DEPARTMENT OF DEFENSE

1. DEPARTMENT OF DEFENSE Challenges For FAP in “The Way Ahead” August 10, 2009

2. Challenges • Demonstrating effectiveness • Implementing promising, good & best practices • Improving accuracy of data collection • Creating joint bases • Improving DoD’s response to domestic abuse and child abuse • Revising the Case Review Committee process • Addressing the Reserve Component • Addressing Wounded, Ill, and Injured service members treatment for family violence

3. Demonstrating Effectiveness • It’s a “best practice” • It’s superior to alternative approach(es) because it • Produces better results, or • Produces equal results more efficiently/cheaply/in accord with values & culture • It’s not superior, but it’s a “good” practice • So far, it’s only a “promising” practice

4. Demonstrating Effectiveness • It’s a promising/good/best practice because it: • Is designed on a logic model • Replicates/builds on evidence-supported practice • Has positive results from program evaluation • Has ongoing systematic data collection and analysis

5. Implementing Best Practice (2) • Build a logic model • Define desired immediate, intermediate, & long-term outcomes • Identify and assess strategies/activities that may produce them • Are they available? Are they appropriate? • Ascertain how/why would they produce them • Theoretical foundation • Results of prior research/evaluation • Identify and assess what data will measure success/failure • What data collection methods are available? • What analysis needs to be performed?

6. Implementing Best Practice (3) • Incorporate Evidence-Supported Practice (ESP) • ESP combines: • Best research evidence with • Best clinical experience that is • Consistent with family/client values

7. ESP Categories • In declining order: • Well-supported by research evidence • Supported by research evidence • Promising Research evidence • Failure to demonstrate effect • Concerning practice • Not able to be rated California Evidence-Based Clearinghouse for Child Welfare http://www.cachildwelfareclearinghouse.org

8. ESP factors: • No empirical/clinical evidence or theoretical basis indicating substantial risk of harm, compared to likely benefits • Book, manual, other writings describing protocol • Form of control to show benefit of practice over placebo • Randomized controlled trial (RCT) • Untreated group/placebo group/matched wait list group • Reliable and valid outcome measures applied consistently and accurately • Duration of sustained effect • Publication in peer-reviewed professional literature • Replication • If multiple outcome studies, overall weight supports benefit of the practice http://www.cachildwelfareclearinghouse.org

9. Implementing Best Practice (4) • Plan evaluation before starting • Document current protocol & outcomes • Select new model’s data collection strategy & select instruments • Pilot test new protocol • Ensure fidelity to model • Prepare and disseminate protocol manual • Train staff in protocol • Monitor fidelity of experimental and control groups to respective protocols

10. Implementing Best Practice (5) • Collect data • Conduct edit checks • Analyze and draw conclusions • Identify applicability and limitations of study • Prepare findings for publication • Cooperate with replications

11. Importance of Edit Checks • Errors can have consequences • 2 errors on substantiated incidents per installation change: • USA rates: • CAN rate +/- by 0.54 • DA rate +/- by 0.83 • DoD rates: • CAN rate +/- by 0.1 • DA rate +/- by 0.2 • Can lead to erroneous interpretations

12. Force Well-Being Scales • “Are the wheels coming off?” • Semi-annual lagging indicators • Risk Behaviors • Spouse abuse by AD personnel • Child abuse/neglect • By AD personnel • By AD parent • By civilian parent • By combined parents • Compare current half year to half year in FY 2000

13. Force Well-Being Scales • (Effects of Data Errors on Army and DoD rates)

14. Hickam AFB Andersen AFB Bolling AFB McChord AFB NWS Charleston Fort Dix& NAES Lakehurst NAF Washington Fort Richardson Randolph AFB & Fort Sam Houston Fort Eustis NS Pearl Harbor NB Guam NSA-W Anacostia Annex Fort Lewis Charleston AFB McGuire AFB Andrews AFB Elmendorf AFB Lackland AFB Langley AFB Implementing Joint Basing

15. Implementing Joint Basing (2) • Supported installation’s program integrates into supporting installation’s program • FAP construed as “base support function” NOT “mission support function • FAP standardized services approximate COLS

16. MOU Personnel Issues to Implement Joint Basing • Personnel billets/positions • Military FAOs & SWs • Civil Service & NAF • Contractors • Installation or centralized contract • Seniority/priority placement • Credentialing process • Location • Supervision • Funding • FY 2010 PBAS, MIPRs and other temporary “fixes” • FY 2011 PBAS

17. Changing the Case Review Committee Process • Purposes • To reduce variability in decision-making • Improve quality of data in Central Registry • Improve fairness • Improve FAP’s reputation • To promote a coordinated community response • Promote command and investigative agencies’ responsibilities • Refocus FAP to clinical work • To ensure respect for privacy rights • To improve efficiency

18. The New CRC: CCSM+IDC • Clinical Case Staff Meeting (“CCSM”) • Safety planning and action • FAP assessment and treatment planning • Occurs ASAP • Incident Determination Committee (“IDC”) • Administrative decision: Does incident meet criteria for incident to be entered into Central Registry with personal identifiers? • FAP communicates treatment plan to unit commander

19. The New CRC: CCSM+IDC • Incident Determination Committee (“IDC”) • Chaired by senior commander • Composition limited to those with relevant information for determination • Preclude discussion of irrelevant information, especially information protected by privacy rights

20. Incident Determination CommitteeJoint-Service Criteria for CR • To be entered into FAP Central Registry with personal identifiers incidents must have: • Act (or failure to act) plus • Harm (except for sexual abuse) with specific thresholds • Actual injury • Reasonable potential for injury • Acute significant fear reaction • Criteria have demonstrated validity and reliability • Exclusions reduced by raising harm threshold

21. The New Process • Enhances command role • Unit commander pre-IDC action for victim safety • Unit commander pre-IDC administrative/ disciplinary action, as appropriate • Higher level commander chairing the IDC promotes: • Prompt attendance • Preparation • Focused attention • Protection of privacy rights

22. Addressing Domestic Abuse • Increase OSD FAP funding for victim advocates • GAO Study • Civilian advocates’ issues • Legislation for an OSD Office of the Victim Advocate • Coordinated community response projects • Availability and training of law enforcement • Command priorities • Enhanced visibility of command actions

23. Data collection in the Reserve Component • How much family violence occurs in the Reserve Component? • Civilian child abuse data collection process is problematic • OSD working with HHS on NCANDS • No civilian data collection system for domestic abuse • No public agency system • Can’t require nonprofit agencies to collect data

24. Addressing Family Violence in the Reserve Component • Expanding access to FAP prevention services • Web-based materials • Ad Council public awareness campaign • Civilian home-visiting programs • Intervention • Availability of resources • Restricted reporting • Line of duty issue

25. Data Collection Involving Wounded, Ill & Injured (WII) Service Members • How much family violence occurs in WII? • FAP is exploring joint research, matching databases • FAP Central Registry • Deployment to hostile areas • Wounded/Injured • Mental health problem

26. Addressing Family Violence in WII Service members • Protocol for reporting family violence in Warrior Transition Units • Intervention/treatment challenges • Civilian advocates urge DoD to emphasize criminal justice approach • Is this the right approach if domestic abuse arises after combat-operational stress and/or PTSD? • Coordination with the Veterans Administration

27. Domestic Abuser Treatment for WII Personnel • Are State standards for “batterer treatment” ESP? (Low rates of success) • One possible reason: “one size fits all” group psycho-education by unlicensed professionals • Psycho-social assessments not incorporated • Doesn’t incorporate dual diagnosis problems • No therapeutic alliance to change behavior • FAP is proposing range of modalities by licensed professionals • Individualized assessment • Motivation to change

28. Treatment of Abusers with Depressive Disorders & PTSD • Treatment should address: • Anger and impulse control • Self-medication with alcohol • Low self-esteem • Controlling others to maintain safe environment • Addiction to risk, especially in PTSD • Anxiety • Need to coordinate FAP treatment with: • Mental health treatment • Substance abuse treatment