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 Commander Brenda Gearhart Marital & Family Therapy Program Manager BH Division, USA MEDCOM 19 November 2011 UNCLASSIFIED

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

BRIEFING OUTLINE PURPOSE: Provide an update on military marriage and family therapy programs and to discuss some of the current issues involved. 1. DoD The Basics 2. DoD Marriage & Family Demographics 3. DoD Marriage & Family Programs 4. Issues on the Horizon 5. The Military MFT Alliance Slide 3 of 41

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 Slide 4 of 41

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 Billion 2 ; 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 beneficiaries 4 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.. Slide 5 of 41

Department of Defense (2) We operate in every time zone and in every climate with more than 450,000 employees overseas 1 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 32 nd 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) 39 th 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. Slide 6 of 41

Department of Defense (3) We operate our own healthcare system and healthcare training programs: 59 hospitals, 364 health clinics 1 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. Slide 7 of 41

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/Caucasian 2 56% married; 44% have children; 5% are single parents 2 Many reservists, retirees, and their spouses and children Age distribution of the TRICARE beneficiary population. 1 NOTE: Percentages shown are percentages for each sex, not the whole beneficiary population. 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. Slide 8 of 41

Components of the Armed Forces 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 Slide 9 of 41

DOD MARRIAGE AND FAMILY DEMOGRAPHICS Slide 10 of 41

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. (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 Slide 11 of 41

DoD Active Duty Family Status 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 Slide 12 of 41

Marriage Trends by Service 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 Slide 13 of 41

DoD Marital Status by Gender by Service 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 Slide 14 of 41

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 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 Slide 15 of 41

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. (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 Slide 16 of 41

DoD Annual Divorce Rates by Service 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 Slide 17 of 41

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 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 Slide 18 of 41

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? 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 Slide 19 of 41

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% 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 Slide 20 of 41

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. Slide 21 of 41

Child Maltreatment (DoD Family Advocacy Program FY 2010 Data) 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. Slide 22 of 41

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. Slide 23 of 41

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. Slide 24 of 41

DOD MARRIAGE AND FAMILY THERAPY PROGRAMS Slide 25 of 41

TRICARE: DoD Programs 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 Slide 26 of 41

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. Slide 27 of 41

DoD Programs (Con t) 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

DoD Programs (Con t) 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. Slide 29 of 41

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. Slide 30 of 41

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. Slide 31 of 41

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. Slide 32 of 41

ISSUES ON THE HORIZON Slide 33 of 41

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 Size of Army (Downsizing) Recruit BH Quality Perfection (Zero Deficit) BH Problems Stress Fear of BH Stigma Slide 34 of 41

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. Slide 35 of 41

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. Slide 36 of 41

ALLIANCE OF MILITARY AND VETERAN FAMILY BEHAVIORAL HEALTH PROVIDERS Slide 37 of 41

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. Slide 38 of 41

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 Slide 39 of 41

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 Slide 40 of 41

COL Anthony Tony Cox 210-381-6544 (Blackberry) tony.cox@us.army.mil Slide 41 of 41