or family readiness in order to survive.




ALLIANCE OF MILITARY AND

VETERAN FAMILY BEHAVIORAL

HEALTH PROVIDERS




The “Alliance”

• Began in 2010 as a “loose” outreach and partnership network for

family behavioral health (BH) providers

• Called Marriage and Family Counseling Collaborative (MFCC) until

July 2011

• Members include all Services, VA, other federal and non-federal

agencies, association, universities/colleges and community

participants.

• Seeks to optimize the preparedness of behavioral health providers

who are working to enhance the resilience, recovery and

reintegration of Service members, Veterans, and their Family

members and communities throughout the military, post-military, and

family life cycles.




The “Alliance” (Con’t)

• Serve as venue for BH providers to share and acquire information

and resources

• Provide and identify continuing education opportunities

• Participate jointly on projects and developing tools

• Work with Graduate programs to develop military and veteran family

behavioral health tracks

• Maintain five audience-specific Resource Guides related to military

and veteran family issues:

– Domestic Violence Resource Guide

– Sexual Assault Resource Guide

– Healthcare Providers Resource Guide

– Continuing Education Resource Guide

– Family Support Resource Guide

• Generate a Monthly Newsletter to all 600+ listserv members




Alliance Activities Planned for 2012

• Develop permanent Web site for Alliance resources and for

interactive activities

• Develop, disseminate, analyze and provide results of Survey of

members

Register for the Alliance and receive the monthly Newsletter at:

http://deploymentpsych.org/resources/marriage-family




COL Anthony “Tony” Cox

210-381-6544 (Blackberry)

[email protected]


Military Marital and Family Therapy Policies and Practices

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