Family-Centered Preventive Intervention for Military
Families: Implications for Implementation Science
William Beardslee & Patricia Lester & Lee Klosinski &
William Saltzman & Kirsten Woodward & William Nash &
Catherine Mogil & Robert Koffman & Gregory Leskin
Published online: 15 July 2011
# Society for Prevention Research 2011
Abstract In this paper, we report on the development and
dissemination of a preventive intervention, Families Over-
Coming Under Stress (FOCUS), an eight-session family-
centered intervention for families facing the impact of
wartime deployments. Specific attention is given to the
challenges of rapidly deploying a prevention program
across diverse sites, as well as to key elements of
implementation success. FOCUS, developed by a UCLA-
Harvard team, was disseminated through a large-scale
demonstration project funded by the United States Bureau
of Navy Medicine and Surgery (BUMED) beginning in
2008 at 7 installations and expanding to 14 installations by
2010. Data are presented to describe the range of services
offered, as well as initial intervention outcomes. It proved
possible to develop the intervention rapidly and to deploy it
consistently and effectively.
Keywords Preventive intervention.Resilience.Military
families.Combat operational stress
The recent Institute of Medicine (IOM) report reviewed
evidence for prevention and promotion strategies for
children and families (National Research Council and
Institute of Medicine [NRCIOM] 2009), detailing develop-
ments in the field since the last report (NRCIOM 1994).
Both in the IOM report (NRCIOM 2009) and in other
commentaries (Proctor et al. 2002), there has been a call for
greater study of how to implement and disseminate
programs widely and effectively. The sustained operational
tempo in Iraq and Afghanistan created an urgent national
need to support military readiness by enhancing family
resilience and provided an opportunity to test a new model
of intervention development and dissemination.
About one million service members, approximately 43%
of all military personnel, are parents (Office of the Deputy
under Secretary of Defense 2007). Throughout wartime
deployments, these families face many stressors, including
repeated relocation, parental absence, and fears and concerns
(Palmer 2008; Segal 1986). Several earlier studies suggest
that military children typically exhibit resilience and well-
being, despite these stressors (Cozza et al. 2005; Jensen et
al. 1996). However, more current studies indicate increased
child distress during parental deployment (Chartrand et al.
2008; Flake et al. 2009), risk for child maltreatment
(McCarroll et al. 2000), and cumulative risk of deployment
W. Beardslee (*)
Children’s Hospital Boston, Harvard Medical School,
21 Autumn Street, Suite 130.2,
Boston, MA 02215, USA
P. Lester:L. Klosinski:W. Saltzman:C. Mogil:G. Leskin
UCLA Semel Institute for Neuroscience and Human Behavior,
760 Westwood Plaza, Room A8-159,
Los Angeles, CA 90024, USA
United States Bureau of Navy Medicine and Surgery,
2300 E Street, NW Bldg. #6,
Washington, DC 20372-5300, USA
Department of Psychiatry, VA San Diego Healthcare System,
3350 La Jolla Village Drive,
San Diego, CA 92161, USA
National Intrepid Center of Excellence,
8901 Wisconsin Blvd,
Bethesda, MD 20889-5600, USA
Prev Sci (2011) 12:339–348
separation on adolescent emotional adjustment (Chandra
et al. 2010). As a part of our team’s intervention develop-
ment strategy, we conducted an assessment of the effects of
deployments on families, which suggested that parental
combat deployments have an impact that lasts beyond the
duration of deployment and is associated with outcomes in
children, predicted both by the length of deployment and the
level of parental psychological distress (Lester et al. 2010b).
Furthermore, across a variety of intervention strategies,
there has been strong endorsement for structured manual-
based programs that enhance parenting and parent–child
relationships (NRCIOM 2009; Sandler et al. 2010). A central
tenant of developmental research is that effective caregiver-
child relationships provide an essential framework for
building child adaptive skills, including emotional and
behavioral self-regulation (Nachmias et al. 1996; Rutter and
Quinton 1984; Sroufe et al. 2005). Interventions that
promote adaptive skills and behaviors in children and
parents, particularly those that enhance parent–child com-
munication, bonding, and family management, reduce
problem behaviors and emotional distress in children
throughout development (Feinberg and Kan 2008; Spoth et
al. 2002). Given that military families have many existing
strengths and that family factors play a central role in
mediating childhood stress, it seemed prudent to design an
intervention that built on these strengths, yet further
enhanced protective family processes, particularly in light
of the repeated deployments of the current conflicts.
FOCUS (Families OverComing Under Stress) was specif-
ically developed as a family-centered preventive intervention
strategy adapted for the needs of military families facing the
stressors of multiple deployments. Strength-based approaches
with families have a particularly strong evidence base
(Beardslee and Knitzer 2003; NRCIOM 2009); therefore,
the concept of resilience, which focuses on positive
adaptation in the face of significant adversity, was central
to FOCUS. Early conceptions of resilience focused on the
role of individual traits contributing to childhood hardiness
or “invulnerability” (Rutter 1985). Subsequent longitudinal
studies that permitted more in-depth analyses of resilient
processes highlighted the importance of attachment relation-
ships as predictors of child resilience when exposed to
hardship, trauma, or loss, the importance of families, and the
need to understand the broader ecological context surround-
ing the child (Sroufe 2005; Werner 1993). In particular,
children’s outcomes in the face of adverse events were
significantly mediated by the quality of parenting and the
caregiving environment (Masten 2004).
Chronology of Intervention Development
Given the urgent national need for a rapid, scalable
framework of preventive services for military families, our
military partners requested that FOCUS be developed and
implemented without first conducting a randomized trial.
Instead FOCUS was developed by adapting and consoli-
dating key aspects of existing strength- and evidence-based
interventions utilized in comparable contexts. From the
beginning, FOCUS was conceived to be a trauma-informed,
skill-based, family-centered prevention (selective and indi-
cated) intervention designed to promote family resiliency
and to mitigate the sequelae of highly stressful deployment-
related events on children and parents. The early develop-
ment of FOCUS was facilitated by collaboration between
its developers at the UCLA Semel Institute/Children’s
Hospital, Harvard University and the National Child
Traumatic Stress Network (NCTSN), and was supported
through funding from the Frederick R. Weisman Philan-
thropic Foundation. In order to meet the needs of the
greatest number of military families, FOCUS was designed
to be highly scalable. Additionally, the intervention had to
be straightforward to deliver; only approaches that could be
taught to a wide range of providers in a variety of settings
could be considered. Finally, it needed to be highly portable
and flexible so it could be quickly disseminated to a variety
of very different communities, geographies, family types,
and military service requirements.
The three foundational programs from which FOCUS
was developed all had a family-level, rather than an
individual-level, perspective. They were all directed toward
children and parents who were at risk for mental disorders
or serious life impairment, and yet none were conceived to
provide treatment for a mental disorder. They were selective
or indicated preventive interventions, as defined by the
IOM Committee on Prevention of Mental Disorders
(Mrazek and Haggerty 1994) and endorsed by the recent
IOM prevention report (2009).
The first intervention, Project TALK (Teens and Adults
Learning to Communicate), is a manualized, family-
centered, prevention intervention developed to promote
positive psychological adjustment in adolescents affected
by parental illness (Lester et al. 2008; Rotheram-Borus et
al. 2001, 2004, 2006). Project TALK contributed a proven
model for a modularized prevention intervention, as well as
the implementation of cognitive-behavioral skills delivered
in a prevention framework across the family system.
Additionally, Project TALK informed FOCUS developers
regarding risk and protective factors operating in stressed
families (Lester et al. 2003, 2010c). The second preventive
intervention strategy on which FOCUS was founded was
the UCLA Trauma-Grief Intervention, a school-based,
trauma-focused, cognitive-behavioral therapy program
developed in post-war Bosnia for children and parents
exposed to trauma and loss in war zones and other violent
community settings (Layne et al. 2001). FOCUS incorpo-
rated from this intervention core elements of trauma-
340Prev Sci (2011) 12:339–348
informed psychoeducation and skill-building techniques.
Family Talk, the third foundational component of FOCUS,
is a brief, family-based preventive intervention that
addresses obstacles to communication and the lack of
attention to parenting common in families affected by
parental depression (Beardslee et al. 2003, 2007; Beardslee
and Gladstone 2001; D’Angelo et al. 2009). The Family
Talk intervention contributed to FOCUS a systematic
approach to sharing a family narrative, as well as practical
strategies to building resilience.
Crucial to intervention uptake, the FOCUS framework was
then integrated with the military’s public health model for
instructed. The central prevention and resiliency framework
being developed in the U.S. Navy (USN) and U.S. Marine
Corps (USMC) concurrently with FOCUS—and which in-
formed implementation of FOCUS—is the Stress Continuum
Model, a destigmatizing heuristic for recognizing significant
but preclinical levels of distress and functional impairment in
service members and their spouses and children (Nash 2011).
The Stress Continuum Model and an early intervention
model, Combat and Operational Stress First Aid, have been
disseminated as the core of organization-wide, leader-directed
Combat and Operational Stress Control (COSC) efforts (U.S.
Marine Corps & U.S. Navy 2010). FOCUS incorporated the
COSC Model into its assessment components, promoting a
classification of family and family-member strengths and
vulnerabilities according to their severity and relative need for
interventions. FOCUS also utilizes the language of the COSC
Model in its psychoeducational components and skill-building
An initial FOCUS manual integrating elements from the
source interventions and the COSC model, as well as a set
of key informant interviews, family focus groups, and
environmental and systems assessment, was finalized in
2007 (Saltzman et al. 2007) after piloting with USMC
families at Camp Pendleton, California during the early
years of the Afghanistan and Iraq wars (Saltzman et al.
2009). In 2008, the Navy Bureau of Medicine and Surgery
(BUMED) funded FOCUS as a service program for
selected USN and USMC installations through a contract
with the UCLA Semel Institute Intervention Team.
Individual Family Resiliency Training (IFRT) Central to the
FOCUS intervention is IFRT, an eight-session resiliency
training program for parents and children. IFRT includes a
family assessment completed online with real-time feedback
immediately available to the intervention provider (referred to
in FOCUS as a Resiliency Trainer). During initial sessions, the
Resiliency Trainers provide family members with education
about the impact of combat operational stress and deployment
in terms that are developmentally relevant to the family.
Throughout training, there is a focus on shared family-level
skills across the deployment cycle: communication, goal
setting, problem solving, emotion regulation, and managing
combat/deployment reminders. The eight sessions of the
FOCUS intervention are structured to include three phases, as
described in Fig. 1: (1) Narrative Construction: initial sessions
with the parents alone, to collect a family history and to begin
constructing a narrative of deployments, and two sessions
with the children, apart from the parents, to construct age-
appropriate narratives of deployments and other family
challenges; this phase helps family members reflect on their
experiences and reactions, appreciate differences in reactions
across the family, bridge estrangements and develop a family-
level sense of meaning. (2) Parent Planning: one or two
sessions with the parents, apart from children, to prepare them
for a leadership role in the family sessions, including
promoting appropriate sharing of narratives, identification of
effective strategies for addressing children’s concerns, and
practice of core skills that can be used at home or during
family sessions; and (3) Narrative Sharing and Skill Practice:
two to three sessions to share the family’s deployment
narratives, construct meaning of their experiences, practice
newly acquired skills, and plan for the future. Detailed
descriptions of the intervention skills and goals have been
reported previously (Lester et al. 2010a, 2011a).
Prevention as a “Suite of Services” In initial planning with
military partners, it was clear that a continuum of
approaches would be most effective at reaching the largest
number of military families. Consistent with a public health
approach described by Wingood and DiClemente (2006),
FOCUS developed a “suite of services,” each of which
provided the core IFRT psychoeducation and skills, but at
different levels of intensity, moving from universal to
indicated prevention services (Fig. 2). For outreach and
educational purposes, FOCUS trainers provided briefings
and trainings to base command, community, and base
service providers, and to take part in large-scale briefings
for service members and their families. Moreover, FOCUS
staff were embedded in the overall framework of care and
could respond to the needs of the military community. For
example, if a death in combat or a large mobilization
occurred, FOCUS staff responded via appropriate expert-
based workshops to families or larger group briefings (i.e.,
grief, trauma, reintegration, deployment) conducted in
coordination with other systems of care. For service
members, children, and families who were not able or
ready to participate in the full IFRT program, single-session
skill-based workshops and consultations were offered.
These broader-based services were especially important
during the start-up of each site and often served as
gateways for families to enter the eight-session IFRT
program. As the unique needs of families with very young
children, couples, and the wounded, ill, and injured
Prev Sci (2011) 12:339–348341
population were identified, further adaptations of IFRTwere
developed. The suite of services was found to be
particularly useful for military families who needed help
quickly before or after deployment and whose time and
resource constraints required a flexible or modular format.
Site Selection In the first year, BUMED selected nine USN
included the number of attached families, number of unit
deployments, and degree of service members’ combat expo-
sure. There was considerable site variability, ranging from
relatively small installations with around 4,000 active duty
personnel to much larger bases, the largest of which had more
than 40,000 active duty service members. In the second year of
service, five additional USN and USMC installations were
added, including the USMC Wounded Warrior Regiment.
Additionally, a pilot, which expanded services to U.S. Army
and Air Force installations, was added during the second year.
Personnel Selection and Training A key to successful
program implementation was hiring FOCUS site staff
Sessions 1 & 2
Sessions 3 & 4
Sessions 6 − 8
FOCUS: Individual Family ResiliencyTraining
•Real time check-up
•Real time check-up
Psychoeducation and Skills Building
& Skills Practice
Fig. 1 Individual Family
Community and Leadership
Skill Building Group
FOCUS Suite of Services:
Public Health Strategy for Implementation
Fig. 2 FOCUS suite of services
342 Prev Sci (2011) 12:339–348
members who embodied the highest levels of professional
expertise along with an entrepreneurial spirit that was
necessary to “stand up” a new service within a complex and
competitive service market. Full-time resident teams con-
sisting of a Site Director to manage the local site, one to
four Resiliency Trainers, and administrative support were
hired after being interviewed using standardized guides.
Whenever possible, military spouses or retired service
members were recruited, which provided FOCUS with key
insights into the community and which helped with building
alliances. Furthermore, Site Directors and Resiliency Trainers
had to be excellent clinicians—doctoral or master’s level
mental health practitioners—with a background in child and
family psychology. This was critical, as FOCUS staff had to
implement a manualized program with fidelity while exercis-
ing sufficient clinical judgment to customize the intervention
for the unique needs of military families.
In order to quickly train new FOCUS staff, an 80-hour
on-line training was paired with a full week of in-person
training that drew upon case material, role play, skill
practice, and personal reflection. The on-line training
provided important content areas including military culture,
combat and operational stress, child traumatic stress, child
development, post-traumatic stress disorder/traumatic brain
injury (PTSD/TBI), and administrative functions. In-person
training allowed for demonstration and practice of FOCUS
sessions and core skills. To prepare staff to work with their
local communities, the training described differences
between and within each service branch and included
material about the specific military installations, differences
in deployment experiences and cycles, and community
norms and values. The shared training experience led to a
strong esprit de corps and provided a basis for ongoing
dialogue. Central to the training strategy was provision of
core supervisory support both as-needed and on a regular
basis, as well as continued training relevant to emerging
science, community issues, and quality improvement data.
In addition to ensuring effective intervention delivery,
FOCUS supervisors were consulted to problem-solve about
such implementation matters as finding office space,
building relationships, and networking. Supervision was
also implemented through an on-line “learning community”
model, which integrated lessons learned across sites and
provided a virtual community for addressing model
implementation issues and identifying training needs.
Program Outreach and Engagement Given that FOCUS
was a new program entering into an existing continuum of
care for military families, considerable thought was given
to avoiding issues of territoriality while becoming a
working member of the base community. The first step
towards that goal was to embed FOCUS services within the
military structure by physically locating them on military
installations. Led by BUMED, FOCUS staff employed a
strategy of first securing support from the local command at
each base, identifying a lead point of contact with a central
position within the base service community, and then
actively outreaching to all stakeholders and potential
gatekeepers within the base and surrounding community.
This included the leadership and staff of family support
services, base medical facilities, schools, chaplains, as well
as other military preventive and support programs.
To further spread the word, FOCUS staff members
participated in pre- and post-deployment briefings; wrote
columns in base newspapers and public service announce-
ments; and provided consultations, workshops and trainings
for parents and children and community service providers.
Outreach, partnership building, and program promotion
occupied a significant portion of FOCUS staff time,
especially during each site’s first year of operation.
Engagement strategies had to be customized for each base,
as there were significant differences in the cultures and
community structures of Marine, Navy, Army and Air
Force installations. Even after a period of initial intense
program promotion, outreach remained key to FOCUS
success. Site Directors typically spent approximately 50%
of their time doing outreach, 25% delivering services, and
25% managing the site. Resiliency Trainers settled into a
pattern of providing services for 75% of their time and
conducting briefs for the remainder.
Framing and Positioning of Services Recognizing the
reluctance of many military personnel to seek mental health
services, the overall aim was to make this prevention model
available in a confidential and non-stigmatizing manner. To
enhance family engagement, FOCUS was not implemented
as a mental health treatment, but as a non-clinical resiliency
training program developed with an educational preventive
curriculum. Participation in the intervention was not noted in
the medical or service records of participating service members
or their families. FOCUS providers were formally designated
as “Resiliency Trainers” to avoid clinical connotation and to
promote family resiliency as a component of training and
preparation for deployment. The program focused on identify-
ing strengths and enhancing family resilience through skill
at home. Whenever possible, this framing was supported by
locating FOCUS offices away from medical and mental health
service sites, offering family-friendly hours on evenings and
weekends, and decorating the meeting rooms in a colorful and
Data Management Leveraging the technology infrastructure
of the UCLA Semel Institute and NCTSN, we were able to
system. The IT platform provided multiple levels of technology
Prev Sci (2011) 12:339–348 343
support for rapid implementation, including real-time family
assessment, program website and on-line interactive family
resiliency training, basic and advanced trainings through
an on-line learning center, and specific Internet-based tools
customized for FOCUS. An innovative Internet-based cloud
datamanagementsystem(describedpreviouslyinLester et al.
2010a) has been used for program management, implemen-
tation, and evaluation.
Evaluation Strategy Evaluation efforts were focused on
providing real-time assessment data for each family that
could be used to immediately customize the intervention
according to the family’s specific needs and wishes, to track
effectiveness of the program in key targeted domains, and
to guide outreach efforts and further program refinement.
To render the family’s assessment data immediately useful
to the Resiliency Trainer and family, a color-coded flagging
system consistent with the COSC Model was used; when
family members filled out the measures on computers, their
responses were automatically scored and a report provided
with feedback on relative family strengths and ways in
which the intervention should be customized.
This on-line family “check-up” assessed parent (service
member and spouse report), child (parent report and child
self-report) and family adjustment at time of entry into the
program, as well as at program exit and follow-up, using
standard, widely used measures where available. Specific
domains assessed include parent and child psychological
symptoms, general family functioning, loss and grief reactions,
coping skills, and strengths/resiliency. An additional set of
ratings measured each parent’s satisfaction and perception of
responses to FOCUS, we have examined the initial implemen-
tationresults of IFRTcompleted with 488 families (742 parents
and 873 children). Described previously in the American
Journal of Public Health (Lester et al. 2011b), initial
outcomes have demonstrated significant reductions in child
emotional and behavioral distress, as well as statistically
significant improvements in prosocial behaviors (Strengths
and Difficulties Questionnaire; Goodman et al. 2000).
Children participating in FOCUS reported significantly
increased use of positive coping strategies, including dealing
with stressful life events, problem solving, and emotion
regulation (Kidcope; Spirito et al. 1988). Significant reduc-
tions in both service member and civilian parent psychological
symptoms through assessment of change scores and preva-
lence rates were found on the Brief Symptom Inventory
(Derogatis 1993). Family functioning improved in the
problem solving, communication, roles, affective responsive-
ness, and behavior control areas on the McMaster Family
Assessment Device (Ryan et al. 2005). These were particu-
larly important as they were specific dimensions targeted by
resiliency training. Furthermore, ratings of program satisfac-
tion were very high, and families reported positive perceptions
of change for all key intervention domains.
Due to the FOCUS suite of services as well as
community satisfaction, the intervention reaped a large
number of families. Table 1 describes the range of activities
and provides an account of participants in each activity.
Table 2 provides statistics on the number of participants for
the family resiliency training services for the same period of
time, including both skill-building groups and IFRT. The
large increase in Year 2 over Year 1 was due in part to more
sites being involved, and by the beginning of Year 2, to all
original sites being fully operational. While customized
IFRT was a central facet of the service mission, it should be
noted that a greater number of people engaged FOCUS
through community briefings and educational workshops.
Families found their way to FOCUS through a variety of
different pathways (Table 3). The greatest number of
participants was self-referred, followed by referrals from
schools, military social services, military health providers,
and other military sources. This indicates both that families
had an awareness of what they needed and that the military
service systems supported FOCUS. Notably, it was not
uncommon for some family members to need clinical
intervention or other support service referrals; these were
provided and tracked in order to support greater access to
care for service members and their families (Table 4). The
data on referrals emphasizes that FOCUS often provided a
gateway to engaging individuals in other services and
demonstrated how selective and indicated psychological
health prevention services may fit into a continuum of care.
Furthermore, the suite of services has ensured that FOCUS
will be able to realign and integrate itself into a critical role
in the evolving world of military family services.
adapt interventions flexibly to meet individual, family and
community needs, and to build sustained relationships across
the community. Supporting Wingood and DiClemente’s
(2006) application of Roger’s (1983) characteristics of
adoptable interventions, FOCUS strengths can be classified
into five characteristics: (1) Complexity. We chose to develop
and implement an intervention with low complexity that
could be delivered by a wide range of personnel in various
settings. (2) Relative advantage. In contrast to existing
services, FOCUS was confidential, strength-based, and
skills-oriented; congruent with the IOM approach to preven-
tion, as well as the COSC model, FOCUS was implemented
to address specific gaps in selective and indicated prevention
services. (3) Compatibility. The FOCUS team’s development
344 Prev Sci (2011) 12:339–348
command and providers, and military families guaranteed a
tight, sustained feedback loop to promote respect, cultural
compatibility, cultural responsiveness, and sustained consum-
erinputs.(4) Trialability.The FOCUSinterventionunderwent
extensive quality improvement and modification based both
on service delivery experience and on data generated by
families. (5) Observability. The real-time assessments con-
firmed readily observable positive outcomes, verified by
families’ indications of child and family improvement.
An important lesson from the initial demonstration project
included the need to distinguish FOCUS services from
existing universal prevention programs, as well as from
clinical treatment. Educating communities, providers, and
families about the relevance of more intensive prevention in
the context of wartime deployments was also central to the
implementation process. Equally important was that the full
eight-session intervention was developed before other
FOCUS services. This in-depth work helped us understand
what military families generally needed. Doing the full
intervention highlighted a set of core components and key
characteristics and strategies that we were then able to use
in less intensive contexts such as individual consultations
and single session group family skill-building exercises.
Not only did the intervention develop based on evolving
needs and local issues, but so did the various kinds of
partnerships and alliances. As FOCUS services became
operational in the field, families, other service providers on
the continuum, and leadership came to recognize the value
of the intervention. Its uptake increased, and it became a
regular part of the continuum of services offered. Thus, the
alliances themselves evolved, and have continued to evolve
as the program has expanded.
about by the decision not to first conduct a randomized trial
and to move to rapid deployment. Clearly, in many other
circumstances, randomized trials provide the best data about
how interventions work, and for whom they work or do not
from multiple trials of the source interventions. Similarly, we
did not have the resources to have separate individuals
conducting the implementation and dissemination process at
each base, but rather relied on extensive case notes and
senior advisors. We acknowledge that a different kind of data
would have been obtained had we had the resources and
opportunity to study the process. More generally, we
recognize that our data reporting may be subject to bias
because we are relying on information from people who are
delivering the interventions and supervising the work, as well
as from our partners. We view this service demonstration
project as an initial phase; notably, a randomized trial of
FOCUS for combat injured service members and their
families is currently in progress through the Uniformed
University of the Health Sciences.
Research The IOM Prevention Report calls for much more
study of the processes of implementation and dissemination.
Furtherresearch(NRCIOM2009) is especially needed on the
Table 2 Participation in FOCUS services: FOCUS resiliency training
FOCUS resiliency trainingNumber Attendees
Year 1Year 2Total Year 1Year 2Total
FOCUS Family Skill-Building Groups173553 726 Adults
FOCUS Individual Family Resiliency
Training (IFRT) Enrollment
Community outreach and educationEvents Attendees
TotalYear 1 Year 2Total
Total Community Group Briefings
Provider Group Briefings
FOCUS Educational Workshops
Table 1 Participation in
FOCUS services: community
outreach and education
aMarch 10, 2008 through June
bJune 11, 2009 through June 10,
Prev Sci (2011) 12:339–348345
process of rapidly developing and deploying interventions
that strengthen families facing traumagenic events, including
natural disasters and terrorist attacks. If possible, comparative
designs—either random assignments with long-term follow-
up or time series analyses—should be used both to evaluate
that make effective rapid deployment possible. Our experi-
ence with different military installations and service branches
highlights the importance of understanding specific ecologic
contexts in which interventions are delivered and of being
able to flexibly adapt the core strategies to those contexts.
Similarly, knowledge is sorely needed about organizational
characteristics that enable interventions to incorporate effec-
tive family-based prevention services, as well as the most
effective ways to disseminate interventions and provide
resources to families. While in our own work it was not
possible to employ a randomized design in this intervention
and deployment cycle, we certainly believe that future
research designs will provide more detailed study of the
efficacy of core components of FOCUS.
Future Directions for FOCUS
Expansion of Services From the beginning, FOCUS was
developed to be highly scalable in order to meet the needs
of the large number of military families with children who
experience multiple deployments. In addition to the
uniformed services, there are other populations, such as
Veterans, National Guard and Reservists, who may benefit
from a family-centered preventive approach. Other settings
for customized FOCUS services may include more intensive
settings, such as the National Intrepid Center for Excellence,
where families of warriors affected by traumatic brain injury
and combat related mental health problems will be served.
Development of Web-Based Interactive Family Services We
have developed a website (www.focusproject.org) with
educational materials, as well as a portal to our interactive
family resiliency training activity (FOCUS World), based
on the FOCUS experience. FOCUS World provides military
families with the opportunity to learn and practice key
resiliency skills, build an on-line family deployment
narrative, engage in real-time interactions with other family
members, and download useful family tools and activities.
The web-based program is designed to serve as a direct
service to families living away from delivery sites, as well as
to provide booster opportunities for families who have gone
through FOCUS. These web-based services will increasingly
become incorporated into the FOCUS intervention.
Future Intervention Development More broadly, much
more attention needs to be given to a conceptual framework
that describes methods for rapidly developing interventions
by combining existing interventions or developing new
approaches from existing ones. We believe that the FOCUS
intervention was greatly strengthened by bringing together
three different perspectives (medical illness, trauma, and
depression/life adversity), as well as being integrated with
the military public health model. Furthermore, although
each of the foundational interventions has been widely used
and has a strong evidence base, it is not realistic to think
that interventions devised a decade ago meet the challenges
faced today. We believe that much more attention needs to
be paid to how established preventive interventions need to
be changed and modified over time to meet the needs of
different cultural groups, changing demographics, and
Table 4 Referral sources by FOCUS through June 2010
Health and Wellness Services
Additional FOCUS Services
Mental Health Provider-Community
Military One Source
Mental Health Provider-Military
Table 3 Referral sources to FOCUS through June 2010
Source of referrals Percentage of referralsa
Health Care Provider
Mental Health Provider
Military Social Services
aDue to rounding, percentages may not sum to 100%
346Prev Sci (2011) 12:339–348
disease and illness patterns. We believe that doing this
collaboratively with other intervention developers offers the
best possibility for new intervention development.
It proved possible to rapidly develop and deploy an
intervention that addressed an urgent unmet need. Basing
the work on other related strength-based family preventive
interventions; being able to deliver both the full interven-
tion and distinct components in a suite of services to meet
specific community, individual and family needs; having
effective data management systems to allow the individu-
alization of programs for families; paying strong attention
to the alliance at both the leadership level and on the
ground; and having a high quality staff with extensive
support and a very strongly shared sense of mission; all
contributed to this success and are likely to be applicable
and necessary to other similar intervention situations.
Ours was a profoundly shared mission. Through our
work, we came to have enormous admiration for the
courage and remarkable strengths of service personnel and
their families. The service members, their caregivers, and
the families themselves became our partners both in
intervention development and in understanding how to help
other families. We are deeply grateful to them.
Navy Bureau Medicine and Surgery (BUMED) for the implementation
of FOCUS Project Resiliency Training Program for Military Families.
They also acknowledge the strength, honor, commitment, and
sacrifices made by military families on behalf of our country.
The authors acknowledge the support of the
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