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MILITARY MEDICINE, 180, 3:246, 2015
Total Force Fitness: The Military Family Fitness Model COL Stephen V. Bowles, MS USA*; Liz Davenport Pollock, P hD f; Monique Moore, P hD f; Shelley MacDermid Wadsworth, PhD§; Colanda Cato, P hD f; Judith Ward Dekle, MSW/I; Sonia Wei Meyer, BSjj; Am ber Shriver, BS**; Col Bill Mueller, USAF M C ff; CAPT Mark Stephens, MC U S N Jf; SFC Dustin A. Seidler, ARNG§§; CDR Joseph Sheldon, CH USNHH; COL James Picano, MS USAR (Ret.)TjJI; CAPT Wanda Finch, USPHSf; COL Ricardo Morales, USA***; Col Sean Blochberger, USMC (Ret.)*; CAPT Matthew E. Kleiman, U S P F IS ttt; SGM Daniel Thompson, SF U S A R ftt; Lt Col Mark J. Bates, USAF, BSC (Ret.)f
ABSTRACT The military lifestyle can create formidable challenges for military families. This article describes the Military Family Fitness Model (MFFM), a comprehensive model aimed at enhancing family fitness and resilience across the life span. This model is intended for use by Service members, their families, leaders, and health care providers but also has broader applications for all families. The MFFM has three core components: (1) family demands, (2) resources (including individual resources, family resources, and external resources), and (3) family outcomes (including related metrics). The MFFM proposes that resources from the individual, family, and external areas promote fitness, bolster resilience, and foster well-being for the family. The MFFM highlights each resource level for the purpose of improving family fitness and resilience over time. The MFFM both builds on existing family strengths and encourages the development of new family strengths through resource-acquiring behaviors. The purpose of this article is to (1) expand the military’s Total Force Fitness (TFF) intent as it relates to families and (2) offer a family fitness model. This article will summarize relevant evidence, provide supportive theory, describe the model, and proffer metrics that support the dimensions of this model.
INTRODUCTION The U.S. Military is composed of nearly 1.38 million active duty members with over 1.94 million dependents, including spouses, children, and adult dependents.1 There are over 848,000 Service members combined in the Reserve and National Guard with over 1.1 million family members.1 Mil itary service typically requires frequent moves2 and many occupational categories carry the risk of injury and/or death.
The complex and uncertain global environment the modern military faces places continuous demands on military families. Families are critical components of Service member fitness and are essential to the well-being of the military as an enter prise. It is important, therefore, to develop a model to assess and support military family fitness. The Military Family Fitness Model (MFFM) is multifaceted based on conceptual theory and empirical literature. The
*The Eisenhower School, National Defense University, 408 4th Ave nue, Washington, DC 20319. tDepartment of Military and Emergency Medicine, Human Perfor mance Resource Center, Uniformed Services University of Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814. ^Defense Centers of Excellence for Psychological Health & Traumatic Brain Injury, 1335 East West Highway, 9th Floor, Silver Spring, MD 20910. §Military Family Research Institute, Purdue University, Hanley Hall, Room 210, 1202 West State Street, West Lafayette, IN 47907. ||Department of Defense, Military and Community Family Policy, Pentagon, Washington, DC 20301. ^Beijing University of Aeronautics and Astronautics, XueYuan Road No. 37, HaiDian District, Beijing, China. **Department of Psychology, George Mason University, 4400 University Drive, Fairfax, VA 22030.
ttHuman Systems Integration Directorate, 711 HPW/HP, 2510 Fifth Street, Room W400E, Wright Patterson AFB, OH 45433. $^Department of Family Medicine, Uniformed Services University of Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814. §§Department of Psychology, Southern Illinois University, Carbondale, IL 62901. ||||Office of Religious Affairs (Jl), The Pentagon, Room 2C856, Washington, DC 20318. ^Department of Veterans Affairs, Northern California Health Care System, 150 Muir Road, Martinez, CA 94553. ***5th Brigade, U.S. Army Cadet Command, San Antonio, TX 78204. tttBehavioral Health Services Division, United State Coast Guard, 2703 Martin King Jr Avenue, Southeast, Washington, DC 20593-7907. j^ W arrior Transition Unit, Fort Bragg, NC 28310 doi: 10.7205/MILMED- D-13-00416
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Total Force Fitness: The Military Family Fitness Model
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FIGURE 1.
Military Family Fitness Model.
MFFM highlights potential areas of individual, family, and external strength-building resources that can foster adaptive outcomes as well as prevent or mitigate maladaptive out comes for military families3 (Fig. 1). There is a need for an integrated model of family fitness and a framework to identify effective resources. A previous family fitness-focused model was based on one branch of the service.4 The purpose of this paper is to (1) build on the military’s Total Force Fitness ( IFF) intent as it relates to families and (2) offer a model for family fitness. This article will summarize relevant evidence, provide supportive theory, describe the model, and proffer metrics that support the dimensions of this model. The TFF paradigm focuses on promoting holistic Service member health, families’ health, readiness, and optimal performance (Fig. 2).5 Using relevant evidence with supportive theory, we
FIGURE 2.
Total Force Fitness Model.
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describe the model, and offer metrics to support relevant out comes for each dimension of the proposed model.
DEFINITION OF FAMILY FITNESS AND RESILIENCE Military families are as diverse as civilian families. They vary in structure and include, however are not limited to, nuclear families, intergenerational families, blended families, and single-parent families. Moreover, they also vary in organiza tion, including female, male, and dual-headed households as well as households including significant others.6 Families also vary in experience, including both recently formed families as well as families that have experienced divorce and death. Additionally, military families (as well as civilian) vary in ethnic and cultural representation, including both domestic minority groups and foreign-born members. Regardless of structure, all military families face unique challenges and opportunities related to military service and culture. Family fitness refers to the ability of families to effec tively cope with the challenges posed by military service. Family fitness is the dynamic process of reinforcing current skills and resources and/or acquiring new skills and resources to create a resilient or “fit” family system. This dynamic process of acquiring resources (at the individual, family, and external levels) to manage competing family demands can result in adaptive (emotional well-being, effective communi cation, improved family functioning) and/or maladaptive out comes (spouse/child abuse, work-family conflict) that together determine general family fitness. All members of military families should have access to the resources and programs for proactive support. It is important to distinguish between family “fitness” and family “resilience.” By definition, resilient families adapt
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Total Force Fitness: The Military Family Fitness Model effectively and become stronger following adverse events.7-11 In contrast, fit families have not necessarily encountered adverse events, but will likely exhibit resilience in the face of adversity.7-11 Fit, or “ready,” families are knowledgeable about potential challenges and equipped with the necessary skills to competently face those challenges. They are aware of and able to use resources available to them. Fit families function successfully in supportive environments that allow for healthy individual development and well-being. Being fit does not make families immune to the daily struggles and hassles of life. This prepares families to respond effectively to difficulties, access support/resources as needed, and develop a better capacity to become resilient when adverse or trau matic situation occur for the family. A key assumption of the MFFM is that characteristics of fit families can be learned. Therefore, identifying both adaptive and maladaptive responses to familial stress is important. This concept is anal ogous to preparing for athletic competition— successful prac tice improves real-life performance.
METHODS AND APPROACH A team of military and civilian health professionals conducted an extensive literature review of the best available evidence pertaining to resilience and family fitness. Databases, includ ing Ebsco, PubMed, Psyc Info, OVID, and Google Scholar, were systematically reviewed using key search terms and search arrays for English language articles dated 2001 to 2013 from peer-reviewed journals.
THEORETICAL FRAMEWORK FOR MFFM The MFFM was designed to complement the TFF model by focusing on the demands and resources related to psycholog ical health outcomes. The underlying framework of demands and resources integrates two empirically supported models that provide demand-resource perspectives of systems func tioning on community and organization levels.11-14 The MFFM is also influenced by family systems models including the Double ABCX model of family stress,10 the Circumplex Model of Family A daptability,15 and the Family Fitness Model (an early version of the M FFM ).16
TABLE I. Individual Resources
Individual Characteristics Awareness Emotional Intelligence Spirituality Decision making
Coping
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The theory of demands and resources posits that stress places a demand on an individual or families who must then utilize existing resources (external and internal) to promote adaptive outcomes. Previous studies have used this perspec tive as a method of conceptualizing fam ilies.17'18 The MFFM framework builds on this theory to identify specific demands, resources, and outcomes. Individuals, families, and support agencies should be able to easily use this framework to edu cate and support family systems. Leaders can provide guid ance with this framework by systematically providing resource awareness and support for families. This framework empha sizes family strengths that can be taught and practiced. Key features of the MFFM also include a systems perspective with interface between (1) the individual, (2) the family, and (3) the external environmental stakeholders (e.g., leader, unit, social support system, military, and civilian community).
INDIVIDUAL RESOURCES Identifying and utilizing resources for each family member is key to building family fitness. The MFFM recognizes the following individual dimensions: individual characteristics, awareness, emotional intelligence, spirituality, decision mak ing, and coping. Family members’ individual resources can interface both adaptively and maladaptively with the family system. Previously defined psychological fitness resources12 that also serve as individual family resources include practic ing adaptive coping strategies,19'20 for example, problemfocused coping found in a submarine mission21; marines receiving mental fitness training before deployment reported acting with greater awareness and decrease in perceived stress22; and working on a team while making a decision (like a family) has been found to be more effective than an indi vidual making a decision.23 Communication is a critical indi vidual resource that will be discussed in the family section.24 Individual characteristics, emotional intelligence, and spiritu ality are the other MFFM individual resources that will be described below (Table I).
Individual Characteristics Individual characteristics are qualities of temperament, emo tion, or behavior displayed by individual family members.
Definition of Individual Resources
Individual characteristics, skills, abilities and experiences used in combination with other family members resources that impact the individual and family. Maintaining and building individual resources for each family member is key to building the adaptive family in the MFFM. Individual resources can interface both positively and negatively with the family system to influence family fitness. Qualities of temperament, emotion, or behavior displayed by an individual (e.g., self-confidence, optimism, or hardiness). The ability to accurately perceive relevant stimuli from the environment while ignoring irrelevant stimuli. 12 The ability to accurately assess others and one’s own emotions and feelings. An individual’s personal experience in the existential search for purpose and meaning in life. The process by which an individual uses thoughts and behaviors to evaluate and choose steps in order to meet a preconceived goal. 13 Decision-making includes both rational and intuitive thinking processes that influence how an individual makes personal choices and responds to challenges. 12 The ability to manage stress in order to maintain optimal health and performance. 12
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The characteristics of individuals may impact the ability of the family unit to manage stress. For example, certain prom inent resilience characteristics such as self-confidence, opti mism, and perseverance were found in single parents following the death of a spouse.25 Additionally, personality characteristics such as courage negatively correlate with anx iety in children,26 and empathy negatively correlates with abusive behaviors in low income mothers.27 Parental charac teristics such as agreeableness, emotional stability, and extra version are shown to play a role in the development of these same characteristics in adolescents. The named characteris tics also predict later education success, higher income, and competent parenting in those same adolescents.28 Hardiness, a characteristic previously found in military populations, may also be an effective factor for families and couples.29” 3 1 Emotional Intelligence Emotional intelligence is defined as the ability to accurately recognize self-emotions and others emotions, as well as the ability to use knowledge pertaining to emotions to enhance one’s thinking processes about a personal or social situa tion .3'-'33 Research has shown that individuals that score higher in emotional intelligence have greater marital satis faction than those scoring lower in emotional intelligence.34 Furthermore, emotional intelligence leads to higher quality relationships in groups that are characterized by sharing, sup port, and trust.35 Finally, one review of emotional intelli gence research found that this concept may be predictive of several aspects of psychological health .36 Spirituality “Spirituality” can best be understood as an individual’s per sonal experience in the existential search for purpose and meaning in life. Spiritual practices that are expressions of spiritual values and beliefs, include prayer, meditation, service, devotion, psychophysical exercise, ethical conduct, study of sacred texts, mindfulness, and concentration .37 Past research has found that religiosity and spiritual well-being may reduce anxiety and depressive symptoms.38 Service members that reported medium levels of spirituality and combat exposure are able to buffer depression and post-traumatic stress disor
TABLE II. Family Resources Communication Cohesion Appraisal Adaptability/Flexibility Coping Routines, Celebrations, and Traditions
der (PTSD) symptoms.39 Atheists or those who profess no religious affiliation may experience similar results if they are grounded in strong philosophical values and beliefs. The spirituality of individual members and the interface with the family may be especially important given the adverse cir cumstances military families face given operational environ ments. Although individual fitness is an important component of the MFFM, it is not the only factor, which influences overall family fitness. FAMILY RESOURCES Family relationships can be significant sources of support and play a crucial foundational role in total family fitness.40 According to family systems theory, every family is com posed of multiple subsystems; we will focus on the couple and parent-child subsystems.41,42 The couple subsystem is the primary control subsystem for families.41 Military cou ples, despite the hardships of frequent separation, often main tain satisfying relationships43 that can positively impact and strengthen the entire family. The second subsystem, the parent-child subsystem, can also provide valuable buffering against stress and increase family resilience.44 For example, children whose parents (or other supportive adults) treat them with high levels of warmth and low levels of hostility are more likely to display resilience in the long term .4 Changes to subsystem dynamics can create additional challenges to resilience across the life cycle, especially when the family constellation changes as a result of divorce, remar riage, injury, or death. Depending on the nature of challenges faced, adjustments required, and resources available, all fam ilies might require additional strengths and skills. The fol lowing family skills and attributes may help strengthen and maintain family fitness for families: communication, cohe sion, appraisal, adaptability/flexibility, coping and routines, celebrations, and traditions (Table II). Communication A definition previously used for couples, which can be adapted for families, notes that communication entails both listening for and expressing thoughts and feelings, as well as decision-related problem solving.45 Communication that
Definition of Family Resources
Family skills and abilities that strengthen the family. Communication entails both listening for and expressing thoughts and feelings, as well as decision related problem solving. The emotional bonding between family members. The ability to assess the seriousness of a situation and ways for the family can adapt. The ability to adjust to change while remaining stable. Strategies that families employ to deal with problems while maintaining balance and caring for family members’ needs. Routines and rituals can stabilize and strengthen family connections and include daily and periodic shared activities, sporting or music events, and annual gatherings.
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Total Force Fitness: The Military Family Fitness Model promotes resilience is clear and incorporates open expression to convey feelings and or resolve conflicts.45 46 Undue stress, however, can interfere with communication.46'47 Research examining military family communication sug gests that couples are more apt to successfully deal with the stress of being separated during deployments when they plan communication activities, discuss affection, and remain pos itive and future-oriented through multiple communication modalities including telephone calls, letters, electronic mail, video messaging, and webcams.48 Maintaining consistent communication and the sharing of intimate information have been identified as important adaptive processes for couples dealing with the complexities of maintaining operational security.49 For example, a study examining PTSD and com munication found that for more satisfied couples, more com munication in the form of emails, packages, and letters during deployment was associated with lower PTSD symp toms postdeployment, whereas the opposite was true for those with lower marital satisfaction.60 When external mili tary stressors (such as PTSD from combat exposure) are experienced postdeployment, couples may be more likely to experience emotional distancing.61 Results from the Families Over Coming Under Stress program suggest that resiliencybased interventions (e.g., building family strengths of cohe sion, communication, and support) can lead to decreases in parental distress and unhealthy family functioning and reduced levels of impairment and distress.52 Lastly, civilian and military studies demonstrate that communication skills can be taught, and that these skills positively impact relation ship quality.53'54
Fam ily A p p raisal
Family appraisals assess: (1) the seriousness of any given stressor and (2) potential hardships resulting from the stressor, and (3) ways to adapt to crisis and strengthen the fam ily.10 Family narratives are ways that family members can create shared meaning. They can be a tool to bring up emotions, reactions, and ongoing concerns individuals have felt (or are feeling) in order to construct a shared appraisal that can help improve resilience.62 It is normal for family members to have multiple viewpoints and interpretations of the same event. Understanding these interpretations can help individ uals feel more empathy and view life as more manageable and meaningful.46 62 For military families, unique appraisal areas are associated with deployment and other aspects of the military lifestyle. For example, it can be challenging when there is not agree ment within the family about commitment to the military. On the other hand, stressors related to the military can increase stress and lead to more negative appraisals of the mission.63 High operational tempo and frequent moving are other com ponents of military life that can lead to increased issues within families. Lastly, the process of narrating deployment experiences in a way that acknowledges the fam ily’s past challenges and successes can organize and describe events in a way that enhances individual and family fitness.62 Families with a strong sense of coherence (appraising one’s world as manageable, meaningful and understandable) are more likely to adapt well after crises.10'64’65
A d a p ta b ility a n d Flexibility Cohesion
Cohesion is defined as emotional bonding between family members.5'6 Cohesive families integrate trust, appreciation, and support, and incorporate a balance between closeness and independence.15 55 56 Although most families aim for balanced levels of cohesion and independence, depending on the family life cycle phase, culture, etc., it may be adaptive for some families to be disengaged or very close— as long as everyone is in agreement.57 Problems in family functioning can occur if there are different needs for cohesion.67 In addition to its influence on overall family functioning, cohesion can be a valuable resource for couples.58 After reviewing civilian and (limited) military research on couple adaptation after injury, researchers suggest that cohesion can be enhanced by appraising challenge together (“as a ‘w e’ experience”).59 On the other hand, external military stressors, such as PTSD and experienced post deployment, are linked to lower relationship quality and more relational dissatisfaction, thus hindering positive cohesion.60 Lastly, Service members with PTSD in supportive relationships tend to use behavioral health services,61 whereas individuals with more severe PTSD symptoms are less likely to seek family- or coupleoriented treatment.60
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Flexibility is the ability to adjust to change while remaining stable.44 Family flexibility helps individuals rebound from and adapt to stressors and “bounce” forward.44'46 When confronted with stress, families assess and then respond to the situation.10 If the stressor continues, families must determine ways to fulfill everyday responsibilities while confronting the stress until either the family adjusts or the challenge disap pears.44'46 Theoretically, when the accumulation of stressors exceeds the ability to respond to stress or maintain balance, families are at risk for poor outcomes.44'46 Many military couples learn to adapt to the demands of deployments, which is sometimes referred to as “internal adaptation” where couples learn how to maintain their rela tionship within the military environment.21,43"57 Military families must also adapt to changes in roles, routines, and responsibilities within their family following the deploy ment.66 Military youth also adapt to parental deployments and exhibit the strength of blending in with new environments or peer groups.67 Despite adaptive adjustments for many families, there is evidence for some families that deployments are a consider able source of stress because of behavioral health conditions that disrupt family life, requiring time to adjust during the reintegration phase of the deployment cycle.68"70
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Total Force Fitness: The Military Family Fitness Model Reallocating family roles, routines, and functions; using available resources (e.g., family support groups); and focus ing on strengths and what one can control have been sug gested to help bolster families flexibility as each member adapts to new circumstances.71,72
Family Coping Family coping involves utilizing resources inside and outside the family to manage stressful situations as a “synergistic whole”— either through active or passive strategies or through behaviors to strengthen or maintain the stability and well-being of family m em bers.10 Along with individual coping styles, families must also cope as systems. Family problem-solving is a method of determining solutions to problems or stressful situations.10 Families who adaptively and proactively problem solve are less likely to accumulate stress over tim e.10,43,44 Positive family coping entails strategies that families employ to deal with problems while maintaining balance and caring for the needs of each family member in the system .10 Approach coping through direct interpersonal communication has been found to be associated with better family functioning with a family member suffering from chronic PTSD symptoms.73 Alternatively, happy couples use adaptive coping such as humor and affection to move beyond negativity in their dis cussion to continue conversations.74
Family Routines, Celebrations, and Traditions Routines and rituals stabilize and strengthen family connec tions and may build resilience in families.46’57,66’75 Routines and traditions include daily and periodic shared activities (family meals), sporting or music events, and annual celebra tory gatherings (holidays, birthdays, and reunions)46,56 cus tomized for each family.57 Likewise, for many families, preparations for separation and reunion are both anchored in and enriched by fam ilies’ religious/spiritual practices, cus toms, and/or traditions. Relocations and deployments disrupt normal routines and traditions, underscoring the importance of maintaining consistent family routines during relocations, deployments, and reunions.57,76
TABLE III. External Resources Military Leadership Influence Unit Support Social Support Network Community Resources (Civilian and Military) and Community Involvement
EXTERNAL RESOURCES Utilizing individual and family resources constitutes two resources in the process of developing a family fitness. The culture of military units and communities can be a resource of strength or source of stress for families. Some of the civilian and military resources that are available to military families to bolster their family fitness include relationship development, medical resources, family support programs, and a sense of belonging to a community.12,77,78 In this sec tion, we highlight the categories of leadership, unit support, social support, and community resources as key external strengthening resources that are available to support military families. We explore each category as potential moderators of the stress experienced by military families (Table III).
Military Leadership Influence The commitment of military leaders to support family well being surpasses that of most civilian employers79 and may contribute to the willingness of military families to take on the demands of the military.80 Research suggests that the concern that leaders demonstrate for the family during deployment produces a sense of community and “culture within” for families whereby they can better confront challenges. Fami lies feel a greater ability to meet demands when leadership is concerned and responsive to their needs.80 Leadership is also considered important for creating and maintaining the ties between Service members and their families, and it is also important for encouraging the military family to be involved . . . . . . 70 in civic activities. Leaders serve an important role in helping military cou ples manage work-life conflict. The most common predictor of work-life conflict is the workload or amount of work performed.81 Also supportive leadership may buffer trau matic stress symptoms from combat exposure.82 Based on a civilian study, subordinates that rated their supervisor as family supportive generally reported less work-family con flict, more job satisfaction, and greater compliance with the work safety program.83 There is a need in the military to appropriately support flexible work schedules and telework for parent-child relationships.84 Efforts of leaders to support work-life balance lead to work-family well-being.
Definition of External Resources
Leadership, social, unit and community that serves as resources of education and support to influence and motivate families to positive family fitness. The impact of military leaders’ influence and support of family work-life well-being which contributes to the willingness of military families to endure the demands of military life. Assistance and encouragement from unit personnel. An experience of being appreciated, loved, and/or assisted by other people and/or a social network. Support programs to enhance the ability of military families to maintain their well-being and cope effectively with challenges. Community involvement is the level of engagement between a military family and the community in which they reside.
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Unit Support An Army study showed the level of support provided to the family impacts the Service members commitment to the mil itary.85 Both unit and informal support is important for adap tive outcomes and adaptation by families.81 Unit culture that is supportive serves as a mediator of deployment-related stress on family quality of life.80 Unit cohesion is suggestive of lower levels of mental health conditions.86 In a qualitative study, female spouses generally found benefits to programs such as “Family Readiness Groups” (though not necessarily working spouses) and behavioral health while there were challenges, with both family care plans and caretaker issues for unit support processes.87 In general, support for families through the unit “family readiness group” helps families cope with deployment and separations because of extended training. Social Support Network While military leader and unit support can significantly impact military families’ efforts to achieve and maintain fitness, social support can have an influence as well. The findings from a qualitative study on adolescents with a deployed parent found that after their parents were deployed, some found both infor mal and formal support from within family and outside of family sources helpful in coping with the deployment. How ever, this varied across individuals.71For children, adolescents, and adults, it is important to have a supportive relationship or relationships for promoting resilience.9 Pets can be consid ered a member of the family and have also been shown to provide social support.88 Past research has also shown that an effective intervention for adolescent military family members includes involvement in social support networks.9'71 Belong ing to a community social network such as church, social groups, and community organizations can serve as a healthy counterbalance and safety net for military families coping with reintegration after separation and or loss. Community Resources (Civilian and Military) and Community Involvement The Department of Defense (DoD) provides support pro grams to enhance the ability of military families to maintain their well-being and cope effectively with challenges. Whether families reside on military installations or hundreds of miles from the closest member of their unit, a feeling of connection with the local community and its resources can influence levels of fitness. During Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF), the reliance of the Services on the National Guard and Reserve Component has increased. These families have reported difficulty in accessing continu ous support services and programs as their Service members move on and off of active duty.72 In an effort to mitigate the impact of the active duty transition on National Guard, Reserve, and other geographically dispersed families, pro grams such as the Joint Family Support Assistance Program
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were created to develop capacity within local communities to identify and meet the ongoing needs of military families who live off of military bases. Community involvement is defined here as the level of engagement between a community and the military families that reside there. When compared to past conflicts, there has been a notable difference in the support and engagement by federal and local government agencies as well as nongovern mental organizations seeking to help military families cope with the current challenges of the military life. The DoD has collaborated with other federal agencies, nonprofit organiza tions, and nationally recognized community-based services that offer established programs to ensure that these programs are accessible for Service members and their families who are geographically dispersed.89 Barriers to utilizing resources tended to fall into one of three interrelated categories: (1) awareness, (2) accessibility, and (3) acceptability.90 Com munication with military families regarding available resources remains among the toughest challenges and there fore it should be a top priority. A special consideration when examining these barriers is when the family transfers to a new location. In these situations, there is a loss of connection to neighbors, schools, and health care providers that the family established in their previous community, and there is a need for support in making those connections in their new location. This might be especially salient for behavioral health care, as the relocation necessitates establishing a relationship with a new provider who will require some time to understand family dynamics and issues in order to be maximally effective.
OUTCOMES The MFFM provides a theoretical framework for understanding family strengths and resources as well as a way of understand ing adaptive and maladaptive family outcomes (see Table IV). The model highlights the complex interplay among individual, family, and external resources that are theorized to be associ ated with adaptive and maladaptive family functioning. Fewer resources and greater areas of weakness are theorized within the MFFM to be associated with negative outcomes. Contrast ingly, more areas of strength are theorized to be associated with more adaptive outcomes. Below, specific maladaptive and adaptive outcomes are summarized and discussed. Some of the constructs of well-being that we envision as being important to family fitness are reflected in Table IV outcomes of interest. The following sections discuss adaptive outcomes which affect family fitness. Adaptive Outcomes Families who are better prepared for adversity within MFFM domains are theorized to have better and more adaptive out comes. For example, approach coping (e.g., trying to solve problems, making plans, keying into the positive in each situation, and proactively confronting hard situations) is asso ciated with better family functioning,73 and communicating
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Total Force Fitness: The Military Family Fitness Model TABLE IV.
MFFM Outcomes
Adaptive Outcomes Individual
Family
External
Approach coping with PTSD may improve family relationships/functioning50'73,91 Reduced risk for child emotional and behavioral problems44'93 Maternal Support98 Long-term resilience in children/fewer .• ■ 4 4 Q? negative emotions Increased family bonding49'92 Family support promotes resilience95 Adaptive coping/improved family functioning65 Better communication fosters resilience49 Marital satisfaction (postdeployment) lower PTSD50 Smooth job transition/job success/work family balance81'83 Perceived social support/improved parenting105 Job satisfaction/reduced work-family conflict81,83 Improved work performance and retention96
(keeping in contact and having more meaningful discussions) during deployment helps couple and family bonding, decreases stress, and fosters resilience.49'91 Particularly during times of family transitions, having a family understanding of events as comprehensible, manageable, and meaningful helps families adapt successfully.57'67 Family of origin parenting can have a lasting impact (either negative or positive) .44'92,93 For example, high-quality parenting (i.e., nurturing-involved parenting) is associated with long-term resilience in children, and fewer negative emotions and behavioral problems.44'92,93 On the other hand, other researchers found that hostile behaviors by parents to youth were repeated by those youth when they were parents, except when there was a co-parent who parented with warmth and support.94 They found that the warmth and support of the co-parent actually can disrupt the intergenerational transmis sion of harsh parenting from the other co-parent.94 Relationship status is associated with better psychological health and resilient outcomes. For example, a study of OEFOIF veterans found that being in a relationship was associ ated with lower PTSD rates and higher resilience. The study concluded that mitigating psychosocial stressors, increasing feelings of control and purpose, and enhancing family support may promote resilience postcombat.95 Additionally, a qualita tive study of Service members’ and their spouses’ experiences of deployment found that communicating, being flexible, and maintaining emotional intimacy were key characteristics of couples that adapted well during and after deployment.49 Accessing support outside the family can often build family strength as well. For example, social support from friends, family, and unit leaders has been associated with adaptive outcomes such as positive perceptions of parental behaviors,70 job success,81 and improved work-family balance.81,83 Family friendly work environments were also positively correlated with work performance and retention .96 Also, per ceived maternal support has been associated with lower risk
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Maladaptive Outcomes Psychological health problems impacting family (sleep disorders, sexual problems, depression, PTSD, adjustment disorders, suicide risk)51,60,63’98'99’104 Substance abuse100 Child depression101 Child psychosocial problems102 Increased use of health care59 Child abuse1114 Poor Couple Adjustment, Decreased marital/relationship satisfaction103 Relationship dissatisfaction (spouse and partner)51 Conflictual Communication64 Domestic violence, physical/ emotional Abuse103 Work-family conflict is often associated with higher levels of depression and physical symptoms81'83
for child conduct and emotional symptoms.97 The next section provides indicators for maladaptive outcomes for the family.
Maladaptive Outcomes Individuals do not operate in isolation of the family or the external environment. Stressors that occur within families or are external to families can impact individual family members. For example, stressful events, like combat expo sure and family separation, are more likely to be associated with negative individual and family outcomes such as psy chological fitness problems (i.e., depression, trauma, and PTSD symptoms) and family fitness problems (e.g., intimate relationship problems, decreased marital satisfaction, and poor family adjustment) .51,60,63,98 Negative interactions and/or higher relational dissatisfac tion are associated with an increased risk of suicide deaths,99 heavy drinking, 100 and an increased use of health care among Service members.59 Similarly, based on past research, paren tal deployment is associated with depression, both among the deployed and their children. 101 In studies of Army spouses of deployed military members, parental stress had the most sig nificant predictive value of psychosocial problems among chil dren. 102 For military couples, specific aspects of military life can challenge adaptive processes and resilient functioning. Service members who returned from deployment experiencing depression or PTSD symptoms experienced more difficulty adjusting to their family. 103 Additionally, Service members who recently returned from war reported increases in individ ual negative outcomes such as sleep problems, sex problems, and dissociation that were linked to decreased relationship satisfaction.51 Another study examining separated couples found that husbands with PTSD symptoms experienced lower marital satisfaction, parenting alliances, and spousal bonding. This study additionally found that both spouses exhibited higher levels of negative communication.63
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Total Force Fitness: The Military Family Fitness Model Families with poor coping skills may also be at greater risk for domestic violence. Specifically, recent research has found that the presence of family readjustment problems is associated with physical and emotional abuse within families, with abuse (defined as shouting, pushing, or shoving during an argument) occurring in 53.7% of the families surveyed. The same study found that family reintegration is more likely to be problematic for those with PTSD and depression.'113 Furthermore, a study of parents enrolled in Army-sponsored home visitation programs indicated that common child abuse predictors for both mother and father are depression, family strife, and parental stress. Gender-specific risks include low family expressivity for fathers, whereas limited family cohe sion, low support, and marital displeasure indicated risks for m others.104 These outcomes, as well as the other existing MFFM domains, can be assessed through some potential metrics offered.
TABLE V. Resource/Domain Individual Resource Domains Family Systems Couple Subsystem
Parent-Child Subsystem General Family Functioning Family Resource Domains Family Appraisal Cohesion Adaptability and Flexibility
Communication
Coping (Coping now includes Family Problem Solving)
Routines and Traditions External Resource Domains Leadership Community and Social Support Unit Support Community Resources and Involvement
POTENTIAL METRICS The MFFM provides a resource framework in which MFFM domains can be measured. Each of the services of the DoD continue to evolve their assessments of the individ ual, family, and external unit/organization for fitness and resilience. Although each service already has various approaches to assess family health, we offer a comprehen sive model of what we believe to be the critical domains that can be assessed. A group of civilian and military researchers identified potential metrics available across MFFM domains. Although the group did not do a full systematic review of all family metrics, the initial appraisal of metrics identified several metrics that on further evaluation may show promise for assessing the domains identified in the MFFM. Metrics were identified in all domains in the family assessments except family appraisal. Group consensus was used to assess which
MFFM Resources, Domains, and Metrics Metrics (Refer to Psychological Fitness12 for further information) Dyadic Adjustment Scale (DAS)1 Marital Instability Index (M il)107 Quality of Marriage Index108 Conflict Tactics Scale— Revised (CTS-R)109 Communication Patterns Questionnaire (CPQ)110'111 Alabama Parenting Questionnaire— 9 (APQ)112 McMaster Family Assessment Device (FAD)113 No assessment found at this time. Family Adaptability and Cohesion Evaluation Scales (FACES IV)55,114 Family Adaptability and Cohesion Evaluation Scales (FACES IV)53’114 Family Adaption Scale (FAS)64 Self-report Family Inventory (SFI)115 Communication Patterns Questionnaire (CPQ)110’111 McMaster Family Assessment Device (FAD)113 Communication Subscale-FACES IV55' 114 Family Adaption Scale (FAS)54 Self-report Family Inventory (SFI)115 Family Crisis Oriented Personal Evaluation Scale (F-COPES)" Family Crisis Oriented Personal Evaluation Scale (F-COPES)
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Total Force Fitness: The Military Family Fitness Model COL Stephen V. Bowles, MS USA*; Liz Davenport Pollock, P hD f; Monique Moore, P hD f; Shelley MacDermid Wadsworth, PhD§; Colanda Cato, P hD f; Judith Ward Dekle, MSW/I; Sonia Wei Meyer, BSjj; Am ber Shriver, BS**; Col Bill Mueller, USAF M C ff; CAPT Mark Stephens, MC U S N Jf; SFC Dustin A. Seidler, ARNG§§; CDR Joseph Sheldon, CH USNHH; COL James Picano, MS USAR (Ret.)TjJI; CAPT Wanda Finch, USPHSf; COL Ricardo Morales, USA***; Col Sean Blochberger, USMC (Ret.)*; CAPT Matthew E. Kleiman, U S P F IS ttt; SGM Daniel Thompson, SF U S A R ftt; Lt Col Mark J. Bates, USAF, BSC (Ret.)f
ABSTRACT The military lifestyle can create formidable challenges for military families. This article describes the Military Family Fitness Model (MFFM), a comprehensive model aimed at enhancing family fitness and resilience across the life span. This model is intended for use by Service members, their families, leaders, and health care providers but also has broader applications for all families. The MFFM has three core components: (1) family demands, (2) resources (including individual resources, family resources, and external resources), and (3) family outcomes (including related metrics). The MFFM proposes that resources from the individual, family, and external areas promote fitness, bolster resilience, and foster well-being for the family. The MFFM highlights each resource level for the purpose of improving family fitness and resilience over time. The MFFM both builds on existing family strengths and encourages the development of new family strengths through resource-acquiring behaviors. The purpose of this article is to (1) expand the military’s Total Force Fitness (TFF) intent as it relates to families and (2) offer a family fitness model. This article will summarize relevant evidence, provide supportive theory, describe the model, and proffer metrics that support the dimensions of this model.
INTRODUCTION The U.S. Military is composed of nearly 1.38 million active duty members with over 1.94 million dependents, including spouses, children, and adult dependents.1 There are over 848,000 Service members combined in the Reserve and National Guard with over 1.1 million family members.1 Mil itary service typically requires frequent moves2 and many occupational categories carry the risk of injury and/or death.
The complex and uncertain global environment the modern military faces places continuous demands on military families. Families are critical components of Service member fitness and are essential to the well-being of the military as an enter prise. It is important, therefore, to develop a model to assess and support military family fitness. The Military Family Fitness Model (MFFM) is multifaceted based on conceptual theory and empirical literature. The
*The Eisenhower School, National Defense University, 408 4th Ave nue, Washington, DC 20319. tDepartment of Military and Emergency Medicine, Human Perfor mance Resource Center, Uniformed Services University of Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814. ^Defense Centers of Excellence for Psychological Health & Traumatic Brain Injury, 1335 East West Highway, 9th Floor, Silver Spring, MD 20910. §Military Family Research Institute, Purdue University, Hanley Hall, Room 210, 1202 West State Street, West Lafayette, IN 47907. ||Department of Defense, Military and Community Family Policy, Pentagon, Washington, DC 20301. ^Beijing University of Aeronautics and Astronautics, XueYuan Road No. 37, HaiDian District, Beijing, China. **Department of Psychology, George Mason University, 4400 University Drive, Fairfax, VA 22030.
ttHuman Systems Integration Directorate, 711 HPW/HP, 2510 Fifth Street, Room W400E, Wright Patterson AFB, OH 45433. $^Department of Family Medicine, Uniformed Services University of Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814. §§Department of Psychology, Southern Illinois University, Carbondale, IL 62901. ||||Office of Religious Affairs (Jl), The Pentagon, Room 2C856, Washington, DC 20318. ^Department of Veterans Affairs, Northern California Health Care System, 150 Muir Road, Martinez, CA 94553. ***5th Brigade, U.S. Army Cadet Command, San Antonio, TX 78204. tttBehavioral Health Services Division, United State Coast Guard, 2703 Martin King Jr Avenue, Southeast, Washington, DC 20593-7907. j^ W arrior Transition Unit, Fort Bragg, NC 28310 doi: 10.7205/MILMED- D-13-00416
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Total Force Fitness: The Military Family Fitness Model
Resources Fam ily Fitness O u tc o m e
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FIGURE 1.
Military Family Fitness Model.
MFFM highlights potential areas of individual, family, and external strength-building resources that can foster adaptive outcomes as well as prevent or mitigate maladaptive out comes for military families3 (Fig. 1). There is a need for an integrated model of family fitness and a framework to identify effective resources. A previous family fitness-focused model was based on one branch of the service.4 The purpose of this paper is to (1) build on the military’s Total Force Fitness ( IFF) intent as it relates to families and (2) offer a model for family fitness. This article will summarize relevant evidence, provide supportive theory, describe the model, and proffer metrics that support the dimensions of this model. The TFF paradigm focuses on promoting holistic Service member health, families’ health, readiness, and optimal performance (Fig. 2).5 Using relevant evidence with supportive theory, we
FIGURE 2.
Total Force Fitness Model.
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describe the model, and offer metrics to support relevant out comes for each dimension of the proposed model.
DEFINITION OF FAMILY FITNESS AND RESILIENCE Military families are as diverse as civilian families. They vary in structure and include, however are not limited to, nuclear families, intergenerational families, blended families, and single-parent families. Moreover, they also vary in organiza tion, including female, male, and dual-headed households as well as households including significant others.6 Families also vary in experience, including both recently formed families as well as families that have experienced divorce and death. Additionally, military families (as well as civilian) vary in ethnic and cultural representation, including both domestic minority groups and foreign-born members. Regardless of structure, all military families face unique challenges and opportunities related to military service and culture. Family fitness refers to the ability of families to effec tively cope with the challenges posed by military service. Family fitness is the dynamic process of reinforcing current skills and resources and/or acquiring new skills and resources to create a resilient or “fit” family system. This dynamic process of acquiring resources (at the individual, family, and external levels) to manage competing family demands can result in adaptive (emotional well-being, effective communi cation, improved family functioning) and/or maladaptive out comes (spouse/child abuse, work-family conflict) that together determine general family fitness. All members of military families should have access to the resources and programs for proactive support. It is important to distinguish between family “fitness” and family “resilience.” By definition, resilient families adapt
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Total Force Fitness: The Military Family Fitness Model effectively and become stronger following adverse events.7-11 In contrast, fit families have not necessarily encountered adverse events, but will likely exhibit resilience in the face of adversity.7-11 Fit, or “ready,” families are knowledgeable about potential challenges and equipped with the necessary skills to competently face those challenges. They are aware of and able to use resources available to them. Fit families function successfully in supportive environments that allow for healthy individual development and well-being. Being fit does not make families immune to the daily struggles and hassles of life. This prepares families to respond effectively to difficulties, access support/resources as needed, and develop a better capacity to become resilient when adverse or trau matic situation occur for the family. A key assumption of the MFFM is that characteristics of fit families can be learned. Therefore, identifying both adaptive and maladaptive responses to familial stress is important. This concept is anal ogous to preparing for athletic competition— successful prac tice improves real-life performance.
METHODS AND APPROACH A team of military and civilian health professionals conducted an extensive literature review of the best available evidence pertaining to resilience and family fitness. Databases, includ ing Ebsco, PubMed, Psyc Info, OVID, and Google Scholar, were systematically reviewed using key search terms and search arrays for English language articles dated 2001 to 2013 from peer-reviewed journals.
THEORETICAL FRAMEWORK FOR MFFM The MFFM was designed to complement the TFF model by focusing on the demands and resources related to psycholog ical health outcomes. The underlying framework of demands and resources integrates two empirically supported models that provide demand-resource perspectives of systems func tioning on community and organization levels.11-14 The MFFM is also influenced by family systems models including the Double ABCX model of family stress,10 the Circumplex Model of Family A daptability,15 and the Family Fitness Model (an early version of the M FFM ).16
TABLE I. Individual Resources
Individual Characteristics Awareness Emotional Intelligence Spirituality Decision making
Coping
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The theory of demands and resources posits that stress places a demand on an individual or families who must then utilize existing resources (external and internal) to promote adaptive outcomes. Previous studies have used this perspec tive as a method of conceptualizing fam ilies.17'18 The MFFM framework builds on this theory to identify specific demands, resources, and outcomes. Individuals, families, and support agencies should be able to easily use this framework to edu cate and support family systems. Leaders can provide guid ance with this framework by systematically providing resource awareness and support for families. This framework empha sizes family strengths that can be taught and practiced. Key features of the MFFM also include a systems perspective with interface between (1) the individual, (2) the family, and (3) the external environmental stakeholders (e.g., leader, unit, social support system, military, and civilian community).
INDIVIDUAL RESOURCES Identifying and utilizing resources for each family member is key to building family fitness. The MFFM recognizes the following individual dimensions: individual characteristics, awareness, emotional intelligence, spirituality, decision mak ing, and coping. Family members’ individual resources can interface both adaptively and maladaptively with the family system. Previously defined psychological fitness resources12 that also serve as individual family resources include practic ing adaptive coping strategies,19'20 for example, problemfocused coping found in a submarine mission21; marines receiving mental fitness training before deployment reported acting with greater awareness and decrease in perceived stress22; and working on a team while making a decision (like a family) has been found to be more effective than an indi vidual making a decision.23 Communication is a critical indi vidual resource that will be discussed in the family section.24 Individual characteristics, emotional intelligence, and spiritu ality are the other MFFM individual resources that will be described below (Table I).
Individual Characteristics Individual characteristics are qualities of temperament, emo tion, or behavior displayed by individual family members.
Definition of Individual Resources
Individual characteristics, skills, abilities and experiences used in combination with other family members resources that impact the individual and family. Maintaining and building individual resources for each family member is key to building the adaptive family in the MFFM. Individual resources can interface both positively and negatively with the family system to influence family fitness. Qualities of temperament, emotion, or behavior displayed by an individual (e.g., self-confidence, optimism, or hardiness). The ability to accurately perceive relevant stimuli from the environment while ignoring irrelevant stimuli. 12 The ability to accurately assess others and one’s own emotions and feelings. An individual’s personal experience in the existential search for purpose and meaning in life. The process by which an individual uses thoughts and behaviors to evaluate and choose steps in order to meet a preconceived goal. 13 Decision-making includes both rational and intuitive thinking processes that influence how an individual makes personal choices and responds to challenges. 12 The ability to manage stress in order to maintain optimal health and performance. 12
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The characteristics of individuals may impact the ability of the family unit to manage stress. For example, certain prom inent resilience characteristics such as self-confidence, opti mism, and perseverance were found in single parents following the death of a spouse.25 Additionally, personality characteristics such as courage negatively correlate with anx iety in children,26 and empathy negatively correlates with abusive behaviors in low income mothers.27 Parental charac teristics such as agreeableness, emotional stability, and extra version are shown to play a role in the development of these same characteristics in adolescents. The named characteris tics also predict later education success, higher income, and competent parenting in those same adolescents.28 Hardiness, a characteristic previously found in military populations, may also be an effective factor for families and couples.29” 3 1 Emotional Intelligence Emotional intelligence is defined as the ability to accurately recognize self-emotions and others emotions, as well as the ability to use knowledge pertaining to emotions to enhance one’s thinking processes about a personal or social situa tion .3'-'33 Research has shown that individuals that score higher in emotional intelligence have greater marital satis faction than those scoring lower in emotional intelligence.34 Furthermore, emotional intelligence leads to higher quality relationships in groups that are characterized by sharing, sup port, and trust.35 Finally, one review of emotional intelli gence research found that this concept may be predictive of several aspects of psychological health .36 Spirituality “Spirituality” can best be understood as an individual’s per sonal experience in the existential search for purpose and meaning in life. Spiritual practices that are expressions of spiritual values and beliefs, include prayer, meditation, service, devotion, psychophysical exercise, ethical conduct, study of sacred texts, mindfulness, and concentration .37 Past research has found that religiosity and spiritual well-being may reduce anxiety and depressive symptoms.38 Service members that reported medium levels of spirituality and combat exposure are able to buffer depression and post-traumatic stress disor
TABLE II. Family Resources Communication Cohesion Appraisal Adaptability/Flexibility Coping Routines, Celebrations, and Traditions
der (PTSD) symptoms.39 Atheists or those who profess no religious affiliation may experience similar results if they are grounded in strong philosophical values and beliefs. The spirituality of individual members and the interface with the family may be especially important given the adverse cir cumstances military families face given operational environ ments. Although individual fitness is an important component of the MFFM, it is not the only factor, which influences overall family fitness. FAMILY RESOURCES Family relationships can be significant sources of support and play a crucial foundational role in total family fitness.40 According to family systems theory, every family is com posed of multiple subsystems; we will focus on the couple and parent-child subsystems.41,42 The couple subsystem is the primary control subsystem for families.41 Military cou ples, despite the hardships of frequent separation, often main tain satisfying relationships43 that can positively impact and strengthen the entire family. The second subsystem, the parent-child subsystem, can also provide valuable buffering against stress and increase family resilience.44 For example, children whose parents (or other supportive adults) treat them with high levels of warmth and low levels of hostility are more likely to display resilience in the long term .4 Changes to subsystem dynamics can create additional challenges to resilience across the life cycle, especially when the family constellation changes as a result of divorce, remar riage, injury, or death. Depending on the nature of challenges faced, adjustments required, and resources available, all fam ilies might require additional strengths and skills. The fol lowing family skills and attributes may help strengthen and maintain family fitness for families: communication, cohe sion, appraisal, adaptability/flexibility, coping and routines, celebrations, and traditions (Table II). Communication A definition previously used for couples, which can be adapted for families, notes that communication entails both listening for and expressing thoughts and feelings, as well as decision-related problem solving.45 Communication that
Definition of Family Resources
Family skills and abilities that strengthen the family. Communication entails both listening for and expressing thoughts and feelings, as well as decision related problem solving. The emotional bonding between family members. The ability to assess the seriousness of a situation and ways for the family can adapt. The ability to adjust to change while remaining stable. Strategies that families employ to deal with problems while maintaining balance and caring for family members’ needs. Routines and rituals can stabilize and strengthen family connections and include daily and periodic shared activities, sporting or music events, and annual gatherings.
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Total Force Fitness: The Military Family Fitness Model promotes resilience is clear and incorporates open expression to convey feelings and or resolve conflicts.45 46 Undue stress, however, can interfere with communication.46'47 Research examining military family communication sug gests that couples are more apt to successfully deal with the stress of being separated during deployments when they plan communication activities, discuss affection, and remain pos itive and future-oriented through multiple communication modalities including telephone calls, letters, electronic mail, video messaging, and webcams.48 Maintaining consistent communication and the sharing of intimate information have been identified as important adaptive processes for couples dealing with the complexities of maintaining operational security.49 For example, a study examining PTSD and com munication found that for more satisfied couples, more com munication in the form of emails, packages, and letters during deployment was associated with lower PTSD symp toms postdeployment, whereas the opposite was true for those with lower marital satisfaction.60 When external mili tary stressors (such as PTSD from combat exposure) are experienced postdeployment, couples may be more likely to experience emotional distancing.61 Results from the Families Over Coming Under Stress program suggest that resiliencybased interventions (e.g., building family strengths of cohe sion, communication, and support) can lead to decreases in parental distress and unhealthy family functioning and reduced levels of impairment and distress.52 Lastly, civilian and military studies demonstrate that communication skills can be taught, and that these skills positively impact relation ship quality.53'54
Fam ily A p p raisal
Family appraisals assess: (1) the seriousness of any given stressor and (2) potential hardships resulting from the stressor, and (3) ways to adapt to crisis and strengthen the fam ily.10 Family narratives are ways that family members can create shared meaning. They can be a tool to bring up emotions, reactions, and ongoing concerns individuals have felt (or are feeling) in order to construct a shared appraisal that can help improve resilience.62 It is normal for family members to have multiple viewpoints and interpretations of the same event. Understanding these interpretations can help individ uals feel more empathy and view life as more manageable and meaningful.46 62 For military families, unique appraisal areas are associated with deployment and other aspects of the military lifestyle. For example, it can be challenging when there is not agree ment within the family about commitment to the military. On the other hand, stressors related to the military can increase stress and lead to more negative appraisals of the mission.63 High operational tempo and frequent moving are other com ponents of military life that can lead to increased issues within families. Lastly, the process of narrating deployment experiences in a way that acknowledges the fam ily’s past challenges and successes can organize and describe events in a way that enhances individual and family fitness.62 Families with a strong sense of coherence (appraising one’s world as manageable, meaningful and understandable) are more likely to adapt well after crises.10'64’65
A d a p ta b ility a n d Flexibility Cohesion
Cohesion is defined as emotional bonding between family members.5'6 Cohesive families integrate trust, appreciation, and support, and incorporate a balance between closeness and independence.15 55 56 Although most families aim for balanced levels of cohesion and independence, depending on the family life cycle phase, culture, etc., it may be adaptive for some families to be disengaged or very close— as long as everyone is in agreement.57 Problems in family functioning can occur if there are different needs for cohesion.67 In addition to its influence on overall family functioning, cohesion can be a valuable resource for couples.58 After reviewing civilian and (limited) military research on couple adaptation after injury, researchers suggest that cohesion can be enhanced by appraising challenge together (“as a ‘w e’ experience”).59 On the other hand, external military stressors, such as PTSD and experienced post deployment, are linked to lower relationship quality and more relational dissatisfaction, thus hindering positive cohesion.60 Lastly, Service members with PTSD in supportive relationships tend to use behavioral health services,61 whereas individuals with more severe PTSD symptoms are less likely to seek family- or coupleoriented treatment.60
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Flexibility is the ability to adjust to change while remaining stable.44 Family flexibility helps individuals rebound from and adapt to stressors and “bounce” forward.44'46 When confronted with stress, families assess and then respond to the situation.10 If the stressor continues, families must determine ways to fulfill everyday responsibilities while confronting the stress until either the family adjusts or the challenge disap pears.44'46 Theoretically, when the accumulation of stressors exceeds the ability to respond to stress or maintain balance, families are at risk for poor outcomes.44'46 Many military couples learn to adapt to the demands of deployments, which is sometimes referred to as “internal adaptation” where couples learn how to maintain their rela tionship within the military environment.21,43"57 Military families must also adapt to changes in roles, routines, and responsibilities within their family following the deploy ment.66 Military youth also adapt to parental deployments and exhibit the strength of blending in with new environments or peer groups.67 Despite adaptive adjustments for many families, there is evidence for some families that deployments are a consider able source of stress because of behavioral health conditions that disrupt family life, requiring time to adjust during the reintegration phase of the deployment cycle.68"70
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Total Force Fitness: The Military Family Fitness Model Reallocating family roles, routines, and functions; using available resources (e.g., family support groups); and focus ing on strengths and what one can control have been sug gested to help bolster families flexibility as each member adapts to new circumstances.71,72
Family Coping Family coping involves utilizing resources inside and outside the family to manage stressful situations as a “synergistic whole”— either through active or passive strategies or through behaviors to strengthen or maintain the stability and well-being of family m em bers.10 Along with individual coping styles, families must also cope as systems. Family problem-solving is a method of determining solutions to problems or stressful situations.10 Families who adaptively and proactively problem solve are less likely to accumulate stress over tim e.10,43,44 Positive family coping entails strategies that families employ to deal with problems while maintaining balance and caring for the needs of each family member in the system .10 Approach coping through direct interpersonal communication has been found to be associated with better family functioning with a family member suffering from chronic PTSD symptoms.73 Alternatively, happy couples use adaptive coping such as humor and affection to move beyond negativity in their dis cussion to continue conversations.74
Family Routines, Celebrations, and Traditions Routines and rituals stabilize and strengthen family connec tions and may build resilience in families.46’57,66’75 Routines and traditions include daily and periodic shared activities (family meals), sporting or music events, and annual celebra tory gatherings (holidays, birthdays, and reunions)46,56 cus tomized for each family.57 Likewise, for many families, preparations for separation and reunion are both anchored in and enriched by fam ilies’ religious/spiritual practices, cus toms, and/or traditions. Relocations and deployments disrupt normal routines and traditions, underscoring the importance of maintaining consistent family routines during relocations, deployments, and reunions.57,76
TABLE III. External Resources Military Leadership Influence Unit Support Social Support Network Community Resources (Civilian and Military) and Community Involvement
EXTERNAL RESOURCES Utilizing individual and family resources constitutes two resources in the process of developing a family fitness. The culture of military units and communities can be a resource of strength or source of stress for families. Some of the civilian and military resources that are available to military families to bolster their family fitness include relationship development, medical resources, family support programs, and a sense of belonging to a community.12,77,78 In this sec tion, we highlight the categories of leadership, unit support, social support, and community resources as key external strengthening resources that are available to support military families. We explore each category as potential moderators of the stress experienced by military families (Table III).
Military Leadership Influence The commitment of military leaders to support family well being surpasses that of most civilian employers79 and may contribute to the willingness of military families to take on the demands of the military.80 Research suggests that the concern that leaders demonstrate for the family during deployment produces a sense of community and “culture within” for families whereby they can better confront challenges. Fami lies feel a greater ability to meet demands when leadership is concerned and responsive to their needs.80 Leadership is also considered important for creating and maintaining the ties between Service members and their families, and it is also important for encouraging the military family to be involved . . . . . . 70 in civic activities. Leaders serve an important role in helping military cou ples manage work-life conflict. The most common predictor of work-life conflict is the workload or amount of work performed.81 Also supportive leadership may buffer trau matic stress symptoms from combat exposure.82 Based on a civilian study, subordinates that rated their supervisor as family supportive generally reported less work-family con flict, more job satisfaction, and greater compliance with the work safety program.83 There is a need in the military to appropriately support flexible work schedules and telework for parent-child relationships.84 Efforts of leaders to support work-life balance lead to work-family well-being.
Definition of External Resources
Leadership, social, unit and community that serves as resources of education and support to influence and motivate families to positive family fitness. The impact of military leaders’ influence and support of family work-life well-being which contributes to the willingness of military families to endure the demands of military life. Assistance and encouragement from unit personnel. An experience of being appreciated, loved, and/or assisted by other people and/or a social network. Support programs to enhance the ability of military families to maintain their well-being and cope effectively with challenges. Community involvement is the level of engagement between a military family and the community in which they reside.
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Unit Support An Army study showed the level of support provided to the family impacts the Service members commitment to the mil itary.85 Both unit and informal support is important for adap tive outcomes and adaptation by families.81 Unit culture that is supportive serves as a mediator of deployment-related stress on family quality of life.80 Unit cohesion is suggestive of lower levels of mental health conditions.86 In a qualitative study, female spouses generally found benefits to programs such as “Family Readiness Groups” (though not necessarily working spouses) and behavioral health while there were challenges, with both family care plans and caretaker issues for unit support processes.87 In general, support for families through the unit “family readiness group” helps families cope with deployment and separations because of extended training. Social Support Network While military leader and unit support can significantly impact military families’ efforts to achieve and maintain fitness, social support can have an influence as well. The findings from a qualitative study on adolescents with a deployed parent found that after their parents were deployed, some found both infor mal and formal support from within family and outside of family sources helpful in coping with the deployment. How ever, this varied across individuals.71For children, adolescents, and adults, it is important to have a supportive relationship or relationships for promoting resilience.9 Pets can be consid ered a member of the family and have also been shown to provide social support.88 Past research has also shown that an effective intervention for adolescent military family members includes involvement in social support networks.9'71 Belong ing to a community social network such as church, social groups, and community organizations can serve as a healthy counterbalance and safety net for military families coping with reintegration after separation and or loss. Community Resources (Civilian and Military) and Community Involvement The Department of Defense (DoD) provides support pro grams to enhance the ability of military families to maintain their well-being and cope effectively with challenges. Whether families reside on military installations or hundreds of miles from the closest member of their unit, a feeling of connection with the local community and its resources can influence levels of fitness. During Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF), the reliance of the Services on the National Guard and Reserve Component has increased. These families have reported difficulty in accessing continu ous support services and programs as their Service members move on and off of active duty.72 In an effort to mitigate the impact of the active duty transition on National Guard, Reserve, and other geographically dispersed families, pro grams such as the Joint Family Support Assistance Program
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were created to develop capacity within local communities to identify and meet the ongoing needs of military families who live off of military bases. Community involvement is defined here as the level of engagement between a community and the military families that reside there. When compared to past conflicts, there has been a notable difference in the support and engagement by federal and local government agencies as well as nongovern mental organizations seeking to help military families cope with the current challenges of the military life. The DoD has collaborated with other federal agencies, nonprofit organiza tions, and nationally recognized community-based services that offer established programs to ensure that these programs are accessible for Service members and their families who are geographically dispersed.89 Barriers to utilizing resources tended to fall into one of three interrelated categories: (1) awareness, (2) accessibility, and (3) acceptability.90 Com munication with military families regarding available resources remains among the toughest challenges and there fore it should be a top priority. A special consideration when examining these barriers is when the family transfers to a new location. In these situations, there is a loss of connection to neighbors, schools, and health care providers that the family established in their previous community, and there is a need for support in making those connections in their new location. This might be especially salient for behavioral health care, as the relocation necessitates establishing a relationship with a new provider who will require some time to understand family dynamics and issues in order to be maximally effective.
OUTCOMES The MFFM provides a theoretical framework for understanding family strengths and resources as well as a way of understand ing adaptive and maladaptive family outcomes (see Table IV). The model highlights the complex interplay among individual, family, and external resources that are theorized to be associ ated with adaptive and maladaptive family functioning. Fewer resources and greater areas of weakness are theorized within the MFFM to be associated with negative outcomes. Contrast ingly, more areas of strength are theorized to be associated with more adaptive outcomes. Below, specific maladaptive and adaptive outcomes are summarized and discussed. Some of the constructs of well-being that we envision as being important to family fitness are reflected in Table IV outcomes of interest. The following sections discuss adaptive outcomes which affect family fitness. Adaptive Outcomes Families who are better prepared for adversity within MFFM domains are theorized to have better and more adaptive out comes. For example, approach coping (e.g., trying to solve problems, making plans, keying into the positive in each situation, and proactively confronting hard situations) is asso ciated with better family functioning,73 and communicating
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Total Force Fitness: The Military Family Fitness Model TABLE IV.
MFFM Outcomes
Adaptive Outcomes Individual
Family
External
Approach coping with PTSD may improve family relationships/functioning50'73,91 Reduced risk for child emotional and behavioral problems44'93 Maternal Support98 Long-term resilience in children/fewer .• ■ 4 4 Q? negative emotions Increased family bonding49'92 Family support promotes resilience95 Adaptive coping/improved family functioning65 Better communication fosters resilience49 Marital satisfaction (postdeployment) lower PTSD50 Smooth job transition/job success/work family balance81'83 Perceived social support/improved parenting105 Job satisfaction/reduced work-family conflict81,83 Improved work performance and retention96
(keeping in contact and having more meaningful discussions) during deployment helps couple and family bonding, decreases stress, and fosters resilience.49'91 Particularly during times of family transitions, having a family understanding of events as comprehensible, manageable, and meaningful helps families adapt successfully.57'67 Family of origin parenting can have a lasting impact (either negative or positive) .44'92,93 For example, high-quality parenting (i.e., nurturing-involved parenting) is associated with long-term resilience in children, and fewer negative emotions and behavioral problems.44'92,93 On the other hand, other researchers found that hostile behaviors by parents to youth were repeated by those youth when they were parents, except when there was a co-parent who parented with warmth and support.94 They found that the warmth and support of the co-parent actually can disrupt the intergenerational transmis sion of harsh parenting from the other co-parent.94 Relationship status is associated with better psychological health and resilient outcomes. For example, a study of OEFOIF veterans found that being in a relationship was associ ated with lower PTSD rates and higher resilience. The study concluded that mitigating psychosocial stressors, increasing feelings of control and purpose, and enhancing family support may promote resilience postcombat.95 Additionally, a qualita tive study of Service members’ and their spouses’ experiences of deployment found that communicating, being flexible, and maintaining emotional intimacy were key characteristics of couples that adapted well during and after deployment.49 Accessing support outside the family can often build family strength as well. For example, social support from friends, family, and unit leaders has been associated with adaptive outcomes such as positive perceptions of parental behaviors,70 job success,81 and improved work-family balance.81,83 Family friendly work environments were also positively correlated with work performance and retention .96 Also, per ceived maternal support has been associated with lower risk
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Maladaptive Outcomes Psychological health problems impacting family (sleep disorders, sexual problems, depression, PTSD, adjustment disorders, suicide risk)51,60,63’98'99’104 Substance abuse100 Child depression101 Child psychosocial problems102 Increased use of health care59 Child abuse1114 Poor Couple Adjustment, Decreased marital/relationship satisfaction103 Relationship dissatisfaction (spouse and partner)51 Conflictual Communication64 Domestic violence, physical/ emotional Abuse103 Work-family conflict is often associated with higher levels of depression and physical symptoms81'83
for child conduct and emotional symptoms.97 The next section provides indicators for maladaptive outcomes for the family.
Maladaptive Outcomes Individuals do not operate in isolation of the family or the external environment. Stressors that occur within families or are external to families can impact individual family members. For example, stressful events, like combat expo sure and family separation, are more likely to be associated with negative individual and family outcomes such as psy chological fitness problems (i.e., depression, trauma, and PTSD symptoms) and family fitness problems (e.g., intimate relationship problems, decreased marital satisfaction, and poor family adjustment) .51,60,63,98 Negative interactions and/or higher relational dissatisfac tion are associated with an increased risk of suicide deaths,99 heavy drinking, 100 and an increased use of health care among Service members.59 Similarly, based on past research, paren tal deployment is associated with depression, both among the deployed and their children. 101 In studies of Army spouses of deployed military members, parental stress had the most sig nificant predictive value of psychosocial problems among chil dren. 102 For military couples, specific aspects of military life can challenge adaptive processes and resilient functioning. Service members who returned from deployment experiencing depression or PTSD symptoms experienced more difficulty adjusting to their family. 103 Additionally, Service members who recently returned from war reported increases in individ ual negative outcomes such as sleep problems, sex problems, and dissociation that were linked to decreased relationship satisfaction.51 Another study examining separated couples found that husbands with PTSD symptoms experienced lower marital satisfaction, parenting alliances, and spousal bonding. This study additionally found that both spouses exhibited higher levels of negative communication.63
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Total Force Fitness: The Military Family Fitness Model Families with poor coping skills may also be at greater risk for domestic violence. Specifically, recent research has found that the presence of family readjustment problems is associated with physical and emotional abuse within families, with abuse (defined as shouting, pushing, or shoving during an argument) occurring in 53.7% of the families surveyed. The same study found that family reintegration is more likely to be problematic for those with PTSD and depression.'113 Furthermore, a study of parents enrolled in Army-sponsored home visitation programs indicated that common child abuse predictors for both mother and father are depression, family strife, and parental stress. Gender-specific risks include low family expressivity for fathers, whereas limited family cohe sion, low support, and marital displeasure indicated risks for m others.104 These outcomes, as well as the other existing MFFM domains, can be assessed through some potential metrics offered.
TABLE V. Resource/Domain Individual Resource Domains Family Systems Couple Subsystem
Parent-Child Subsystem General Family Functioning Family Resource Domains Family Appraisal Cohesion Adaptability and Flexibility
Communication
Coping (Coping now includes Family Problem Solving)
Routines and Traditions External Resource Domains Leadership Community and Social Support Unit Support Community Resources and Involvement
POTENTIAL METRICS The MFFM provides a resource framework in which MFFM domains can be measured. Each of the services of the DoD continue to evolve their assessments of the individ ual, family, and external unit/organization for fitness and resilience. Although each service already has various approaches to assess family health, we offer a comprehen sive model of what we believe to be the critical domains that can be assessed. A group of civilian and military researchers identified potential metrics available across MFFM domains. Although the group did not do a full systematic review of all family metrics, the initial appraisal of metrics identified several metrics that on further evaluation may show promise for assessing the domains identified in the MFFM. Metrics were identified in all domains in the family assessments except family appraisal. Group consensus was used to assess which
MFFM Resources, Domains, and Metrics Metrics (Refer to Psychological Fitness12 for further information) Dyadic Adjustment Scale (DAS)1 Marital Instability Index (M il)107 Quality of Marriage Index108 Conflict Tactics Scale— Revised (CTS-R)109 Communication Patterns Questionnaire (CPQ)110'111 Alabama Parenting Questionnaire— 9 (APQ)112 McMaster Family Assessment Device (FAD)113 No assessment found at this time. Family Adaptability and Cohesion Evaluation Scales (FACES IV)55,114 Family Adaptability and Cohesion Evaluation Scales (FACES IV)53’114 Family Adaption Scale (FAS)64 Self-report Family Inventory (SFI)115 Communication Patterns Questionnaire (CPQ)110’111 McMaster Family Assessment Device (FAD)113 Communication Subscale-FACES IV55' 114 Family Adaption Scale (FAS)54 Self-report Family Inventory (SFI)115 Family Crisis Oriented Personal Evaluation Scale (F-COPES)" Family Crisis Oriented Personal Evaluation Scale (F-COPES)
