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Final Evaluation

You will create a final program evaluation of the program you have evaluated for your community agency. Your final evaluation will have several components described below. Attention should be given to formatting and layout so that a professional product is presented. Final evaluations may be shared with the organization with student permission. Please use 12-point Times New Roman font. There is no set page requirement, however, aiming for 12-15 pages can be a goal. Points will not be deducted if you have more or fewer pages, rather, points will be deducted for not meeting the requirements of the assignment.

An example of a program evaluation will be posted on Module 14. This is posted to let you see how your program evaluation might be formatted and what the information might look like when compiled together. You can also google program evaluations to find other examples if those are helpful for you.

Executive Summary: Think of the executive summary as an abstract like we would read in a published journal article. The executive summary is a snapshot and overview of the evaluation that you are presenting and the information that will follow in the report in more detail. This should include the statement of the problem (use and appropriately reference citations) that your program seeks to solve; the program’s impact; and a summary of your results.

Program Description: In this section you are going to describe the program being evaluated in detail. You can think about this as an assessment, if you were writing an assessment of a client, what is important to know? Write about the program and describe the program. You should have started this with your logic model assignment. You will want this to be more robust and complete for the final evaluation. Some questions to help get you started may include: What is the purpose of the program? Who does it serve? How does it work? How long does it last?, etc. In this section you will draw on empirical articles from peer reviewed journals to connect the program and what we know about this focus area. At least 5 empirical articles should be used throughout the final evaluation.

Program Setting: In this section you will provide the context for the program you are evaluating. As social workers we consider the person in the environment. This is no different for a program evaluation. Think of your program as the “person” and the setting as the environment. Where is the agency located? What is the community like? What is important to know? For example, if the agency is in Germantown, what might be important for someone to know about the area and the clients that might participate in the program? If your program and agency are in Orange Mound, what might be important? If the program draws clients from across Memphis, what is important to know about the population, the community, the structure? Describe the agency, the city, the neighborhood, etc. Paint the picture for your audience of the setting. You can also consider using pictures to bring the setting to life if you would like. Be sure to appropriately cite your references.

Program Goals: In this section you are going to state and describe the goals of the program. You will draw on what you have in your logic model (modify if necessary). The goals include the outcomes (short-term goals) and the impact (long-term goals). For this section you will do more than simply state the goals. You will describe them and provide complete sentence narrative to help draw connections between the problem that the program is addressing (stated in your executive summary) and connecting to aspects in the program description and setting. As you are pulling your evaluation together, you are telling a cohesive story from beginning to end, not just having pieces to check off a list. If you keep this in mind, it will help with flow and your evaluation will be more fluid and complete. You may have literature to connect in this section.

Method: Int his section you are describing the methods you used for your data analysis. In detail you will describe your data, how you analyzed your data (the statistical tests you chose to use and why). In this section you will also describe your sample (provide some information about who the data are from, for example, clients? staff members? etc.)

Results Narrative: In this section you are presenting the results in narrative form. You will provide the results from your analyses. This section should include descriptive data as well as the results from the statistical analyses. Your results section should provide all the detail necessary for the reader to understand what tests you ran and the results. This should be complete so the reader does not have to look at charts/figures/graphs to understand what was found during the analysis.

Results Figures: For this portion, you will need to have several graphs and/or tables embedded within your written document. You will need to reference these in your narrative. Similar to charts and table sin published articles, when writing about the information in a pie chart, for example, you would write the information and then say (see figure 1). Then you place the pie chart in the document. Similar to the narrative portion, your charts, figures, and graphs must be appropriate for the data and be able to convey the necessary information to stand on their own. The reader should not need to reference the narrative in order to understand the charts, figures, and graphs.

Implications & Recommendations: In this section you will discuss implications and make recommendations for the program and agency. You will discuss the results and what they mean for the program, agency, clients, etc. You will also make recommendations. Also think about policy recommendations (this can be program policy, agency policy, local policy, state policy, or federal policy). Your recommendations should be based on the goals of the program and the results of your evaluation and should connect back to the literature.

The Hope House provides services to clients that are affected or infected with HIV and poverty. The following services are provided: free HIV testing, childcare, and social services. Hope House offers free HIV testing to anyone 18 years or older, and they provide two options for testing. An individual has the option to receive a free in person test, or they have the option to receive a free take home test. Tests are confidential and administered by a local social worker (Hope, House 2021).

According to Hope House 2021, childcare is offered to children ages 6 weeks to 5 years. The childcare center is open Monday through Friday 7:30am-3:30pm. The center is accredited through NAEYC (National Association for the Education of Young Children), and the teachers all have an associate degree or higher in early childhood education or an education-related field. The specific program area that I will be focusing on will be the childcare area. Childcare is important in ensuring that the child is growing socially, emotionally, and developmentally.

The childcare program area ensures that the children are learning from age appropriate curriculums, and it also ensures that the children are developing in their gross motor skills. Hope House offers a preschool service to clients as well. Hope House began their preschool program in 1995 as a three-day week program to better serve children and prepare them for kindergarten success. Preschool services are now offered to 20 children Monday through Friday from 7:45am until 3:30pm. The preschool is also NAEYC (National Association for the Education of Young Children) accredited (Hope House, 2021).

The final services offered is social services. The social services program offers a variety of services for adult clients living with HIV. Services include: trauma services, emergency services, life skills education/assistance, mental health services, and health living services. Social services are available for individual appointment only. There are also food pantry services provided Monday, Tuesday, Wednesday, and Friday 8:30am-12:00pm, and 4:00pm-6:00pm (Hope House, 2021).

In order to receive services, clients must be 18 years of age or older, and referrals should be made through a medical case manager. I will be evaluating the childcare area of the program to ensure that the Hope House is receiving adequate funding and resources to provide quality childcare services to their clients. I will also be evaluating if hired staff is capable of providing appropriate educational services through this program. I will evaluate effectiveness of learning material that is utilized as well as the quality of the education program.

I would also like to evaluate if the staff is providing sufficient weekly curriculums that specifically address the learning needs of the children. I will evaluate whether or not the funding/donations received are appropriate and adequate enough to provide appropriate learning materials such as books, supplies, furniture, etc. Lastly, there will be an evaluation of the community partners that collaborate with Hope House to ensure that those partners are providing an adequate amount of needed resources. There will also be an evaluation to determine if any additional community partners can be utilized and implemented to provide additional resources.

References

House, H. (2021, n.d.). Hope House. Hope house website. retrieved from

https://www.hopehousememphis.org/how-we-serve/social-services

Resources/Inputs	Activities	Outputs	Outcomes/Short-Term Goals	Impact/Long-Term Goals
What resources are needed to make the program operate? (e.g. staff time; volunteer hours; planning time; money; knowledge; expertise; materials; equipment; space; supplies; partners)	What are your planned activities? How will you accomplish them? (e.g. what the program does; what will be developed, what will be delivered, what will be facilitated; partnerships)	What products or services will be delivered? (e.g. how many X will be developed; how many Y will be delivered; how many Z will be facilitated, etc.)	How will the products/services impact participants? (e.g. awareness; knowledge; attitudes; skills; opinions; behavior, participation, retention; social action; policies…think of these in terms of the data you have, what can you use that will show outcome)	What is the larger benefit of the program on organizations, communities, and systems? (e.g. think of these as long-term goals, change in conditions, social change; economic change; civic change; environmental change, etc.)
Public and private funding-Funding sources can come from grant funding or private donations from individuals or community partners (ex: 100,00/yr operating budget).	Fundraising/Donations to assist with the purchase of classroom supplies, furniture, learning materials, etc.	Number of children who participate in high quality learning. Purchase and provide educational activities, books, games, and supplies conducive for learning.	Better quality educational programs.	Increased academic proficiency.
Staffing: 2 Full-time childcare staff for each classroom. 3 Part-time volunteers/1 full-time volunteer.	Trained and licensed teachers to execute age appropriate learning.	Weekly curriculums and learning plans will be developed and implemented for the classrooms.	Increased number of learners with improved reading and gross motor skills.	Improved learning outcomes.
Community partnerships and public relations.	Food donations and community partnership with the Memphis food bank and other local partners.	Weekly food distribution provided for meals and snacks.	Health meals/snacks provided daily.	Improved health and access to nutritious foods.

An Evaluation of
U.S. Military Non-Medical
Counseling Programs
Thomas E. Trail, Laurie T. Martin, Lane F. Burgette, Linnea Warren May,
Ammarah Mahmud, Nupur Nanda, Anita Chandra
C O R P O R A T I O N

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iii
Preface
The U.S. Department of Defense offers non- medical counseling through two programs: Mili-
tary and Family Life Counseling (MFLC) and Military OneSource. These programs, estab-
lished in 2004, are centrally managed in the Office of Deputy Assistant Secretary of Defense
for Military Community and Family Policy (ODASD [MC&FP]). To date, assessment of non-
medical counseling programs has primarily focused on pro cess and satisfaction mea sures rather
than program outcomes. Because of the lack of information on program outcomes, ODASD
(MC&FP) asked R AND’s National Defense Research Institute (NDRI) to evaluate MFLC
and Military OneSource to better understand their impact on military members and their
families. This study set out to answer the question of whether non- medical counseling pro-
grams are effective in improving program outcomes and if effectiveness varies by prob lem type
and/or population.
This report provides detailed findings of R AND NDRI’s analy sis based on two surveys
provided to program participants— the first two to three weeks after participating in counsel-
ing sessions and the second three months later. We designed the surveys to gain information
on improvement in the prob lems for which the participant sought help; whether negative
impacts on their work and daily lives had subsided; whether improvements were sustained in
the short and long term (i.e., over three months); and participant perceptions about the pro-
gram itself and the counselors with whom they worked.
The report should be of interest to policymakers and program leadership. Policymakers
can use study findings as they make decisions about continuation and expansion of non-
medical counseling provided through MFLC and Military OneSource. Program leadership
can determine where the program is most effective and for whom, and can use the findings to
pinpoint program areas in need of improvement or greater attention.
This research was sponsored by ODASD (MC&FP) and conducted within the Forces
and Resources Policy Center of R AND NDRI, a federally funded research and development
center sponsored by the Office of the Secretary of Defense, the Joint Staff, the Unified Com-
batant Commands, the Navy, the Marine Corps, the defense agencies, and the defense Intel-
ligence Community.
For more information on the R AND Forces and Resources Policy Center, see http://
www.rand.org/nsrd/ndri/centers/frp.html or contact the director (contact information is pro-
vided on the web page).

http://www.rand.org/nsrd/ndri/centers/frp.html

v
Table of Contents
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii
Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix
Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
Acknowl edgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxiii
CHAPTER ONE
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Purpose of This Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Needs of Military Families . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Ser vice Member Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Spouse and Family Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Changing Needs over Time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
DoD’s Response to Individual and Family Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Military and Family Life Counseling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Military OneSource . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Effectiveness of Military Support Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Organ ization of This Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
CHAPTER T WO
Evaluation Design, Methodology, and Analytic Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Evaluation Design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Inclusion Criteria for Study Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Recruitment of Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Survey Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Wave 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Wave 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Administrative Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Response Rates and Study Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
MFLC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Military OneSource . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Demographic Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Analytic Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Quantitative Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Qualitative Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

vi An Evaluation of U.S. Military Non-Medical Counseling Programs
CHAPTER THR EE
Severity and Overall Prob lem Resolution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Prob lem Type . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Short- Term Changes in Prob lem Severity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Subgroup Differences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Long- Term Changes in Prob lem Severity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Subgroup Differences in Long- Term Prob lem Resolution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Impact of Non- Medical Counseling on Deployment Preparedness and Retention Intentions . . . . . . . . 29
Deployment and Reintegration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Willingness to Stay in the Military . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Chapter Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
CHAPTER FOUR
Resolution of Stress and Anxiety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Short- Term Changes in Stress and Anxiety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Subgroup Differences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Short- Term Changes in the Level of Stress at Work and in One’s Personal Life . . . . . . . . . . . . . . . . . . . . . . . . 39
Long- Term Changes in Stress and Anxiety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Long- Term Changes in the Level of Stress at Work and in One’s Personal Life . . . . . . . . . . . . . . . . . . . . . 43
Chapter Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
CHAPTER FIV E
Interference with Work and Daily Life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Short- Term Changes in Prob lem Interference with Work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Subgroup Differences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Long- Term Changes in Prob lem Interference with Work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Short- Term Changes in Interference with Daily Routines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Subgroup Differences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Long- Term Changes in Prob lem Interference with Daily Routines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Subgroup Differences in Long- Term Changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Short- Term Changes in Difficulty Coping with Day- to- Day Demands . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Subgroup Differences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Long- Term Changes in Difficulty Coping with Day- to- Day Demands . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Subgroup Differences in Long- Term Changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Chapter Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
CHAPTER SIX
Connection to Ser vices and Referrals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Connection to Ser vices Outside of Non- Medical Counseling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Program Follow- Up with Connections to Outside Ser vices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Subgroup Differences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Chapter Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68

Contents vii
CHAPTER SEV EN
Experiences with MFLC and Military OneSource Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Ease of Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Speed of Connecting to Counseling Ser vices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Ease of Making Appointments That Fit with Participant Schedule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Confidentiality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Continuity of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Future Use and Recommendation of Program to Others . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
Anticipated Future Use of Program. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
Likelihood of Recommending Non- Medical Counseling to Others . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Chapter Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
CHAPTER EIGHT
Perceptions of Non- Medical Counselors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Professionalism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Counselor Showed Interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
Level of Professionalism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
Counselor Listened Carefully . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
Counselor Spent Enough Time with Participant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
Information Was Explained in a Way That Was Easy to Understand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
Left Counselor’s Office with Questions Answered . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
Cultural Competency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
Cultural, Language, or Religious Concerns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
Understood Military Culture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
Knowledge of the Presenting Prob lem and Adequacy of Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Counselor Knowledge of Presenting Prob lem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
Number and Types of Resources Provided . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Met Client Needs Overall . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Chapter Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
CHAPTER NINE
Summary and Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
Policy Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
Programmatic Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
APPENDIX ES
A. Data Collection, Weighting, and Analytic Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
B. Survey Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
C. Tables of Significant Subgroup Differences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145

ix
Figures
2.1. Logic Model for Evaluation of Non- Medical Counseling Programs . . . . . . . . . . . . . . . . . . . . . . . . 12
3.1. Average Estimated Probability of Prob lem Severity Ratings Before and
After Non- Medical Counseling, Wave 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
3.2. Average Estimated Probability of Short- Term Changes in Prob lem Severity
Ratings, Wave 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
3.3. Average Estimated Prob lem Severity over Time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
3.4. Average Estimated Probability of Severity Ratings over Time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
3.5. Average Estimated Probability of Perceived Impact of Non- Medical
Counseling on Deployment Preparation and Reintegration, Wave 1 . . . . . . . . . . . . . . . . . . . . . . 30
3.6. Average Estimated Probability of Perceived Impact of Non- Medical
Counseling on Willingness to Stay in the Military, Wave 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
4.1. Average Estimated Probability of Frequency of Stress and Anxiety Before and
After Non- Medical Counseling, Wave 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
4.2. Average Estimated Probability of Short- Term Changes in Stress and
Anxiety, Wave 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
4.3. Average Estimated Probability of Changes in Level of Stress at Work After
Non- Medical Counseling, Wave 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
4.4. Average Estimated Probability of Changes in Level of Stress in Personal Life
After Non- Medical Counseling, Wave 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
4.5. Average Estimated Frequency of Stress or Anxiety over Time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
4.6. Average Estimated Probability of Frequency of Stress or Anxiety over Time . . . . . . . . . . . . . 42
4.7. Average Estimated Probability of Changes in Level of Stress at Work After
Non- Medical Counseling, Wave 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
4.8. Average Estimated Probability of Changes in Level of Stress in Personal Life
After Non- Medical Counseling, Wave 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
5.1. Average Estimated Probability of Ratings of Prob lem Interference with
Work Before and After Non- Medical Counseling, Wave 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
5.2. Average Estimated Probability of Short- Term Changes in Prob lem
Interference with Work, Wave 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
5.3. Average Estimated Frequency of Prob lem Interference with Work over Time . . . . . . . . . . . . . 51
5.4. Average Estimated Probability of Frequency of Prob lem Interference with
Work over Time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
5.5. Average Estimated Probability of Ratings of Prob lem Interference with
Daily Routines Before and After Non- Medical Counseling, Wave 1 . . . . . . . . . . . . . . . . . . . . . . . 53
5.6. Average Estimated Probability of Short- Term Changes in Prob lem
Interference with Daily Routines, Wave 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
5.7. Average Estimated Frequency of Prob lem Interference with Daily
Routines over Time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

x An Evaluation of U.S. Military Non-Medical Counseling Programs
5.8. Average Estimated Probability of Frequency of Prob lem Interference with
Daily Routines over Time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
5.9. Average Estimated Probability of Ratings of Difficulty Coping with
Day- to- Day Demands, Wave 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
5.10. Average Estimated Probability of Difficulty Coping with Day-to-Day Demands,
Wave 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
5.11. Average Estimated Frequency of Difficulty Coping with Day- to- Day
Demands over Time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
5.12. Average Estimated Probability of Frequency of Difficulty Coping with
Day- to- Day Demands over Time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
6.1. Average Estimated Probability of Connection to Ser vices Outside of
Non- Medical Counseling, Wave 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
6.2. Average Estimated Probability of Connection to Physical and Mental
Health Providers Due to Non- Medical Counseling, Wave 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
6.3. Average Estimated Probability of Satisfaction with Program Follow- Up
on Connections to Recommended Outside Ser vices, Wave 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
7.1. Average Estimated Probability of Satisfaction with the Speed of Connecting
to Non- Medical Counseling Ser vices, Wave 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
7.2. Average Estimated Probability of Ease of Making Appointments, Wave 1. . . . . . . . . . . . . . . . . 73
7.3. Average Estimated Probability of Satisfaction with the Confidentiality of
Personal and Family Information, Wave 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
7.4. Average Estimated Probability of Satisfaction with the Continuity of Care, Wave 1 . . . . . . . . 76
7.5. Average Estimated Probability of Satisfaction with Follow- Up After Missed
Appointment, Wave 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
7.6. Average Estimated Probability of Likelihood of Future Program Use, Wave 1 . . . . . . . . . . . . 78
8.1. Estimated Share Agreeing That Counselor Showed Interest in Questions and
Concerns, Wave 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
8.2. Estimated Share with Satisfaction with Level of Professionalism, Wave 1 . . . . . . . . . . . . . . . . . . 83
8.3. Estimated Share Agreeing That Counselor Listened to Them Carefully, Wave 1 . . . . . . . . . . . 84
8.4. Estimated Share Agreeing That Counselor Spent Enough Time with Them,
Wave 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
8.5. Estimated Share Agreeing That Counselor Explained Things in a Way
That Was Easy to Understand, Wave 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
8.6. Estimated Share Who Left Counselor’s Office with All of Their Questions
Answered, Wave 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
8.7. Estimated Share Agreeing That Counselor Addressed Cultural, Language,
or Religious Concerns, Wave 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
8.8. Estimated Share Agreeing That Counselor Understood Military Culture, Wave 1 . . . . . . . . . . 91
8.9. Estimated Share Agreeing That Counselor Was Knowledgeable in the Area of
Their Concern, Wave 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
8.10. Estimated Share with Satisfaction with Level of Counselor Knowledge, Wave 1 . . . . . . . . . 93
8.11. Estimated Share with Satisfaction with the Types of Materials Provided, Wave 1 . . . . . . . 94
8.12. Estimated Share with Satisfaction with the Number of Resources Provided, Wave 1 . . . . . . . 95
8.13. Estimated Share Agreeing Counselor Provided the Ser vices They Needed, Wave 1. . . . . . 96

xi
Tables
2.1. Survey Topics Matched to the Logic Model Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
2.2. Demographic Characteristics of the MFLC and Military OneSource
Study Samples . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
3.1. Type of Non- Medical Prob lem Reported by MFLC and Military OneSource
Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
6.1. Percent of Participants Using Support Ser vices in Addition to Non- Medical
Counseling to Address Their Prob lem, Wave 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
A.1. Comparison of MFLC Population to Study Sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
A.2. Comparison of Military OneSource Population to Study Sample . . . . . . . . . . . . . . . . . . . . . . . . . 109
C3.1. Precounseling Ratings of Prob lem Severity by Gender and Prob lem Type
Among MFLC Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
C3.2. Precounseling Ratings of Prob lem Severity by Prob lem Type Among Military
OneSource Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
C3.3. Short- Term Changes in Prob lem Severity by Gender and Prob lem Type
Among MFLC Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
C3.4. Long- Term Changes in Prob lem Severity by Rank Among Military
OneSource Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
C3.5. Willingness to Stay in the Military by Active- Duty Status Among Military
OneSource Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
C4.1. Precounseling Frequency of Stress or Anxiety by Subgroups; MFLC . . . . . . . . . . . . . . . . . . . . . 130
C4.2. Frequency of Stress and Anxiety by Subgroups; Military OneSource
(Marginal Means) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
C4.3. Short- Term Prob lem Resolution of Stress and Anxiety by Subgroups; MFLC . . . . . . . . . . . 131
C4.4. Short- Term Prob lem Resolution of Stress and Anxiety by Subgroups;
Military OneSource . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
C4.5. Short- Term Changes in Level of Personal Stress; Military OneSource . . . . . . . . . . . . . . . . . . . . 131
C5.1. Precounseling Ratings of Prob lem Interference with Work by Ser vice,
Active- Duty Status, and Prob lem Type Among Military OneSource
Participants, Wave 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132
C5.2. Short- Term Changes in Prob lem Interference with Work by Gender and
Ser vice Among MFLC Participants, Wave 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
C5.3. Short- Term Changes in Prob lem Interference with Work by Gender and
Ser vice Member Status Among Military OneSource Participants, Wave 1 . . . . . . . . . . . . . . 133
C5.4. Precounseling Ratings of Interference with Daily Routines Among MFLC
Participants, Wave 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
C5.5. Precounseling Ratings of Interference with Daily Routines Among Military
OneSource Participants, Wave 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
C5.6. Short- Term Ratings of Interference with Daily Routines Among MFLC Participants . . . . . 134

xii An Evaluation of U.S. Military Non-Medical Counseling Programs
C5.7. Long- Term Ratings of Interference with Daily Routines Among Military
OneSource Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
C5.8. Precounseling Ratings of Difficulty Coping with Day- to- Day Demands
Among MFLC Participants, Wave 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
C5.9. Precounseling Ratings of Difficulty Coping with Day- to- Day Demands
Among Military OneSource Participants, Wave 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
C5.10. Long- Term Changes in Ratings of Difficulty Coping with Day- to- Day
Demands Among MFLC Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136
C6.1. Perception of Connection to Ser vices Among MFLC Participants . . . . . . . . . . . . . . . . . . . . . . . . 136
C6.2. Perception of Connection to Ser vices Among Military OneSource
Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
C6.3. Satisfaction with Follow- Up Among MFLC Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
C6.4. Satisfaction with Follow- Up Among Military OneSource Participants . . . . . . . . . . . . . . . . . . . 137
C7.1. Ease of Making Appointments Among MFLC Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
C7.2. Continuity of Care Satisfaction for MFLC Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
C7.3. Continuity of Care Satisfaction for Military OneSource Participants . . . . . . . . . . . . . . . . . . . . 138
C7.4. Recommendation of Military OneSource Ser vices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
C8.1. Level of Satisfaction with Counselor Level of Professionalism Among MFLC
Participants, Wave 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
C8.2. Counselor Showed Interest in Questions and Concerns Among Military
OneSource Participants, Wave 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
C8.3. Level of Agreement That Counselor Listened Carefully; Military OneSource . . . . . . . . . . . 140
C8.4. Level of Agreement That Information Was Explained in a Way That Was
Easy to Understand Among MFLC Participants, Wave 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
C8.5. Level of Agreement That Information Was Explained in a Way That Was
Easy to Understand Among Military OneSource Participants, Wave 1 . . . . . . . . . . . . . . . . . . 141
C8.6. Level of Agreement That Counselor Answered Questions Among Military
OneSource Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
C8.7. Perceived Cultural, Language, and Religious Competence Among Military
OneSource Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142

xiii
Summary
Military families face normal stresses that most families face, such as financial strain, stressful
life events, and relationship prob lems. But they also have to confront stresses that are more
unique to military life, such as frequent moves and frequent separations from family and friends
for military training, assignments, and deployments. The length and frequency of deploy-
ments can also place an unpre ce dented strain on military families. In addition to the emo-
tional stress of worrying about a loved one overseas, the non- deployed spouse must take over
more responsibility at home, including financial management and caretaking of children or
other dependents. Extended absence from one’s spouse or partner can also place added strain
on relationships. While most families are able to successfully overcome the stresses and strains
of deployment and military life with the assistance of family and friends, sometimes families
need additional assistance from counseling and support ser vices offered by the U.S. Depart-
ment of Defense (DoD).
The DoD provides diff er ent counseling supports depending on the needs and preferences
of ser vice members and their families. Under the Assistant Secretary of Defense for Health
Affairs, the DoD provides psychological counseling and psychiatric treatment for psychologi-
cal prob lems that are likely to cause severe impairment or distress, including medically diag-
nosable mental health conditions such as major depressive disorder, posttraumatic stress disor-
der, traumatic brain injury, or drug and alcohol abuse. Most of these prob lems are biologically
based conditions that involve longer- term treatment with medi cations and counseling to resolve
or stabilize.
In addition, the DoD provides for short- term, solution- focused counseling for common
personal and family issues that do not warrant medical or behavioral health treatment within
the military health system. These counseling ser vices, called non- medical counseling within the
DoD, are typically implemented outside the traditional health care setting and are aimed at
addressing a broad array of common prob lems such as stress management, marital or other
relationship prob lems, employment issues, parenting, and grief and loss, along with the par-
tic u lar challenges associated with military life, including deployment adjustment issues asso-
ciated with separation and reintegration. Non- medical counseling ser vices within the DoD
provide access to a trained professional who can help individuals address a range of prob lems
and identify potential strategies that will help overcome them. These ser vices include referrals
to other resources that provide direct assistance for prob lems (e.g., spouse education and
employment programs), training on managing prob lems (e.g., personal financial counseling),
and counseling to help resolve family or personal prob lems that do not require medical or
behavioral health treatment (e.g., marriage counseling, stress reduction). Non- medical coun-
selors rely on diff er ent types of therapeutic or educational techniques aimed at preventing

xiv An Evaluation of U.S. Military Non-Medical Counseling Programs
prob lems (or stress resulting from prob lems) from developing into mental health conditions
that may detract from military and family readiness.
The DoD offers non- medical counseling through two programs: Military and Family Life
Counseling (MFLC) and Military OneSource. These programs, established in 2004, are cen-
trally managed in the Office of Deputy Assistant Secretary of Defense for Military Commu-
nity and Family Policy (ODASD [MC&FP]). Both the MFLC and Military OneSource pro-
grams are offered to members of the active and reserve components, and their families, for up
to 12 sessions per person per presenting prob lem at no cost. Both programs offer confidential,
free assistance to ser vice members and their families seeking help with issues such as finances,
employment and education, parenting and child care, relocation, deployment, reunion, family
members with special needs, relationships, stress, and grief. Both programs employ counselors
with a master’s degree or Ph.D. in relevant fields (e.g., social work, counseling, psy chol ogy)
who are licensed in a state, U.S. territory, or the District of Columbia as an in de pen dent prac-
titioner. If the prob lem requires expertise in an area outside of the counselor’s expertise, the
individual seeking help can be referred to another counselor who possesses the required exper-
tise. The MFLC program provides in- person confidential non- medical, short- term, solution-
focused counseling ser vices. A hallmark of the MFLC program is privacy and confidentiality.
Military OneSource consultation and non- medical counseling ser vices are offered in person,
over the telephone, or via the Internet (e.g., online chat or video link).
To date, assessment of non- medical counseling programs has primarily focused on pro-
cess and satisfaction mea sures rather than program outcomes; evidence on their effectiveness is
limited, primarily due to the lack of coordinated monitoring and evaluation efforts. Because of
the lack of information on program effectiveness, ODASD (MC&FP) asked R AND to evalu-
ate MFLC and Military OneSource to better understand their impact on military members
and their families. Specifically, R AND was asked to expand the focus of research beyond pro-
cess mea sures to also include assessing the extent to which these counseling ser vices result in
successful resolution of clients’ prob lems, explore whether there are notable differences in reso-
lution by prob lem type or client characteristics, and identify areas for program improvement
based on the findings reported by program participants. The findings and conclusions also will
contribute toward the limited amount of research on the effect of non- medical counseling on
military ser vice members and their families.
Evaluation Design and Approach
This evaluation was designed as two separate but parallel studies. While both MFLC and Mili-
tary OneSource provide non- medical counseling ser vices to military- connected individuals
and families, they operate separately and there are impor tant differences in the ways in which
ser vices are delivered (e.g., Military OneSource counseling requires a referral but MFLC accepts
walk-in participants). Despite their differences, however, their goals are the same: to provide
short- term, solution- focused counseling to address general conditions of living and military
lifestyle. As a result, our analytic approach was very similar for both programs; however, we
report our results separately for each.
The objective of this study was to describe the effectiveness of and satisfaction with each
non- medical counseling program. Given the wide range of non- medical counseling needs and
approaches to supporting those needs, this study was not designed to assess the specific meth-

Summary xv
ods used by counselors to help participants resolve their prob lems. The study was also not intended
to determine which of the programs is more or less effective. Differences in program delivery
and the populations each serves can affect the results and so comparisons between the two
programs on similar outcomes should not be made.
For both MFLC and Military OneSource, we conducted two online surveys referred to as
Wave 1 and Wave 2. The Wave 1 survey, completed by participants approximately two to three
weeks after their initial counseling session, was designed to capture participants’ retrospective
assessments of the severity of their prob lem and perceived impact on their life prior to counsel-
ing and an assessment of their prob lems’ severity and perceived impact shortly after initiating
non- medical counseling (i.e., short- term outcomes). Questions addressed respondents’ prob-
lems, prob lem resolution, and their experience with non- medical counseling. The Wave 2
survey, completed by participants three months after completion of the Wave 1 survey, asked
questions about the same mea sures but allowed us to examine changes over time in outcomes
of interest, including prob lem severity, stress and anxiety, and effects on work and family life
(i.e., long- term outcomes). Because the programs provide short- term, solution- focused non-
medical counseling for 12 sessions, three months was considered a reasonable period of time to
mea sure prob lem resolution. At each survey wave, participants were asked to provide open- ended
responses to two questions assessing the perceived strengths and weaknesses of the MFLC or
Military OneSource program.
Data collection occurred from October 2014 to November 2016 for MFLC and from
April 2015 to November 2016 for Military OneSource. Both studies collected data for a mini-
mum of a full calendar year to ensure that findings were not driven by any potential seasonal
variation in non- medical concerns or ser vice use. A total of 2,585 MFLC and 2,892 Military
OneSource participants responded to the Wave 1 survey, and 614 MFLC and 878 Military One-
Source participants responded to the Wave 2 survey. Participants in the study were limited to
adults aged 18 years or older who received at least one in- person non- medical counseling ses-
sion of 30 minutes or more in an individual or couples setting. Ser vice members and eligible
family members across the Air Force, Army, Marines, Navy, and National Guard participated
in the study. Program staff from MFLC or Military OneSource initially recruited eligible par-
ticipants, and those expressing interest in the study were invited by R AND via email to partici-
pate in an online survey. Counselors did not have access to participant responses.
Response rates for both MFLC and Military OneSource were low but not aty pi cal for
studies of military ser vice members and their families (Miller and Aharoni, 2015). Compari-
sons to population- level characteristics of program users revealed that study participants were
representative of the population on demographic characteristics and prob lem type, which sug-
gests that the sample of participants was not biased (Miller and Aharoni, 2015). Where there
were differences between the sample and population characteristics, we adjusted the data to be
representative of the population.
Findings
Our findings focused on outcomes in six broad areas: 1) severity and overall prob lem resolu-
tion, 2) resolution of stress and anxiety, 3) interference with work and daily life, 4) connec-
tion to ser vices and referrals, 5) perceptions of non- medical counseling programs, and 6) per-
ceptions of non- medical counselors. This summary contains an overview of our analy sis of

xvi An Evaluation of U.S. Military Non-Medical Counseling Programs
survey data in each of these areas;1 detailed results are contained in the chapters and appen-
dixes that follow. Although the MFLC and Military OneSource studies were conducted as sepa-
rate evaluations, high- level findings about the potential impact of and experiences with non-
medical counseling can be drawn from both studies; these findings may help to inform policy
decisions.
Severity and Overall Prob lem Resolution
We examined the type of prob lems for which individuals were seeking non- medical counseling
and assessed whether— over the short term— the severity of the prob lem tended to decrease
following non- medical counseling. The most common prob lems participants reported were
family or relationship prob lems, followed by stress, anxiety, or emotional prob lems, and prob-
lems with conflict resolution or anger management. In general, most people who used non-
medical counseling reported being able to resolve their prob lem and reduce its effect on their
lives. Participants reported improvements after initiating counseling, which were maintained
after three months by the majority of participants. A small but impor tant proportion of partici-
pants did not experience a reduction in prob lem severity as a result of non- medical counseling,
especially in the short term. More specifically, our analy sis indicated that
• participants reported a statistically significant overall reduction in prob lem severity fol-
lowing non- medical counseling
• over 65 percent of individuals experienced a reduction in prob lem severity after they
initiated counseling
• reductions in prob lem severity were maintained long term with over 80 percent of indi-
viduals reporting the same or improved prob lem severity three months after receiving
counseling
• women tended to report greater short- term prob lem resolution than men
• open- ended responses suggest that the broader community of ser vice members and their
families may lack awareness of the availability of non- medical counseling through these
programs, particularly through the MFLC program.
Resolution of Stress and Anxiety
Both ser vice members and their families may experience periods of heightened stress and anxi-
ety as a result of the military lifestyle. Stress and anxiety affect every one at some point, and can
impact levels of productivity as well as military and family readiness. Military non- medical
counseling is designed to help individuals with stress management, giving them tools and
strategies to cope effectively when life’s demands become excessive.
Results suggest that, among the majority of participants, the frequency with which indi-
viduals reported feeling stressed or anxious as a result of their prob lem declined following non-
medical counseling, and that these improvements were maintained or continued to improve in
the three months following receipt of non- medical counseling ser vices. Key findings include
the following:
1 In the summary, results are reported across programs in that the numbers provided are for the smallest effect across
results for the MFLC and Military OneSource programs (e.g., “over 65 percent” means that the effect for one program was
65 percent, and the effect for the other program was greater than 65 percent).

Summary xvii
• After initiating counseling, over 70 percent of individuals experienced a reduction in the
frequency of feeling stressed or anxious as a result of their prob lem.
• Improvements were generally maintained three months after receipt of counseling. Over
80 percent reported a reduction in feeling stressed or anxious as a result of their prob lem,
compared to how they felt prior to receiving ser vices.
• Reported levels of stress in one’s work life and personal life were significantly lower fol-
lowing non- medical counseling. Over 60 percent of individuals reported that they expe-
rienced less or much less stress in their work life, and over 65 percent of individuals
reported that they experienced less or much less stress in their personal life after initiating
non- medical counseling.
• Approximately 20 percent of participants continued to report frequent or very frequent
feelings of stress and anxiety three months after non- medical counseling, suggesting that
they may not have benefited as much from counseling ser vices.
Interference with Work and Daily Life
The prob lems that ser vice members and their families experience not only cause them stress,
but also can disrupt their work and daily life routines. We examined how the concerns of
MFLC and Military OneSource participants affected three aspects of daily life: whether they
interfered with work, interfered with daily routines, or made it difficult to cope with day- to- day
demands. After receiving non- medical counseling, participants reported a statistically signifi-
cant decrease in the frequency with which the prob lem interfered with work or daily routines,
and a decrease in difficulty coping with day- to- day demands. These findings provide additional
evidence that non- medical counseling facilitated short- and long- term prob lem resolution
among the majority of participants. Our results showed that:
• Compared to how they felt before counseling, over 55 percent of individuals reported that
their prob lems caused less interference with work in the short term, and over 65 percent
reported less interference with work three months after receiving counseling.
• Compared to how they felt before counseling, over 65 percent reported decreased inter-
ference with daily routines in the short term, and over 74 percent reported decreases in
interference with daily routines in the three months after receiving counseling.
• Compared to how they felt before counseling, over 60 percent of individuals reported less
difficulty coping with day- to- day demands over the short term, and over 71 percent
reported long- term reductions in difficulty coping with day- to- day demands in the three
months after receiving counseling.
• MFLC participants reported short- term declines in prob lem interference with work and
daily life that were maintained over the long term by the majority of participants. Mili-
tary OneSource participants reported more modest short- term declines in prob lem inter-
ference with work and daily life, but the vast majority of Military OneSource participants
reported declines three months later.
Connection to Ser vices and Referrals
In addition to actively helping participants cope with stress, military non- medical counseling
programs are intended to serve as a conduit for connecting participants to ser vices for which
they are eligible and referrals to medical or behavioral health ser vices when needed. We exam-
ined the extent to which participants in non- medical counseling were connected to additional

xviii An Evaluation of U.S. Military Non-Medical Counseling Programs
ser vices, how satisfied participants were with those referrals, and whether the program followed
up with them to make sure they had connected with ser vices. Our results indicated that, of
the non- medical counseling participants who had sought additional support from other
individuals or providers for their prob lem, most were connected with support and ser vices
outside of the program— although not necessarily to support they would not have found on
their own. Moreover, the vast majority of participants were satisfied with program follow-up
to make sure they connected with recommended ser vices. Among participants who reported
that each question was applicable to their prob lem (38–67 percent of all participants), key
findings include:
• Of the 34 percent of MFLC and 37 percent of Military OneSource participants who
reported that they needed support and ser vices outside the program, over 65 percent indi-
cated that they had been connected to those ser vices.
• About 45 percent of participants reported that they needed referrals to medical ser vices,
and a little over half of those participants agreed that their counselor had connected them
with medical ser vices.
• Of the 38 percent of MFLC and 46 percent of Military OneSource participants who
reported needing referrals to physical health ser vices, only around 37 percent agreed that
they had been connected with physical health ser vices they would not have connected
with on their own.
• A larger number of Military OneSource participants (67 percent) reported that they needed
referrals to mental health ser vices, and 69 percent of those participants agreed that they
had been connected with mental health ser vices they would not have connected with on
their own.
• Over 81 percent of non- medical counseling participants who reported that their coun-
selor referred them to outside ser vices were satisfied or very satisfied with program follow-
up to make sure they connected with recommended ser vices.
Perceptions of Non- Medical Counseling Programs
MFLC and Military OneSource are meant to increase access to high- quality ser vices and to
help individuals connect to needed ser vices that will address their prob lems. In addition to
assessing the effectiveness of these ser vices on outcomes related to prob lem resolution and impact
of the prob lem on one’s work and family life, we also examined the experiences individuals had
with these non- medical counseling programs. At the program level, we examined perceptions
related to ease of access, confidentiality, continuity of care, and overall satisfaction as mea sured
by willingness to use ser vices again or recommend them to others. Our findings suggest that a
large majority of participants expressed favorable perceptions of non- medical counseling pro-
grams. While there is slight variability between the two programs, key findings across both
MFLC and Military OneSource include the following:
• Over 90 percent of individuals reported that they were satisfied or very satisfied with the
speed of being connected to a counselor and ease with which they could make an appoint-
ment.
• Over 90 percent of participants were satisfied or very satisfied with the level of confiden-
tiality received.

Summary xix
• Over 90 percent of individuals reported being satisfied or very satisfied with the continu-
ity of care they received.
• Over 90 percent of participants reported that they would be likely or highly likely to use
non- medical counseling ser vices again.
• Despite positive perceptions from the majority of participants, between 1 percent and
7 percent of participants reported being dissatisfied or very dissatisfied on the above pro-
gram dimensions.
In addition, findings, particularly open- ended responses, point to the need for MFLC
and Military OneSource leadership to assess where additional counselors may be warranted to
alleviate stress on the system and ensure every one can access ser vices within a reasonable time
frame. Other findings suggest that periodic reminders to counselors about confidentiality, and
the appearance of confidentiality, may be warranted as this is a hallmark of the program and a
continued concern for many. Results also indicate that program leadership may wish to exam-
ine concerns related to the continuity of care, reported by about 10 percent of the population,
as this lack of continuity may serve as a barrier to faster prob lem resolution.
Perceptions of Non- Medical Counselors
In addition to the perceptions of the non- medical programs, we also asked individuals to report
on their perceptions of their counselors. In this area, we examined perceptions related to profes-
sionalism, communication, cultural competency (i.e., sensitive to cultural/language differences
of participants, understanding of military culture), knowledge of the presenting program, and
whether the counselor met the client’s needs. Our analy sis shows that a large majority of par-
ticipants expressed favorable perceptions of non- medical counselors. While there was slight vari-
ability between the two programs, key findings across both MFLC and Military OneSource
include the following:
• Over 90 percent of participants reported being very satisfied with the level of profession-
alism of the counseling staff.
• Over 95 percent of participants strongly agreed that their counselor listened to them care-
fully and 90 percent agreed or strongly agreed that their counselor spent enough time
with them.
• Over 75 percent of participants agreed or strongly agreed that their counselor addressed
their cultural, language, or religious concerns.
• Over 75 percent of participants agreed or strongly agreed that their counselor understood
military culture.
• Over 90 percent of participants agreed or strongly agreed that their counselor was knowl-
edgeable about their presenting prob lem.
• Over 75 percent of participants were satisfied or highly satisfied with the number of mate-
rials and resources received and 80 percent were satisfied or highly satisfied with the types
of materials and resources provided.
• About 90 percent of participants agreed or strongly agreed that their counselor pro-
vided the ser vices they needed to address their non- medical prob lems and related
concerns.

xx An Evaluation of U.S. Military Non-Medical Counseling Programs
Conclusions and Implications
Findings from this study, though not causal, suggest largely positive outcomes for the partici-
pants of these programs who reported reductions in prob lem severity, stress and anxiety, and
less prob lem interference with work and their personal lives after counseling. In most cases,
these improvements were sustained or continued to improve in the three months after initia-
tion of counseling ser vices. Despite positive perceptions from the majority of participants, non-
medical counseling was not universally successful and a small minority (between 1 percent and
7 percent of participants) expressed dissatisfaction with the program or their counselor. Col-
lectively these findings suggest a number of policy implications and programmatic improve-
ments of interest to program leadership in the Office of the Secretary of Defense (OSD).
Policy Implications
1. The MFLC and Military OneSource programs should continue to be offered to
ser vice members and families. MFLC and Military OneSource are two key compo-
nents of the suite of ser vices and programs offered by the DoD. With consideration of the
programmatic changes suggested below, ser vice members and their families would benefit
from the continued availability of the MFLC and Military OneSource programs.
2. Steps should be taken to increase awareness of the program. Participants noted that
the awareness of these programs— particularly the MFLC program— may be limited in
the broader military community, suggesting that more work could be done to further
disseminate information about the availability of these ser vices.
3. Consider opportunities to expand the program, though expansion should be
informed by additional information or research that was beyond the scope of this
proj ect. Given the strength of findings, the DoD may wish to consider opportunities
for program expansion, particularly in locations where such ser vices do not currently
exist. For the MFLC program in par tic u lar, program and counselor perceptions were
consistently higher for individuals working with MFLC counselors embedded within
units, which may be worth expanding. We strongly recommend that the DoD conduct
additional research on the cost- effectiveness of these programs before determining the
scope of the expansion.
Programmatic Implications
4. Provide opportunities for ongoing support, guidance, and training for counsel-
ors. A small minority of participants reported that they were dissatisfied with a number
of counselor characteristics. These concerns suggest that counselors might benefit from
more opportunities to receive support and guidance from other non- medical counselors
or from supervisors with more experience in the military community. This continuity
in training and approach across counselors may be particularly impor tant for counselors
who are isolated from other military counselors and may also help to standardize high-
quality, evidence- based non- medical counseling approaches and experiences.
5. Strengthen non- medical counseling for child- related concerns. Participants who
sought counseling for child- related concerns, on average, reported lower levels of prob-
lem resolution and lower satisfaction with the continuity of care. By nature, these prob-
lems may be more complex and require additional providers as well as a specialized
understanding of child and youth development that many adult counselors may not

Summary xxi
have. Programs may benefit from working to strengthen delivery of ser vices potentially
through warm handoffs to counselors who hold this more specialized level of training.
6. Identify ways to systematically collect counselor- level feedback and incorporate
findings into per for mance review. While we did not collect information on individ-
ual counselors for the purposes of this study, both the MFLC and Military OneSource
programs may benefit from systematically collecting counselor- level feedback to estab-
lish whether identified concerns are more prevalent for a given counselor or location.
For example, participant feedback would help identify counselors who need additional
instruction or reminders about maintaining confidentiality. Feedback on the counselor
and program overall is critical for continued program improvement. Programs should
develop a confidential procedure for participants to provide feedback.
7. Strengthen continuity of care. Satisfaction with continuity of care varied across respon-
dents. This was particularly true for the MFLC program, where counselors were more
likely to rotate prior to the full resolution of an individual’s prob lem. This rotation often
resulted in a need to start over with a new counselor, which was viewed as inefficient
and disrupting of pro gress.
8. Strengthen screening and connections to other ser vices. Survey results and open-
ended comments from participants suggest that non- medical counseling could benefit
from strengthening connections to other ser vices. About a quarter of participants who
sought additional help for their prob lem reported seeing a private counselor or specialist.
Counselor training should focus on the pro cess by which those with diagnosable mental
health conditions are screened and referred to ensure timely access to the most appropriate
treatment for their concerns. Additional training to help counselors identify and refer
those who may benefit from clinical or more specialized ser vices may be helpful. In
addition, results suggest the need to strengthen the continuity of care during the referral
pro cess by establishing a more formalized, warm handoff and follow-up procedure.
9. Conduct research to better understand how to strengthen ser vice delivery. Despite
improvements in severity, stress, and anxiety among many participants, about 20 percent
reported that they did not experience prob lem resolution as a result of non- medical coun-
seling. The outcome mea sures included in this study were general, by design, but our
findings point to a need to examine what happens within a counseling session to ensure
that approaches are evidence- based and to examine fidelity to training protocols and
approaches in order to assess the quality of care delivered to participants. More insight
may also be gained by examining alignment of non- medical counseling approaches
with the presenting prob lem and by looking at outcomes more specific to the presenting
prob lem. Collectively, these analyses may inform more specific training needs.
The MFLC and Military OneSource programs are designed to provide short- term,
solution- focused counseling for common personal and family issues that do not warrant medi-
cal or behavioral health treatment within the military health system and to link participants
with additional resources to help them resolve their prob lems. They are thus a key component
of the broader support offered to military ser vice members and their families. Findings from
this study suggest that, overall, the programs are successfully providing short- term, confiden-
tial, solution- focused counseling to address general conditions of living and military lifestyle.
Our findings also show some areas where the program could be improved, however. The rec-
ommendations offered here can be used by OSD to further strengthen these programs.

Acknowl edgments
The study team is grateful for the support, oversight, and guidance of our proj ect monitor from
the ODASD (MC&FP), Cathy Flynn. We also extend our appreciation to Mike Hoskins, Jena
Moore, Lindsey Saul, Yuko Whitestone, and Kelly Mohondro from MC&FP for their assis-
tance with the proj ect and for their valuable feedback and insight during our research. We also
extend our appreciation to Carolee Van Horn, David Kennedy, and Beth Riffle also from
MC&FP for their early contributions to the proj ect. We want to thank Ed Brown, director of
non- medical counseling for MC&FP, for his assistance with this proj ect.
We acknowledge the contributions of the MFLC counselors who provided feedback on
the study procedures and who recruited participants for the study. In par tic u lar, we would like
to acknowledge the assistance of Betsy McBride at MHN Government Ser vices and Eugene
Myer at Magellan for their cooperation and assistance with this proj ect. We also thank the
triage con sul tants at Military OneSource for their help recruiting participants for the study,
and to thank Christopher Simmons, Jonathan Wilkerson, and Lucy Buckner for their assis-
tance with Military OneSource data.
At R AND NDRI, we would like to thank the members of our research team, John Daly,
Roald Euller, Ann Haas, and Cla ris sa Sellers, for their help with proj ect monitoring and data
handling and analy sis. We would also like to thank all of the administrative assistants who
entered the data for the proj ect, especially Lemenuel Dungey and Kendra Wilsher, who also
helped with numerous proj ect administration tasks. This report benefited greatly from the
assistance of Barbara Bicksler, who provided helpful feedback on the structure and writing of
this report. We also extend our thanks to our reviewers for their feedback: Eunice Wong, Craig
Bond, Kristie Gore, John Winkler, and Jennifer Lamping Lewis from R AND, and Sandraluz
Lara- Cinisomo from the University of Illinois at Urbana- Champaign.

1
CHAPTER ONE
Introduction
Military families face normal stresses that most families face such as economic strain, stressful
life events, and relationship prob lems. But military families also have to confront the stresses
related to military life, such as frequent moves, frequent separations for military training or
assignments, and deployments. Over the past fifteen years, the length and frequency of deploy-
ments have placed an unpre ce dented strain on military families. In addition to the emotional
stress of worrying about a loved one overseas, the non- deployed spouse must take over more
responsibility at home, including financial management and caretaking of children or other
dependents (Lara- Cinisomo et al., 2011). Extended absence from one’s spouse or partner can
also place a strain on relationships (Karney and Trail, 2017). While most families are able to
successfully overcome the stresses and strains of deployment and military life, many do so with
the informal assistance of friends and family and more formal assistance from counseling and
support ser vices offered by the U.S. Department of Defense (DoD).
The DoD provides diff er ent counseling supports depending on the needs and preferences
of ser vice members and their families. Under the Assistant Secretary of Defense for Health
Affairs, the DoD provides psychological counseling and psychiatric treatment for psychologi-
cal prob lems that are likely to cause severe impairment or distress, including diagnosable
mental health conditions such as major depressive disorder, posttraumatic stress disorder
(PTSD), traumatic brain injury, or drug and alcohol abuse. Most of these prob lems are biologi-
cally based conditions that involve longer- term treatment, medi cations, or other forms of coun-
seling to resolve or stabilize.
In addition, the DoD provides short- term, solution- focused counseling for non- clinical
issues. These counseling ser vices, called non- medical counseling within the DoD, are typically
implemented outside the traditional health care setting and are aimed at addressing common
prob lems such as stress management, marital or other relationship prob lems, employment
issues, parenting, and grief and loss, along with par tic u lar challenges associated with military
life, including deployment adjustment issues associated with separation and reintegration.
Non- medical counseling ser vices within the DoD provide access to a trained mental health
professional who can help individuals address a range of prob lems and identify potential strate-
gies to resolve them. Similar to how social workers or marriage counselors work with civilian
clients, non- medical counselors rely on their training and experience to assess the non- medical
concern and provide individuals with education, resources, tools, and other problem- resolution
strategies that best meet the unique needs of their clients, including referrals to other resources
that provide direct assistance for prob lems (e.g., spouse education and employment programs),
training on managing prob lems (e.g., personal financial counseling), and counseling to help
resolve family or personal prob lems that do not require medical or behavioral health treatment

2 An Evaluation of U.S. Military Non-Medical Counseling Programs
(e.g., marriage counseling, stress reduction). These ser vices are aimed at preventing prob lems
(or stress resulting from prob lems) from developing into mental health conditions that may
detract from military and family readiness.
Though non- medical counseling is also widely available via chaplains and National
Reserve/Guard Family Support Centers, the DoD offers two formalized non- medical counsel-
ing programs: Military and Family Life Counseling (MFLC) and Military OneSource. These
programs are centrally managed by the Office of Deputy Assistant Secretary of Defense for
Military Community and Family Policy (ODASD [MC&FP]). Department of Defense
Instruction 6490.06 (April 21, 2009) outlines policies and responsibilities for providing MFLC
and Military OneSource counseling support in accordance with the authority in DoD Direc-
tive 5124.02 (June 23, 2008). Both programs are offered to members of the active and guard
and reserve components and their families, for up to 12 sessions per person per issue, at no cost.
While similar in objectives, the two programs are complementary in that the footprint and
modes of ser vice delivery differ across programs and individuals can seek ser vices from both
programs. Each program is described in more detail later in this chapter.
To date, assessment of non- medical counseling programs has primarily focused on pro-
cess and satisfaction mea sures rather than program outcomes. Military OneSource, for example,
tracks monthly and annual ser vice use such as in- person and online consultation activity; refer-
rals and warm handoffs to military treatment facilities or an MFLC; reasons for call; and
number of financial consultations given. Similarly, MFLC uses an activity log to track the
number of individuals seeking ser vices; demographics of clients (e.g., geography, military ser-
vice and rank); primary reason for use of MFLC ser vices; referrals given to clients; and number
of sessions provided. In addition to these pro cess mea sures, Military OneSource employs vol-
untary satisfaction surveys to explore the extent to which users felt that their issue was addressed
and the extent to which they encountered difficulties engaging with the counselor.
Evaluations of civilian non- medical counseling programs have been rare. Perhaps the
most common instantiation of non- medical counseling in the civilian world are employee
assistance programs (EAPs). EAPs are workplace- based ser vices designed to provide emotional
and practical support to employees and their families. In contrast to military non- medical
counseling, EAPs also provide support for clinical concerns such as depression, and the most
common reasons for using EAPs relate to relationship prob lems, stress at work, depression, or
anxiety (Clavelle, Dickerson, and Murphy, 2012; Taranowski and Mahieu, 2013). Other issues
include retirement concerns or physical health concerns (Csiernik, 2011). A 2010 survey found
that EAPs in the United States cover over 58 million employees (Taranowski and Mahieu,
2013). The design and reach of EAPs vary widely, but the overarching goal of these programs
is to assist with stress management and to prevent the development of mental health prob lems
through assessment, short- term counseling, and referrals to longer- term treatment if necessary
(Taranowski and Mahieu, 2013). In contrast to the current study, which focuses on in- person
counseling by MFLC or Military OneSource counselors, civilian EAPs typically provide coun-
seling over the phone, via online chat, as part of a web- based group, or via video counseling
(Taranowski and Mahieu, 2013). Reviews of the EAP lit er a ture have concluded that, like non-
medical counseling programs in the military setting, EAPs would benefit from more rigorous
research and evaluation to determine their effectiveness for helping with prob lem resolution
and providing cost savings to employers who sponsor them (McLeod, 2010; Csiernik, 2011;
Taranowski and Mahieu, 2013). Still, the few published studies evaluating EAPs have found
that use of the programs is associated with improvements in employee functioning, inter-

Introduction 3
personal relationships, and reductions in employee feelings of distress (Clavelle, Dickerson,
and Murphy, 2012; Collins et al., 2012; Dickerson, Murphy, and Clavelle, 2012). A recent
study using a quasi- experimental design found that EAPs reduced worker absenteeism, though
not workplace distress, and that EAPs are especially effective for people with lower levels of
depression or anxiety at baseline (Richmond et al., 2017).
Purpose of This Study
The purpose of this study is to evaluate MFLC and Military OneSource to better understand
their impact on military members and their families. Specifically, this study explores the extent
to which these programs result in successful resolution of clients’ prob lems and whether there
are notable differences in resolution by prob lem type or client characteristics. The study did not
focus on one specific type of prob lem addressed by non- medical counseling, but instead exam-
ined prob lem resolution across the broad array of prob lems addressed by these programs. The
study did not include a control group that received no treatment or a diff er ent type of treat-
ment; as a result, we cannot draw causal conclusions about the effectiveness of the program,
and the study was not designed to evaluate specific therapeutic approaches or training provided
by non- medical counselors. Instead, it seeks to understand whether the availability of non-
medical counseling programs more broadly contributes to impor tant outcomes related to mili-
tary and family readiness, including prob lem resolution, reduction of stress and anxiety, and a
reduction in interference with work and daily life. Additionally, this report will contribute
toward the limited amount of research on the effect of non- medical counseling on military ser-
vice members and their families. Key study aims include:
1. to assess whether participants report prob lem resolution or a reduction in symptoms or
prob lem severity following engagement in MFLC or Military OneSource non- medical
counseling
2. to explore whether prob lem resolution is similar across prob lem types and military pop-
ulations
3. to summarize areas for improvement in program design and delivery, as reported by
program participants.
The rest of this chapter describes the needs of military families, the proposed benefits of
non- medical counseling in addressing those needs, and the development of the two largest non-
medical counseling programs within the DoD: the MFLC and Military OneSource
programs.
Needs of Military Families
Military life in general can be challenging for ser vice members and their families. However,
military deployments and other requirements associated with combat operations in Af ghan i-
stan and Iraq have added to the typical stresses of military life. Over 2.5 million ser vice mem-
bers have been deployed to these theaters since 2002, leading to strain on both ser vice mem-
bers and their families (Denning, Meisnere, and Warner, 2014; Tanielian et al., 2014; Karney

4 An Evaluation of U.S. Military Non-Medical Counseling Programs
and Trail, 2017). The mental and physical health burden on military ser vice members is well
documented, and research indicates that combat experience is associated with an increase in
PTSD, depression, anxiety, alcohol and substance abuse, suicide rates, and select chronic diseases
(Westwood et al., 2010; Denning, Meisnere, and Warner, 2014; Tanielian et al., 2014). Spouses
and family of ser vice members also face stressors related to the military lifestyle, including
coping with their ser vice member’s physical and emotional issues as well as their own prob lems
and stressors (American Psychological Association Presidential Task Force on Military Deploy-
ment Ser vices for Youth, Families and Ser vice Members [hereafter “Task Force”], 2007; Lara-
Cinisomo et al., 2011; Tanielian et al., 2014).
Ser vice Member Needs
There is a large lit er a ture documenting ser vice members’ health status specifically related to
mental health issues including PTSD, depression, and anxiety. However, approximately half of
ser vice members experience additional difficulties associated with the military lifestyle such as
deployment and adjustment issues, employment issues, or other concerns as a result of combat
stress (Denning, Meisnere, and Warner, 2014; Castro, Kintzle, and Hassan, 2015). Military
life may also place stressors on ser vice members as a product of frequent relocations, heavy
workloads, a mismatch between skills and job duties, and financial stressors (Hosek, Kava-
nagh, and Miller, 2006; Clemens and Milsom, 2008).
Ser vice members who deploy and separate from their families may experience psychologi-
cal trauma as well as environmental and physiological stressors in combat zones, as well as the
negative consequences of working for extended periods of time without time off (Hosek, Kava-
nagh, and Miller, 2006; Tanielian et al., 2014). Upon return from deployment, reintegration
with family and into civilian life can produce a “reverse culture shock” experience, and may
manifest as feelings of guilt, insecurity, hypervigilance, or feeling “out of sync” or “out of con-
trol” (Hosek, Kavanagh, and Miller, 2006; Hassan et al., 2010; Koenig et al., 2014; Castro,
Kintzle, and Hassan, 2015).
Spouse and Family Needs
According to the DoD, just over 50 percent of active, guard, and reserve ser vice members are
married and about 35 percent are married with children (Defense Manpower Data Center,
2016). According to a 2010 Department of Defense report, 44 percent of the deployed military
personnel for Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) were
parents, out of which 48 percent deployed at least twice (Sandoz, Moyer, and Armelie, 2015).
Unique stressors military families face include separation as a result of training and deploy-
ment (sometimes unexpected, repeated, or extended), uncertainty about the ser vice member’s
location or well- being, additional house hold responsibilities taken on by left- behind family
members, frequent residential moves, a lack of understanding of the deployment experience in
the surrounding community and media, readjusting the deployed parent into house hold rou-
tines, and caregiving for those experiencing mental illness and health care stigma (Weiss et al.,
2010; Chandra et al., 2011; Davis, Ward, and Storm, 2011; Eskin, 2011; Denning, Meisnere, and
Warner, 2014). Ser vice member combat experiences have also shown to be linked with an
increased risk of vio lence in military families— both spousal and child abuse (Rentz et al.,
2007; Task Force, 2007; Danish and Antonides, 2009; Westwood et al., 2010; Sherman and
Bowling, 2011; Gibbs, Clinton- Sherrod, and Johnson, 2012).

Introduction 5
A number of studies have shown that a sense of family readiness— including financial and
mental readiness of family members—is an impor tant influence on ser vice members’ well- being
and intention to stay in the military (Gambardella, 2008; Werber et al., 2008; Sandoz, Moyer,
and Armelie, 2015; Meadows, Tanielan, and Karney, 2016). In contrast, ser vice members who
feel isolated and strug gle to reconnect with family members and others after deployment are at
a higher risk for developing PTSD symptoms (Pemberton et al., 2013; Sandoz, Moyer, and
Armelie, 2015). It has also been estimated that about 50–65 percent of all active- duty soldier
suicides from 2007 to 2011 were triggered by the end of an intimate relationship (Snyder et al.,
2011). Thus, family well- being is not only impor tant for families, but also has implications for
ser vice member well- being and the military as a whole.
Changing Needs over Time
As the nature and scope of military conflicts have shifted over time, so have the psychosocial
needs of military populations and the programs designed to support them. U.S. military con-
flicts of the first de cade of the twenty- first century (e.g., OEF, OIF) were characterized by a
general increase in troop levels, as well as an increased operational tempo which resulted in
longer and more frequent deployments and shorter “dwell times” between deployments for
many ser vice members (Hosek, Kavanagh, and Miller, 2006; Danish and Antonides, 2009).
Reservists were called upon more than in previous years to deploy overseas, leaving civilian
jobs and communities (Danish and Antonides, 2009). Moreover, more female ser vice mem-
bers and dual- military couples were engaged in active duty than in previous conflicts (Task
Force, 2007; Koenig et al., 2014). These changes positioned more military families in the
deployment cycle which, coupled with the greater psychological strain placed on ser vice mem-
bers during recent conflicts, resulted in an increased demand for deployment and transition
ser vices for families between 2001 and 2012 (Hosek, Kavanagh, and Miller, 2006; Danish and
Antonides, 2009).
Military deployments reached a peak in 2009, and a drawdown of U.S. military presence
in the Middle East since 2012 has shifted the needs of ser vice members and their families. A
large population of previously deployed ser vice members and their families now face the chal-
lenge of dealing with the psychological aftermath of 15 years of combat while reintegrating
into a more stable military life. Many ser vice members and their families must also deal with
the stress of preparing to transition to the civilian workforce and civilian life in general (Koenig
et al., 2014). Thus, although the deployment tempo has slowed since 2009, there is a substan-
tial number of ser vice members and their families who are vulnerable from past deployment
experiences (Trail et al., 2015) and continue to need counseling ser vices to cope with their
prob lems.
DoD’s Response to Individual and Family Needs
With the growing and changing needs of ser vice members and their families, the DoD has made
it a priority to address the well- being of military families. The military health system provides
mental and behavioral health ser vices, including psychotherapy, suicide prevention, psycho-
logical screening, medi cation, tele- health, inpatient psychiatric care, residential treatment, and
substance abuse treatment (Weinick et al., 2011; Denning, Meisnere, and Warner, 2014). How-
ever, many ser vice members and their families may not have diagnosable psychosocial issues,

6 An Evaluation of U.S. Military Non-Medical Counseling Programs
or they may be hesitant to seek care in a clinical setting (Castro, Kintzle, and Hassan, 2015).
As a result, a number of programs also exist to support ser vice members and their families in a
non- clinical context. Examples of such programs include those that aim to improve health and
well- being (Bowles and Bates, 2010; Meredith et al., 2011); increase unit strength and morale
(Bowles and Bates, 2010; Meredith et al., 2011); create a ready force (Bowles and Bates, 2010;
Meredith et al., 2011); and increase resilience (Meredith et al., 2011; “Ready Resilient,” 2016).
Two of the largest service delivery options for receiving non- medical counseling that are
administered by the ODASD (MC&FP) are the MFLC and Military OneSource programs.
Both programs were established in 2004 to respond to the non- clinical needs of ser vice mem-
bers in a certain geographic area or to individuals in a par tic u lar military ser vice. These pro-
grams were developed to provide a confidential platform to address daily stressors and to reduce
the stigma that is generally associated with military counseling. Since their inception, they
have expanded to provide support ser vices to military members and their families both domes-
tically and internationally through diff er ent forms of delivery. Non- medical ser vices are pro-
vided by counselors with a master’s degree or Ph.D. in a mental health- related field (e.g., psy-
chol ogy, counseling) and are licensed as an in de pen dent practitioner in a state, U.S. territory,
or the District of Columbia. Prior to working under the MFLC contract, counselors receive
training on all aspects of the contract and on military culture and customs. As employees of
the contractor, counselors receive supervision from their contract supervisor.
Although part of non- medical counseling is focused on providing counseling ser vices for
non- clinical psychological issues such as stress, relationship prob lems, or bereavement, coun-
selors are not trained on or required to use a specific type of assessment or structured therapy
such as brief problem- solving therapy or cognitive- behavioral therapy. Rather, counselors use
a psychoeducational counseling approach which teaches ser vice members and their families
how to anticipate and to address challenges and prob lems. The approach provides partici-
pants with specific information about what is happening; the meaning of specific symptoms;
what is known about the causes, effects, and implications of their issues; and how to find
treatment and/or resources. In this way, psychoeducation is grounded in a preventative
model, in which the knowledge and skills provided by counselors facilitate members’ and
their families’ readiness and resilience, reducing and ideally preventing escalation to clini-
cally harmful levels.
From a prevention perspective, these programs can be conceptualized as selective inter-
ventions that target individuals or subgroups of the population whose risk of developing a
mental disorder is higher than average, as evidenced by psychological or social risk factors
(Mrazek and Haggerty, 1994). Non- medical counseling can help address risk factors that could
other wise cause prob lems to become more severe and endure for longer periods of time. Coun-
seling can also help individuals strengthen or develop protective factors such as emotional
resilience, positive thinking, problem- solving and social skills, stress management skills, and
feelings of mastery (World Health Organ ization, 2004). Although most published articles on
selective interventions are specific to a population, risk factor, or outcome and are not directly
comparable to broader programs like MFLC and Military OneSource, selective interventions
targeted at addressing major life events or stressors have shown significant and long- term reduc-
tions in mental health symptoms (Sörensen, Pinquart, and Duberstein, 2002; Wolchik et al.,
2002; World Health Organ ization, 2004).

Introduction 7
Military and Family Life Counseling
The MFLC program was established in 2004 at Fort Carson, Colorado, in response to the
increasing need for education, information, and support ser vices among ser vice members serv-
ing in the Iraq and Af ghan i stan Wars and their families. The program was designed to provide
non- medical counseling ser vices that address issues specific to the military lifestyle and to pre-
vent prob lems (or stress resulting from prob lems) from developing into mental health issues
that may interfere with military readiness or reintegration. Non- medical counseling through
MFLC is intended to supplement other existing military support programs and is not associ-
ated with clinical ser vices through the military or other medical providers.
Under this program, individuals may receive up to 12 sessions of in- person counseling per
issue. Each session may last from a few minutes to two hours based on individual’s needs.
Family, couple, and group modalities are also utilized. Non- medical counseling is available to
address concerns related to deployment and reintegration; communication; coping with anger,
grief, or stress; and education or work prob lems. Issues that cannot be resolved through brief
or short- term interaction with MFLC are referred to appropriate behavioral or mental health
ser vices, or other TRICARE providers. These include issues related to sexual assault, mental
health concerns that require inpatient care, substance abuse, and domestic vio lence.
A core feature of this program is that counselors do not keep clients’ personally identifiable
information. However, this confidentiality is not maintained in situations that involve domes-
tic vio lence, child abuse, and duty to warn (harm to self or others); such situations are reported
to the respective military, federal, and state authorities. Similarly, individuals who currently see
another counselor, are in review for sexual assault or abuse, take prescribed psychotropic medi-
cation, or have a mental health concern that requires inpatient hospitalizations are not eligible
to receive MFLC ser vices.
MFLC counselors provide counseling on an as needed basis, with delivery of ser vices tai-
lored to meet the diverse needs of ser vice members and families (e.g., outside of normal work
hours, at off- base locations). Originally, MFLC rotated counselors at installations for 30, 60,
or 90 days but has since expanded its methods of delivery to include rotational assignments of
counselors for up to one year on military installations domestically or abroad; counselors
embedded within military units (i.e., assigned to a specific unit of command versus providing
temporary surge support or support across several units); immediate support for three days to
reserve component members for predeployment, deployment, or reintegration activities; and
counselors assigned to Army and Marine Corps recruit commands that may not be near a mili-
tary installation and to the National Guard and reserve components. MFLC also provides
access to “surge” counseling support in which commanders may request up to 20 MFLC coun-
selors to provide 45 days of support to members of a unit returning from combat. In this set-
ting, counselors meet individually with ser vice members to discuss reintegration issues. For
family members, MFLC offers child and youth behavioral ser vices through military- connected
child programs, schools, and summer programs.
Overall, MFLC consists of approximately 2,000 counselors serving on installations, in
Child Development Centers, embedded in military units, schools, camps, and providing sup-
port for surge needs to units returning from combat. MFLC counselors provide support in 17
countries and all U.S. states and territories. In FY15, across all the ser vices they provide, MFLC
counselors had approximately 4.5 million in- person contacts. During the study time frame,
MFLC counselors addressed about 7,400 new adult non- medical counseling cases each month

8 An Evaluation of U.S. Military Non-Medical Counseling Programs
that fit the study specification (i.e., adults only, individual or couples sessions, 30 minute or
longer session). That equates to 88,800 new adult non- medical counseling cases per year.
Military OneSource
Established in 2004, Military OneSource was designed to supplement existing family support
resources (e.g., chaplains, family centers). Military OneSource offers confidential, free assis-
tance to ser vice members and their families— including those on active- duty and members of
the National Guard and reserves, regardless of activation status— who are seeking help with a
range of issues affecting ser vice member and family well- being. Military OneSource support
complements existing military family programs by offering resources and educational materi-
als to individuals, along with non- medical counseling ser vices. Non- medical counseling ses-
sions may focus on an array of issues including finances, employment and education, parenting
and child care, relocation, deployment, faith and spirituality, family members with special
needs, family relationships, stress, grief, and decisionmaking or other general life skills. Indi-
viduals can receive at least 12 free sessions per person per issue. Military OneSource counselors
use psychoeducational strategies to teach participants skills to resolve their issues and confi-
dently approach future prob lems. Individuals with concerns that require more intensive sup-
port may be ineligible for non- medical counseling and can instead use Military OneSource to
obtain information and referrals to more specialized ser vices. These issues may be related to
mental health diagnoses, substance use disorders, prescription medi cation, sexual assault, and
fitness for duty.
Military OneSource is available 24 hours a day, seven days a week, and individuals can
call Military OneSource to be connected to available resources or local non- medical counselors
(within 15 miles or 30 minutes away within the contiguous United States). Along with in-
person counseling, individuals have the flexibility to attend these 50- minute sessions over the
phone, through online instant messaging or email, and via online video calls. Multiple modali-
ties are available to ensure access to non- medical counseling ser vices despite individuals’ loca-
tion. Records are not shared with any entity, including the military, unless a “duty- to- warn”
situation occurs (i.e., child abuse/neglect, imminent safety of the counseling recipient or others,
or illegal activities; DoD, 2009).
Military OneSource contracts with a network of counselors in all U.S. states and territo-
ries. Counselors are located in communities near military installations and National Guard
and reserve activities for easy access by participants. While the number of counselors is consid-
ered proprietary to the contractor, Military OneSource counselors provide more than 170,000
non- medical counseling sessions annually.
Effectiveness of Military Support Programs
While many programs are available to support ser vice members and their families, evidence on
their effectiveness is limited due primarily to the lack of coordinated monitoring and evalua-
tion efforts. For example, the National Academies of Science recently conducted an assess-
ment of the programs available for preventing psychological disorders in ser vice members and
their families and found no comprehensive list of programs, systematic evaluation mecha-
nisms, or standard mea sures used to track effectiveness (Denning, Meisnere, and Warner,
2014). The review determined that while there were many programs addressing a wide array of

Introduction 9
issues, many were duplicative of other programming, few were informed by evidence, and even
fewer were regularly evaluated, if evaluated at all.
The 2014 National Academies of Science review also found that there is no mechanism to
track programs for ser vice members and their families, including monitoring program goals
and impact (Denning, Meisnere, and Warner, 2014). Among programs that resembled counsel-
ing programs, evaluation efforts focused primarily on utilization patterns and client satisfaction
ratings (Meredith et al., 2011). Moreover, while the cost of treating psychological prob lems
among ser vice members more than doubled between 2007 and 2012, systematic information
on cost of programs to prevent psychological issues is not collected (Denning, Meisnere, and
Warner, 2014). Combined with limited information on program outcomes, the military is gen-
erally unable to determine the cost- effectiveness of programs it currently funds (Denning,
Meisnere, and Warner, 2014).
The few programs that have published effectiveness data show improvements in indi-
viduals’ mental health symptoms, including distress, anxiety, and depression (Army Center for
Enhanced Per for mance, Battlemind; Meredith et al., 2011; Task Force, 2007; Bowles and
Bates, 2010); cognitive skills including attention (HeartMath; Meredith et al., 2011), memory
improvements (HeartMath; Meredith et al., 2011) and cognitive per for mance (Mindfulness-
Based Mind Fitness Training; Meredith et al., 2011); and stress level maintenance
(Mindfulness- Based Mind Fitness Training; Meredith et al., 2011). Programs have also dem-
onstrated increased career benefits among program participants, including higher promotion
rates (Hudak et al., 2009) and higher rates of returning to duty following stressful experiences
(Air Force Combat Stress Control and Prevention; Hassan et al., 2010).
A limited number of studies examined the impact of military support programs on fami-
lies. Meadows, Tanielan, and Karney (2016) found that ser vice members and spouses who
were engaged in more preparation activities for deployment reported greater satisfaction in
parenting after deployment. Additionally, Chandra et al. (2011) found that military families
that utilized military support ser vices reported fewer child mental health issues than their
counter parts. Fi nally, Cozza et al. (2010) found that military families with higher levels of
stress prior to a ser vice member’s injury are more likely to be negatively impacted by the injury
than families with lower levels of stress before the injury. This suggests that providing stress- coping
and resilience- building strategies may be beneficial in protecting families against military-
related stressors.
Because of the general lack of studies examining whether non- medical counseling helps
participants resolve prob lems, OSD asked R AND’s National Defense Research Institute
(NDRI) to conduct this study.
Organ ization of This Report
In the remainder of this report, we pres ent the study approach and findings regarding the effec-
tiveness of and satisfaction with non-medical counseling provided through the MFLC and
Military OneSource programs in addressing participants’ prob lems. In Chapter Two, we discuss
the evaluation design, study methodology, and analytic approach. In Chapter Three, we dis-
cuss findings related to prob lem severity and overall prob lem resolution following non- medical
counseling. Chapter Four examines the extent to which stress and anxiety resulting from the
presenting prob lem lessened following non- medical counseling. Chapter Five examines the extent

10 An Evaluation of U.S. Military Non-Medical Counseling Programs
to which prob lem interferences with work and daily life decreased following non- medical coun-
seling. In Chapter Six, we examine connections to other ser vices and referrals resulting from
non- medical counseling. Chapter Seven describes the experiences individuals had with the
non- medical counseling programs and counselors, including their perception of ser vices
received, level of satisfaction, and anticipated future use. Chapter Eight includes a summary of
key findings with implications for the future direction of non- medical counseling.
Each chapter begins with a summary of key, top- level findings that may be most relevant
to a policy audience. Top- level findings are reported for statistically significant effects on the
same variable across programs. When percentages vary between programs, the smallest effect
is reported in the top- level findings. Additional analytic detail and findings are presented in
the remainder of each chapter. This additional detail may be more relevant for MFLC and
Military OneSource program staff or those interested in the specific chapter topic. Additional
information about the data collection and analy sis, survey instruments, and study findings,
including subgroup analyses, can be found in Appendixes A, B, and C, respectively.

11
CHAPTER TWO
Evaluation Design, Methodology, and Analytic Approach
This evaluation was designed as two separate but parallel studies. While both MFLC and Mili-
tary OneSource provide non- medical counseling ser vices to military- connected individuals
and families, as noted in Chapter One, they operate separately and there are impor tant differ-
ences in the ways in which ser vices are delivered. Despite their differences, their goals are the
same: to provide short- term, solution- focused counseling to address general conditions of living
and military lifestyle. As a result, the evaluation design, survey instruments used to collect
data, the timeline for data collection, and our analytic approach were very similar for both
programs.
The objective of this study is to describe the effectiveness of and satisfaction with each
non- medical counseling program in addressing participants’ prob lems overall. The study is not
intended to examine the clinical effectiveness of specific therapies that may be provided to
individuals, specific training techniques counselors might use (e.g., for personal financial coun-
seling, anger management training) or to compare the outcomes of one program to the other.
Because the mode of ser vice delivery and the populations served vary by program, comparisons
between the two programs on similar outcomes should not be made. Similarly, results across
the programs cannot simply be averaged to identify the overall impact of non- medical counsel-
ing programs.
Evaluation Design
Our evaluation design was based on a logic model developed for this evaluation (Figure 2.1).
The logic model starts with DoD investments to implement non- medical counseling. This
takes the form of staff, time, money, materials, and equipment. There are two types of
activities— non- medical counseling provided by either MFLC or Military OneSource, which
should produce specific outcomes. In the short term, the availability of non- medical counseling
should result in improved access to such ser vices, earlier referrals to other ser vices as indicated,
and begin to address the immediate needs and concerns resulting from the presenting prob lem.
Because some prob lems may require multiple sessions, and it may take time to learn how to
effectively utilize the skills and approaches to prob lem resolution shared as part of non- medical
counseling, it is expected that over time individuals will have an increased ability to manage
their presenting prob lem, resulting in a reduction in prob lem severity and a reduction in stress
and anxiety. In the longer term, it is expected that there would be a continued ability to
manage non- medical prob lems, and a maintenance of or further improvement in prob lem
severity and stress. In addition to these effects at an individual level, non- medical counseling

12
A
n
E
va
lu
a
tio
n
o
f U
.S. M
ilita
ry N
o
n
-M
e
d
ica
l C
o
u
n
se
lin
g
P
ro
g
ra
m
s
• Staff
• Time
• Money
• Materials
• Equipment
and facilities
• Technology
Long-term outcomes
Final impacts
• Continued ability to
manage problem(s)
• Maintenance of
improvements of
outcomes
• Satisfaction with
military life
• Family stability
• Health and wellness
of the military
community
• Retention
• Force readiness
• Increased ability
to manage
problem(s)
• Reduction in
problem
severity
• Reduce personal
and/or work
stress associated
with problem
• Improve use of
additional
mentaI health
and
community-
based services
• Address
presenting
problem
• Improve
access to high-
quality and
culturally
competent
counseling
• Decrease
wait time
to receive
counseling
• Refer to
services/early
intervention/
treatment, as
needed
Face-to-face
counseling
Online counseling
Telephonic
counseling
Embedded in
military unit
NOTE: CDC = child development center
On demand
Surge
Rotational
(family centers
CDCs, schools, etc.)
Military and
family life
counseling (MFLC)
Military
OneSource
Non-medical
counseling
Inputs: DoD
investments
Activities:
Services offered
Outputs: Direct
products of services
Short-term
outcomes
Medium-term
outcomes
Longer-term outcomes
and final impacts
RAND RR1861-2.1
Figure 2.1
Logic Model for Evaluation of Non- Medical Counseling Programs

Evaluation Design, Methodology, and Analytic Approach 13
has the potential to have a larger impact within military communities through improvements
in force readiness, family stability, health and wellness, retention, and satisfaction.
We provide a brief overview of the study design here, with additional details provided in
the remainder of this chapter and in Appendixes A and B. For both MFLC and Military One-
Source, data collection occurred in two waves. Eligible individuals were invited to participate
and completed the Wave 1 survey shortly after their first non- medical counseling session. Par-
ticipants were asked to complete a similar survey three months later (Wave 2). Because non-
medical counseling provides short- term, solution- focused counseling for 12 sessions, three
months was considered a reasonable period of time to mea sure long- term prob lem resolution.
Data collection occurred from October 2014 to November 2016 for MFLC and from April 2015
to November 2016 for Military OneSource. The data collection periods differed in length
because of administrative challenges encountered in ensuring an adequate number of partici-
pants from each program. Both studies collected data for at a minimum a full calendar year to
ensure that findings were not driven by potential seasonal variation in non- medical concerns
or ser vice use. Prior to analy sis of the data, for both MFLC and Military OneSource, survey
data were merged with a limited amount of administrative data for those individuals who con-
sented to participate in the study.
Inclusion Criteria for Study Population
Non- medical counseling ser vices, by design, are flexible in their length and mode of delivery
and available to ser vice members, spouses, and other family members, including military-
connected children. While such flexibility can be beneficial in the implementation of a pro-
gram and allow counselors to provide ser vices to meet clients’ needs, these types of differences
pres ent challenges for program evaluation. As such, we worked with program leadership from
the outset to identify the most appropriate study participants. The study population for both
MFLC and Military OneSource was limited to adults aged 18 years or older who received at
least one non- medical counseling session of 30 minutes or more in an individual or couples
setting.
Children were excluded from the study as the non- medical ser vices available to them differ
programmatically from those that adults receive (e.g., ser vices are embedded in schools) and
are provided by a diff er ent set of non- medical counselors with expertise in children and youth.
The requirement that sessions be of 30 minutes or more was included to capture sessions where
participants received more intensive non- medical counseling ser vices (e.g., the study did not
include brief chats with a counselor). As a result, findings from this report should not be gen-
eralized to other populations, modes of delivery (e.g., group counseling sessions, training,
support groups), or length of counseling sessions, which should be evaluated separately. It is
impor tant to note that only individuals who used non- medical counseling ser vices were
included in this study. Although the inclusion of a comparison group would have strengthened
the findings by allowing us to make causal inferences, the logistical challenges of finding indi-
viduals in need of non- medical counseling ser vices but who did not engage with MFLC or
Military OneSource made this option untenable within the scope of this proj ect.

14 An Evaluation of U.S. Military Non-Medical Counseling Programs
Recruitment of Participants
Recruitment of participants for the study took place in two phases. First, program staff from
MFLC or Military OneSource introduced the study to potential participants and asked each
individual whether he or she would be interested in receiving more information about the
study. Then R AND NDRI followed up with official invitations to those individuals expressing
interest.
MFLC counselors introduced the study to eligible participants and handed them a card
where they indicated whether or not they were interested in learning more about the study. If
they were, participants included their email address so that R AND NDRI could invite them
to participate. Each card was stamped with a randomly assigned unique ID number which
allowed us to link survey results for consenting participants to administrative data about their
non- medical counseling session, while ensuring that the strictly confidential nature of the pro-
gram was kept intact.
For Military OneSource, when individuals first contacted Military OneSource about
their prob lem and were determined to be eligible for non- medical counseling ser vices, triage
con sul tants introduced the study and asked whether or not participants were interested in
learning more. If the individual indicated interest, their email address was recorded and saved
in a separate, secure database accessible to RAND NDRI researchers, and RAND NDRI used
that information to invite them to participate in the study. The study team purposefully kept
recruitment activities by program staff at a minimum to ensure potential participants felt com-
fortable accepting or declining study participation, without any perceived influence on counsel-
ing relationships. See Appendix A for a complete description of the recruitment methodology.
Survey Instruments
Wave 1
The Wave 1 survey was taken on average two weeks (for Military OneSource) to one month
(for MFLC) after the participant’s first counseling session. The survey was administered online
and consisted of questions assessing several diff er ent domains related to respondents’ prob lems,
prob lem resolution, and their experience with non- medical counseling. Although many ques-
tions were developed for this study, we drew upon existing standardized mea sures in the civil-
ian and military lit er a ture, where pos si ble, related to prob lem resolution (e.g., Status of Forces
Survey; Defense Manpower Data Center, 2012), provider satisfaction (e.g., CAHPS [Con-
sumer Assessment of Healthcare Providers and Systems] Surveys and Guidance, 2017), and
experiences with non- medical counseling programs like civilian employee assistance programs.
We did not include standardized outcome mea sures specific to non- medical counseling con-
cerns (e.g., grief, relationship challenges) given the variability in needs and presenting prob lems.
Pro cess and outcome mea sures selected for the study were intended to be broadly applicable to
all participants.
Each survey topic corresponded to one or more components of the program logic model
(see Figure 2.1). The survey was designed to capture both participants’ retrospective assess-
ments of the severity of their prob lem and perceived impact on their life prior to counseling, as
well as an assessment of their prob lem’s severity and perceived impact shortly after they began
non- medical counseling (i.e., at the time of the survey). The survey also included participants’

Evaluation Design, Methodology, and Analytic Approach 15
experiences with and perceptions of counseling, referrals to other resources, counselor quality,
and their anticipated future use of the program. Table 2.1 contains a summary of survey topics
and how they correspond to the outcomes in the logic model. The full survey is included in
Appendix B.
Wave 2
The outcome domains and mea sures assessed by the Wave 2 survey were identical to those
assessed at Wave 1 (Appendix B). The survey was also administered online and displayed the
type of prob lem that the respondent identified on the baseline survey. It informed participants
that “we are interested in learning more about your experiences with this issue/concern in the
three months since you completed the initial survey.” Questions were anchored to the three
months since respondents completed the baseline survey. This allowed us to examine changes
over time in our outcomes of interest, including prob lem severity, stress and anxiety, and effects
on work and family life. The survey also included questions related to help- seeking for the
Table 2.1
Survey Topics Matched to the Logic Model Outcomes
Logic Model Outcome
Survey Topic(s) Evaluated in
Both Wave 1 and Wave 2 Surveys
Short- term outcomes
Reduction in prob lem severity Perceived severity, perceived stress, interference with work
and personal life
Increase in access to high- quality1 ser vices Ease of access, perceived counselor quality, perceived
competence, perceived alignment of treatment with need,
adequacy of materials and information, satisfaction with
ser vice, perceived strengths and weaknesses of program
Increase in referrals to other ser vices,
as indicated
Referral to ser vices, types of ser vices accessed outside of
MFLC/Military OneSource
Medium- term outcomes
Increase in ability to manage prob lems and
reduction in prob lem severity
Perceived severity
Reduction in stress Perceived stress, interferences with work and
personal life
Increase in mental health and other
community services
Types of ser vices accessed outside of MFLC/Military
OneSource
Longer- term outcomes and final impacts
Continued ability to manage prob lems Prob lem severity, anticipated future use
Maintenance of improved outcomes Perceived stress, interferences with work and
personal life
Final impacts Self and family felt more prepared for deployment, children
felt better supported, retention in military, recommended
use of non- medical counseling to others
NOTE: The outcomes in the left column correspond to the logic model presented in Figure 2.1.
1 The logic model assumes that the specific ser vices provided to participants are of high quality, but this
evaluation does not directly assess the quality or appropriateness of the specific types of ser vices or supports
provided by non- medical counselors, as these vary considerably across participants. Rather, we use perceptions of
quality, perceptions of adequacy and alignment of ser vices to need, and overall satisfaction as universal
indicators of program quality.

16 An Evaluation of U.S. Military Non-Medical Counseling Programs
same prob lem, including continued support from MFLC or Military OneSource or from other
sources of treatment.
Administrative Data
In order to shorten the number of questions asked on the survey and to obtain the presenting
prob lem for which participants sought help, we matched the survey data for participants who
consented to the study with the administrative rec ords for their counseling session. For MFLC
participants, this involved matching the randomly assigned ID number printed on the study
interest cards and recorded on the activity log for the session by counselors with survey data
bearing the same number. For Military OneSource, survey data were matched with counseling
session rec ords via the participants’ email address. The information from administrative rec-
ords that was used in the current study included participant age, gender, marital status, rela-
tionship to the sponsoring ser vice member (e.g., self, spouse, other family member), ser vice,
component, pay grade, number of prior sessions, whether or not the counselor was embedded
within the sponsor’s unit (MFLC only), and the presenting prob lem (often noted as “V code”
in administrative rec ords1).
Response Rates and Study Participants
MFLC
In order to compute survey response rates, we used the total number of individuals who were
offered the opportunity to take part in the study as the denominator to calculate response rates.
For MFLC participants, the denominator is the total number of unique study solicitation cards
returned to R AND NDRI, and included both those cards with requests for additional infor-
mation about the study (i.e., marked “yes” with an email address) and those not requesting
additional information about the study (i.e., marked “no”). The total number of cards received
from MFLC was 40,494, with 14,903 cards indicating interest in the study (36.8 percent).
Because individuals were given a card after every session, individuals with more than one
counseling session were likely to receive multiple cards. R AND NDRI received 3,259 cards
that included an email address identical to one already included in our list of interested partici-
pants (22 percent of cards indicating interest in the study). Since cards indicating no interest
contained no identifying information, it is unclear how many of those cards were duplicates
(e.g., one person declining interest twice).
In addition, emails to 1,080 interested MFLC participants were returned as undeliver-
able, and attempts to resolve the email addresses of these participants failed. Thus, subtracting
the 3,259 duplicates and 1,080 individuals with undeliverable email addresses from the total
left 36,155 potential participants for the study. A total of 2,585 MFLC participants completed
one or more items on the survey, for a response rate of 7.1 percent, and 2,310 completed every
item on the survey, for a response rate of 6.4 percent. For the Wave 2 survey, a total of 614
1 V codes, as described in the ICD-9- CM “Official Guidelines for Coding and Reporting, Supplementary Classification
of Factors Influencing Health Status and Contact with Health Ser vices,” are used by providers to classify patient visits when
circumstances other than a disease or injury result in an encounter with a provider (e.g., relationship distress, parent- child
relational prob lem; Kostick, 2011).

Evaluation Design, Methodology, and Analytic Approach 17
MFLC participants completed one or more items, and 541 completed all items on the survey
(between 20.9 percent and 26.6 percent of Wave 1 participants).
Military OneSource
Military OneSource maintains a log of calls made to their triage con sul tants and rec ords who
receives a referral to a counselor, which is indicative of the need for a longer (30- minute or
more) counseling session. Using this system, we identified 34,632 unique participants eligible
for the study. Of these, 28,199 expressed interest in receiving more information about the
study (81.4 percent of all eligible participants). Of those, a total of 2,892 individuals completed
one or more items on the survey, for a response rate of 8.6 percent, and 2,417 completed all
items on the survey, for a response rate of 7.2 percent. Since survey items are weighted and
analyzed on an item- by- item basis, the response rate for any one question is between these two
figures. For the Wave 2 survey, a total of 878 Military OneSource participants completed
one or more items, and 793 completed all items on the survey (between 27.4 percent and
36.3 percent of Wave 1 participants).
Response rates for both MFLC and Military OneSource were low, but not aty pi cal for
studies of military ser vice members and their families (Miller and Aharoni, 2015). As with all
surveys, low response rates increase the potential for bias in the results because there is greater
probability that the respondents are not representative of the population the survey is meant to
assess (e.g., respondents could only represent those who are dissatisfied with non- medical coun-
seling). However, comparisons to population- level characteristics of all program users who met
eligibility criteria for the study revealed that study participants were representative of the popu-
lation on demographic characteristics and prob lem type. Numerous studies have found that
sample representativeness, and not the response rate, is the key indicator of a biased sample (see
Miller and Aharoni, 2015). As discussed in detail below, where there were differences between
the sample and population characteristics we adjusted the data to be representative of the
population.
Demographic Information
Demographic information describing the MFLC and Military OneSource study partici-
pants is shown in Table 2.2. We used a pro cess called “raking” to weight the data to be rep-
resentative of the population of non- medical counseling participants. See Appendix A for a
complete description of weighting procedures and comparison of the study sample to the
population.
We should note that all MFLC participants recruited for this study met with their coun-
selor in person, but Military OneSource participants were able to use diff er ent modes to com-
municate with their counselor (e.g., phone, web chats). At Wave 1, 85 percent of Military One-
Source participants had met with their counselor in person, 12 percent had talked with them
over the phone, just less than 2 percent had chatted online, and just over 1 percent had met
with their counselor via video link.
Analytic Approach
We analyzed the survey results using both quantitative and qualitative methods.

18 An Evaluation of U.S. Military Non-Medical Counseling Programs
Quantitative Methods
We analyzed the survey data using two types of regression models: models that describe
responses to survey questions at a single point in time (e.g., prob lem severity ratings at Wave 1)
and models of changes over time (e.g., changes in prob lem severity from precounseling levels
retrospectively assessed at Wave 1 to prob lem severity assessed at Wave 2). In order to explore
whether there were notable differences by prob lem type or client characteristics, all models
included the following covariates: gender; a three- category age variable ( under 25 years;
25–40 years; 41 years and above); whether the respondent was a ser vice member (as compared
to a spouse or other family member); ser vice affiliation (Air Force, Army, Marine Corps, Navy,
or Coast Guard); component affiliation (active or reserve); officer or enlisted (self or sponsoring
family member); and, in the case of MFLC, whether the counselor was embedded in the spon-
soring ser vice member’s unit or not. We also included an indicator of the primary presenting
Table 2.2
Demographic Characteristics of the MFLC and Military OneSource
Study Samples
Characteristic
MFLC
(%)
Military OneSource
(%)
Age
18–24 18.6 6.8
25–40 71.6 69.6
41 and over 9.8 23.6
Ser vice affiliation
Army 49.0 34.7
Marines 14.4 7.5
Air Force 31.7 21.9
Navy 3.8 19.1
Other 1.2 16.7
Rank (self or sponsoring family member)
Enlisted 78.5 68.7
Officer 21.5 31.3
Ser vice member status
Family member 57.2 35.7
Ser vice member 42.8 64.3
Component affiliation
Active duty 98.1 73.4
Guard or reserve 1.9 26.6
Gender
Women 60.4 56.8
Men 39.6 43.2
NOTE: Percentages are weighted to be representative of the MFLC and Military
OneSource non- medical counseling population.

Evaluation Design, Methodology, and Analytic Approach 19
prob lem. Thus, all results reporting differences among client characteristics or prob lem type
control for the other covariates in the model. Given the number of variables representing sub-
groups of client characteristics and prob lem type that were included as covariates, as well as the
number of outcomes that we investigated, we set the criterion p- value for reporting significant
subgroup differences at p < .01. Even though we use a more stringent cutoff than the typical p < .05, we do not control the overall error rate; hence, the subgroup analyses should be con- sidered exploratory. Also, because fewer people responded to both the Wave 1 and Wave 2 surveys, we have less statistical power to detect long- term subgroup differences in outcomes. We also use this type of model to report on distributions of outcome variables across all respondents in a survey wave. Because some individuals did not respond to every question when taking the survey, we wish to account for item non- response in these summaries. Accord- ingly, rather than report raw responses, we report estimated probabilities of providing a par tic- u lar response for each respondent to a par tic u lar wave (regardless of whether the individual responded to the par tic u lar question of interest). Moreover, the estimated probabilities depend on the covariates mentioned in the previous paragraph. In cases where covariates are missing, we multiply impute plausible values, and the reported probabilities are averaged over the mul- tiple imputations. We examined differences in demographics between those who responded to the Wave 2 survey and those who did not. For surveys, the absolute standardized mean difference between groups is a common metric for mea sur ing similarity between two groups. Typically, if the stan- dardized mean differences are below 0.2 for all covariates, the two groups are considered to be similar (i.e., statistically well- balanced). Comparing the demographic characteristics between Wave 2 respondents and non- respondents, the only characteristic that was dissimilar between groups according to this metric was age (standardized mean differences of 0.25 for MFLC and 0.22 for Military OneSource). For both MFLC and Military OneSource samples, older par- ticipants were more likely to complete the Wave 2 survey than were younger participants. Since age was only modestly imbalanced for both MFLC and Military OneSource samples, and the regression models control for age, the potentially confounding effect of age is taken into account in our analyses of the Wave 2 data. See Appendix A for a complete description of the quantitative analytic approach used in this report. Qualitative Methods Survey respondents had the option to provide open- ended responses to two questions assessing the perceived strengths and weaknesses of the non- medical counseling program (“What do you see as the major advantages or strengths of non- medical counseling offered by Military and Family Life Counseling [Military OneSource]?”; “What do you see as the major concerns or challenges related to non- medical counseling offered by Military and Family Life Counseling [Military OneSource]?”). A total of 1,819 MFLC participants (79 percent) and 1,055 Military OneSource participants (44 percent) provided responses to the open- ended questions at Wave 1, and 420 MFLC participants (78 percent) and 619 Military OneSource participants (78 percent) provided responses to the open- ended questions at Wave 2. Researchers used an iterative pro cess to develop codes for responses to each question based on recurring themes. Representative participant quotes from relevant open- ended codes are interspersed throughout the report to illustrate findings from the survey. See Appendix A for a complete description of the qualitative analy sis used in this report. 21 CHAPTER THREE Severity and Overall Prob lem Resolution In this chapter, we first examine the types of prob lems for which individuals are seeking non- medical counseling. We then examine whether individuals experienced short- term decreases in prob lem severity and overall prob lem resolution following non- medical counseling, and whether these reductions were maintained long term. Short- term prob lem resolution was mea- sured by comparing retrospective self- reports of precounseling prob lem severity with the rat- ings of prob lem severity at the time of the Wave 1 survey, taken approximately two to three weeks after a participant’s initial counseling session. Longer- term prob lem resolution and impact were assessed at Wave 2 (three months after the Wave 1 survey). Statistically significant differences among subgroups are discussed in the text and subgroup differences are tabulated in Tables C3.1– C3.5 in Appendix C.1 Key findings from this chapter include: • The most common prob lems participants reported were family or relationship prob lems; followed by stress, anxiety, or emotional prob lems; and prob lems with conflict resolution or anger management. • Participants reported a statistically significant reduction in prob lem severity following non- medical counseling. • Over 65 percent of individuals experienced a reduction in prob lem severity in the short term. • Reductions in prob lem severity were maintained long term with over 80 percent of indi- viduals reporting the same or improved prob lem severity in the three months after receiv- ing counseling. • Women tended to report greater short- term prob lem resolution than men. • Fifty percent or less of participants agreed or strongly agreed that non- medical counseling made them or their families feel more prepared for deployment. Between 30 percent (Military OneSource) and 44 percent (MFLC) of participants agreed or strongly agreed that non- medical counseling made reintegration after deployment easier. 1 All subgroup differences described in this report were significant controlling for other variables in the regression model: gender; a three- category age variable ( under 25 years; 25–40 years; 41 years and above); whether the respondent was a ser- vice member (vs. spouse or other family member); ser vice affiliation (Air Force, Army, Marines, Navy, or Coast Guard); component affiliation (active, reserve); officer or enlisted (self or sponsoring family member); and, in the case of MFLC, whether the MFLC was embedded or not. We also included an indicator of the category for the V code of the primary pre- senting prob lem. 22 An Evaluation of U.S. Military Non-Medical Counseling Programs • Just under half of MFLC participants and 41 percent of Military OneSource participants agreed or strongly agreed that non- medical counseling had an impact on their desire to stay in the military (or remain a military family). • Participant responses to open- ended items suggest that the broader community of ser vice members and their families may lack awareness of the availability of non- medical coun- seling through these programs, particularly through the MFLC program. Prob lem Type As shown in Table 3.1, when asked to report the type of prob lem(s) participants had sought non- medical counseling to address, the majority of MFLC and Military OneSource partici- pants indicated that they had sought counseling for family or relationship prob lems (68 percent and 74 percent, respectively), followed by stress, anxiety, or emotional prob lems (55 percent and 43 percent, respectively). A little over a quarter of MFLC respondents and 21 percent of Military OneSource respondents indicated that they had sought counseling for conflict resolu- tion or anger management. Of those whose current prob lem did not involve family or relationship issues, almost 22 percent and 24 percent had sought help from MFLC and Military OneSource counselors, respectively, for these kinds of issues in the past. Thus, approximately 90 percent of MFLC and Military OneSource respondents had sought help with family or relationship prob lems from MFLC or Military OneSource counselors, either currently or sometime in the past. Similarly, of MFLC or Military OneSource respondents whose current prob lem did not involve stress, anxiety, or emotional prob lems, just over 19 and 13 percent, respectively, had sought help for these kinds of issues in the past. Thus, about three quarters of MFLC respondents and 56 percent of Military OneSource respondents had sought help for stress, anxiety, or emotional prob lems from their respective counselors, either currently or in the past. For this question, participants could select all prob lems for which they were seeing a non- medical counselor. For the remainder of our analyses, however, we examine group differences by primary prob lem type, which was obtained from the primary prob lem (reported in admin- istrative rec ords as ICD 9 “V codes”).2 We used V codes instead of self- reports because the reported V code is the trained counselor’s professional judgment of the primary reason the par- ticipant is seeking counseling. Thus, we were able to assign each participant one primary prob lem type rather than several self- reported prob lem types. To ensure adequate sample size, we col- lapsed the primary V code prob lem type into six prob lem domains. V codes that represented subcategories of prob lems (e.g., “marital and partner prob lems, unspecified”) were collapsed into their larger overall ICD 9 prob lem domains (e.g., “ family or relationship prob lems”). Two prob lem domains with fewer respondents— employment assistance and education assistance prob lems— were combined into an “education or employment” prob lem domain. The six prob- lem domains were therefore child issues; deployment concerns; education or employment; family or relationship; loss or grief; and stress, anxiety, or emotional prob lems. 2 V codes, as described in the ICD-9- CM “Official Guidelines for Coding and Reporting, Supplementary Classification of Factors Influencing Health Status and Contact with Health Ser vices,” are used by providers to classify patient visits when circumstances other than a disease or injury result in an encounter with a provider (e.g., relationship distress, parent- child relational prob lem; Kostick, 2011). Severity and Overall Prob lem Resolution 23 Short- Term Changes in Prob lem Severity On the Wave 1 survey, administered shortly after the first non- medical counseling session, we asked participants to retrospectively assess the severity of their prob lem before receiving coun- seling and also to assess their level of prob lem severity at the time of the survey. Respondents rated the severity of their prob lem on a four- point scale: low, moderate, severe, or very severe. As shown in Figure 3.1, before receiving counseling, most participants rated their prob lems as severe or very severe (69 percent of MFLC and 68 percent of Military OneSource participants). After initiating non- medical counseling (Wave 1), only 14 percent of MFLC and 26 percent of Military OneSource participants rated their prob lem as severe or very severe. To analyze short- term changes in prob lem severity, we examined the proportion of par- ticipants who reported improved versus worsened severity before and after initiating counsel- Table 3.1 Type of Non- Medical Prob lem Reported by MFLC and Military OneSource Participants MFLC Military OneSource Prob lem Type Most Recent Prob lem (%) Sought Counseling for This Prob lem in the Past (%) Most Recent Prob lem (%) Sought Counseling for This Prob lem in the Past (%) Child issues (e.g., academic, behavioral) 11.8 9.7 8.4 5.3 Family or relationship issues 67.8 21.6 73.6 23.6 Conflict resolution or anger management 26.1 14.5 20.8 8.8 Exceptional family member support1 7.0 6.6 2.8 2.2 Stress, anxiety, or emotional prob lems 55.3 19.2 43.1 13.1 Deployment concerns or support 8.3 10.1 7.6 5.0 Reintegration concerns or support 7.2 9.2 5.6 4.7 Relocation/permanent change of station (PCS) concerns or support 7.8 7.0 3.8 2.0 Wounded warrior concerns or support 2.3 3.2 1.0 1.0 Loss or grief 12.8 9.9 10.1 4.5 Personal financial management 5.9 8.2 2.7 3.0 Employment assistance 4.1 4.6 1.5 2.3 Education assistance (for self or spouse) 3.3 5.0 1.4 2.7 Care for disabled or el derly adult 1.2 2.3 0.6 1.1 Other 7.3 3.9 5.1 1.4 NOTE: Respondents were able to check all prob lem types that apply and so totals do not equal 100%. Percentages are weighted to be representative of the MFLC and Military OneSource non- medical counseling population. n sizes varied from 1,842 (other prob lem) to 2,524 ( family or relationship) for MFLC and from 1,938 (other prob lem) to 2,650 (family or relationship) for Military OneSource. 1 The Exceptional Family Member Program is a program that works with other military and civilian agencies to provide comprehensive and coordinated community support, housing, educational, medical, and personnel ser vices to families with special needs. 24 An Evaluation of U.S. Military Non-Medical Counseling Programs ing, mea sured at Wave 1. The analy sis tests whether the proportion of participants getting better versus worse differs from what one would expect from chance alone. Left to chance (if the counseling had no impact), the expectation is that as many participants’ prob lems would improve as would get worse. However, our results indicated that in both programs, the severity of participants’ prob lems was more likely to diminish after counseling than would be expected by chance alone. As shown in Figure 3.2, ratings of prob lem severity decreased after counseling for 79 percent of MFLC participants and 65 percent of Military OneSource participants. About 19 percent of MFLC and 33 percent of Military OneSource participants reported the same level of prob lem severity, and 2 percent of MFLC and Military OneSource participants reported an increase in prob lem severity. Open- ended responses to the questions assessing strengths and weaknesses of the MFLC and Military OneSource programs were not directly compared to quantitative findings on changes in prob lem severity. However, excerpts from open- ended responses provide some con- text to observed data patterns. Many participants mentioned that the program was effective at helping them to resolve the issues for which they sought counseling. Non- medical counseling offered by Military OneSource is an outstanding tool. The mili- tary has placed a lot of stress in my family. The help received via our counseling sessions has made our family stronger and resilient. I am extremely thankful for this ser vice provided, the availability of the help, and the confidentiality of the pro cess. I feel my 5% 42% 3% 23% 26% 43% 29% 52% 37% 11% 39% 20% 32% 3% 29% 6% 0 20 40 60 80 100 Before counseling Shortly after counseling Before counseling Shortly after counseling M FL C M il it a ry O n e S o u rc e Low Moderate Severe Very severe NOTE: ns = 2,358 for MFLC and 2,519 for Military OneSource. Problem severity was assessed at Wave 1. Severity before counseling was retrospectively reported. Severity after counseling captured perceptions of problem severity at the time of the survey. MFLC and Military OneSource estimates were generated in separate regression models. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non-response. Rows may not add to 100% due to rounding. RAND RR1861-3.1 Figure 3.1 Average Estimated Probability of Prob lem Severity Ratings Before and After Non- Medical Counseling, Wave 1 Severity and Overall Prob lem Resolution 25 family’s sacrifice (to support my ser vice) has been acknowledged. (Military OneSource participant) This program helped save my marriage, help guide me to proper mental health care, and gave me more resources than I thought were available to help me with other issues. (MFLC participant) Despite reported improvements for many, for a large subset of participants, including over one- third of Military OneSource respondents, counseling did not help resolve the issues for which they were seeking help. This could be due to issues such as mismatches between coun- selor expertise and participant needs (e.g., a lack of knowledge about military families) or the participants seeking help for prob lems that are out of scope for non- medical counseling (e.g., clinical depression). These factors are explored further in Chapters Six and Seven of this report. Select open- ended responses indicated that some counselors had good intentions but lacked the skills necessary to have an impact on prob lem resolution, while issues with counselor compe- tence hindered the resolution of issues for others. This counseling did not address the issues that I had and was sadly of little or no use as we were limited by time and the counselor had NO experience with military family dynam- ics so half or greater amount of time I was explaining how it all worked. She was compas- sionate and wanted to assist me but NO work was done on my biggest prob lem. (Military OneSource participant) Improved Stayed the same Got worse NOTE: ns = 2,358 for MFLC and 2,519 for Military OneSource. Within-person changes of problem severity before and after counseling, both measured at Wave 1. MFLC and Military OneSource estimates were generated in separate regression models. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non-response. RAND RR1861-3.2 0 10 20 30 40 50 60 70 80 90 100 79% 19% 2% MFLC 65% 33% 2% Military OneSource Figure 3.2 Average Estimated Probability of Short- Term Changes in Prob lem Severity Ratings, Wave 1 26 An Evaluation of U.S. Military Non-Medical Counseling Programs I did not care for my counselor but after telling my story to her, I was too exhausted to change counselors and start over. I only went to three sessions with the counselor because I felt worse after I left each time. (Military OneSource participant) The MFLC that we spoke with lacked compassion and concern. We felt uncomfortable opening up to this MFLC and were discouraged to see him again or any other MFLC, for that matter. Unfortunately, we continue to have unresolved issues. (MFLC participant) I did not benefit from my experience in any way, so I do not see any advantages or strengths of using this resource. (MFLC participant) Subgroup Differences Before Non- Medical Counseling We observed significant subgroup differences in ratings of prob lem severity before counseling by gender among MFLC participants, by ser vice affiliation for Military OneSource partici- pants, and by prob lem type for both MFLC and Military OneSource participants (see Tables C3.1 and C3.2 in Appendix C). Among MFLC participants, a larger proportion of women rated their prob lem as very severe compared to men (34 and 29 percent, respectively), while a larger proportion of men reported moderate severity compared to women (29 and 25 percent, respectively). Among Military OneSource participants, a smaller proportion of those affiliated with the Air Force reported that their prob lem was “very severe” compared to the other ser vices (24 percent as opposed to 30–33 percent, respectively). The significant difference by prob lem type among MFLC participants was largely driven by 38 percent of individuals who rated their most recent family or relationship concern to be very severe, compared to 20–29 percent of participants with other types of prob lems. Similar to MFLC, a large proportion of Military OneSource respondents with family or relationship prob lems rated their prob lem as very severe before counseling—32 percent— compared to 16–25 percent of participants with other types of prob lems. In Short- Term Resolution of Prob lem Severity Results revealed no subgroup differences in short- term prob lem severity changes for Military OneSource, but for MFLC, severity changes differed by prob lem type and gender (see Table C3.3 in Appendix C). MFLC participants seeing a counselor about prob lems with their children tended to be more likely than other groups to have the same severity rating over the short term (27 percent compared to 18–23 percent for other prob lem types), and tended to be less likely to report large improvements in severity over the short term (26 percent com- pared to 31–39 percent for other prob lem types). Still, about 70 percent of MFLC partici- pants seeking help with child prob lems reported some decrease in prob lem severity over the short term. While a large percent of men did report a decrease in prob lem severity over the short term (77 percent), there were significant gender differences in prob lem severity over time. Compared to women, men were slightly more likely to have the same prob lem severity over the short term (21 percent and 18 percent, respectively). Women were more likely than men to report large reductions in severity over the short term (39 percent of women compared to 33 percent of men). Severity and Overall Prob lem Resolution 27 Long- Term Changes in Prob lem Severity The Wave 2 survey, administered three months following the Wave 1 survey, used the same mea sure of prob lem severity. Successful long- term prob lem resolution would be evidenced by maintenance of short- term improvements in prob lem severity or further reduction of prob lem severity over time. A return to precounseling levels of prob lem severity would indicate that, although non- medical counseling resolved prob lems in the short term, those improvements were not sustained long term. This analy sis was limited to the participants who completed these mea sures on both the Wave 1 and Wave 2 surveys (ns = 472 for MFLC and 608 for Mili- tary OneSource). As shown in Figure 3.3, across both programs average prob lem severity decreased in the short term (Wave 1), especially among MFLC participants. At the three- month follow-up, average prob lem severity continued to improve among Military OneSource participants and average short- term reductions were maintained among MFLC participants: about 80 percent of MFLC and 88 percent of Military OneSource participants reported the same or improved prob lem severity after three months. Among Military OneSource participants, 38 percent demonstrated a further reduction in prob lem severity after three months. This suggests that short- term improvements in prob lem resolution were maintained by most participants, and that a substantial number of Military OneSource participants reported additional prob lem resolution in the long term. NOTE: Average severity ratings were calculated for those who completed both Wave 1 (before and after counseling ratings) and Wave 2 (three months after counseling) surveys. ns = 472 for MFLC and 608 for Military OneSource. MFLC and Military OneSource estimates were generated in separate regression models. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non-response. RAND RR1861-3.3 1.5 1.0 2.0 2.5 3.0 3.5 4.0 Before counseling Shortly after counseling Three months after counseling Le ss s e v e re M o re s e v e re MFLC Military OneSource Figure 3.3 Average Estimated Prob lem Severity over Time 28 An Evaluation of U.S. Military Non-Medical Counseling Programs Compared to ratings of prob lem severity before counseling, 81 percent of MFLC and 77 percent of Military OneSource participants demonstrated a long- term reduction in prob- lem severity after three months. About 15 percent of MFLC and 20 percent of Military One- Source participants reported prob lem severity that was similar to severity before receiving counseling. A small percentage of MFLC and Military OneSource participants reported increased severity relative to that which they were experiencing before counseling (3 and 4 percent, respectively). Another way to look at long- term changes in severity is to examine the percent of partici- pants who rated their prob lem severity as low, moderate, severe, or very severe across time. Figure 3.4 is similar to Figure 3.1, but includes responses from the Wave 2 survey. Numbers vary slightly from what is presented in Figure 3.1 as this figure includes responses only from those who completed both surveys. Similar to Figure 3.3, when examined over time, severity ratings remained stable among MFLC participants, and there was a continued reduction in prob lem severity among Military OneSource participants. Three months after counseling, about 15 percent of participants still reported that their prob lem was severe or very severe. Subgroup Differences in Long- Term Prob lem Resolution Results revealed no significant subgroup differences in reported prob lem resolution after three months for MFLC participants. But for Military OneSource, long- term changes in prob lem severity differed by rank (own or sponsoring family member; see Table C3.4 in Appendix C). Low Moderate Severe Very severe 40% 44% 3% 22% 39% 22% 45% 41% 28% 52% 48% 41% 12% 11% 38% 21% 9% 33% 3% 4% 31% 4% 4% Before counseling Shortly after counseling Three months after counseling Before counseling Shortly after counseling Three months after counseling M FL C M il it a ry O n e S o u rc e 0 20 40 60 80 100 NOTE: Severity ratings were calculated for those who completed both Wave 1 (before and after counseling ratings) and Wave 2 (three months after counseling) surveys. ns = 472 for MFLC and 608 for Military OneSource. MFLC and Military OneSource estimates were generated in separate regression models. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non-response. Rows may not add to 100% due to rounding. RAND RR1861-3.4 4% Figure 3.4 Average Estimated Probability of Severity Ratings over Time Severity and Overall Prob lem Resolution 29 Officers and their families were more likely to report improved prob lem resolution from before counseling to the three- month follow-up than were enlisted participants and their families (83 percent and 74 percent, respectively). Enlisted participants and their families were more likely than officers and their families to report the same level of prob lem severity before coun- seling and after three months (23 percent and 15 percent, respectively), with 3 percent of enlisted and 2 percent of officers and their families reporting an increase in severity after three months. Impact of Non- Medical Counseling on Deployment Preparedness and Retention Intentions In addition to asking about prob lem resolution, we asked participants whether non- medical counseling had helped them and their families prepare for deployment and adjust to reintegra- tion, and whether non- medical counseling made them want to stay in the military. Deployment and Reintegration Participants were asked to report on the extent to which they agreed with the statement that “non- medical counseling made them feel more prepared for deployment.” About 50 percent of MFLC participants agreed or strongly agreed with this statement, but about 39 percent indi- cated that they neither agreed nor disagreed with this statement and over 10 percent disagreed or strongly disagreed (see Figure 3.5). Among Military OneSource participants, about 40 percent agreed or strongly agreed that non- medical counseling made them feel more prepared for deploy- ment, but an even higher percentage (46 percent) reported that they neither agreed nor disagreed. About 14 percent of Military OneSource participants disagreed or strongly disagreed that non- medical counseling helped them feel more prepared for deployment. A similar question was asked about whether non- medical counseling made their family feel more prepared for deployment. About 46 percent of MFLC participants agreed or strongly agreed that non- medical counseling made their families feel more prepared for deployment, another 42 percent neither agreed nor disagreed with this statement, and about 11 percent disagreed that non- medical counseling helped their family feel more prepared for deploy- ment. For Military OneSource, about 33 percent of participants agreed or strongly agreed that non- medical counseling made their families feel more prepared for deployment, but over half neither agreed nor disagreed, and about 14 percent disagreed. When asked whether they felt non- medical counseling made reintegration after deploy- ment easier, 44 percent of MFLC and 30 percent of Military OneSource participants agreed or strongly agreed that it did help (Figure 3.5). However, about 46 percent of MFLC and 56 percent of Military OneSource participants neither agreed nor disagreed with this statement. These mea sures are designed to capture longer- term impacts of non- medical counseling, which may explain why the findings are not as strong. However, participant responses did not significantly change between Wave 1 and Wave 2, suggesting that non- medical counseling does not have an additional impact on deployment and reintegration adjustment in the long term. These questions are also focused on deployment preparedness and reintegration, and responses may reflect the relatively slow military operation tempo at the time of the study. Non- medical concerns related to deployment were not as prevalent as others (see Table 3.1), 30 An Evaluation of U.S. Military Non-Medical Counseling Programs suggesting that participants may have been less likely to endorse a positive impact of non- medical counseling on an outcome about which they were not currently concerned. There were no significant subgroup differences on these mea sures. In open- ended responses, participants often mentioned utilizing non- medical counseling ser vices to help cope with deployment, reintegration, and other transitions. Strengths of the program described in open- ended responses included the impact of counseling on ser vice members and family preparation for transitions. I have used this ser vice for about a year. It has helped me cope with my husband’s deploy- ment, helped us re- connect now that he’s home, helped our family dynamic, helped me as an individual. We would be so much worse off without this ser vice. Our provider/counselor is awesome and has helped us gain a stronger marriage and has helped me to be a better spouse. (Military OneSource participant) 10 sessions is great but limits what can be done. I have used the ser vices for both pre deploy- ment and reintegration home to help the transitions. I wish my family could have had counseling sessions WHILE I was deployed. (Military OneSource participant) However, open- ended responses also indicated that some ser vice members may lack aware- ness of the availability of counseling for deployment preparation, based on their experiences with counselors promoting their ser vices after deployment. Additionally, issues with quality and 50% 40% 46% 33% 44% 30% 39% 46% 42% 53% 46% 56% 11% 14% 11% 14% 10% 14% 0 10 20 30 40 50 60 70 80 90 100 MFLC Military OneSource MFLC Military OneSource MFLC Military OneSource I felt more prepared for deployment My family felt more prepared for deployment Reintegration after deployment was made easier Agree/strongly agree Neither agree nor disagree Disagree/strongly disagree NOTE: ns = 579, 537, and 517 for MFLC; 606, 570, and 550 for Military OneSource, respectively. MFLC and Military OneSource estimates for each question were generated in separate regression models. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non-response. RAND RR1861-3.5 Figure 3.5 Average Estimated Probability of Perceived Impact of Non- Medical Counseling on Deployment Preparation and Reintegration, Wave 1 Severity and Overall Prob lem Resolution 31 continuity of counseling postdeployment may help to explain why half of respondents did not feel more prepared for deployment with the availability of non- medical counseling. I found out about MFLC through a counselor that was walking around my camp going shop to shop introducing herself. And while that is great on her part, it should have been something widely publicized especially among military members that deploys and do so frequently. Also, emphasis should be placed on providing counseling to those who need it before deployment and not just post deployment. (MFLC participant) The biggest time I see the MFLCs is right after a deployment and it turns into a check the box kind of thing. Every one must take file through and talk with the MFLC upon rede- ployment but I think the real prob lems start 3–6 months after that and then there are too few MFLCs at that time. (MFLC participant) [A weakness of the Military OneSource program is that it is] only 12 sessions, when many deployments are for an entire year and families may need more assistance to get through the many trials and rough patches. (Military OneSource participant) In fact, a common theme in the open- ended responses was a general lack of awareness about the MFLC program among ser vice members and their families in the broader military community. They are not as known as they should be. They need to be advertised more. I’ve sought counseling, talked to other people on and off base and it took me a while to learn about this program. (MFLC participant) That the ser vices are even available is not common knowledge; I stumbled upon this ser- vice . . . (MFLC participant) Willingness to Stay in the Military We asked participants to indicate their agreement with the statement, “ because of non- medical counseling, I wanted to stay in the military longer (or I wanted to remain a military family for a longer period of time).” As shown in Figure 3.6, just under half of MFLC participants and 41 percent of Military OneSource participants agreed or strongly agreed that non- medical counseling had an impact on their desire to stay in the military (or remain a military family). About 34 percent of MFLC and 39 percent of Military OneSource were neutral on the impact counseling has had on their willingness to stay in the military. A sizable percentage of partici- pants indicated that they disagreed or strongly disagreed that non- medical counseling made them want to stay in the military longer (18 percent of MFLC and 21 percent of Military One- Source participants). As with the questions on deployment and reintegration, this mea sure is designed to capture longer- term impacts of non- medical counseling, which may explain why the findings are not as strong. However, participants’ responses did not substantially change between Wave 1 and Wave 2 (e.g., 49 percent of MFLC participants and 46 percent of Military OneSource participants agreed or strongly agreed at Wave 2), suggesting that participants’ willingness to stay in the military was not further affected by non- medical counseling in the long term. Open- ended responses include examples of the impact of non- medical counseling on par- ticipants’ willingness to stay in the military: 32 An Evaluation of U.S. Military Non-Medical Counseling Programs I would recommend MFLC counselors to every one. I think she has made me not hate the army and deployment nearly as much as I am SURE I would have hated it. Thank you!!! (MFLC participant) It has given me a much needed way to vent and get help with no or low impact on my mili- tary career. This has made a major difference in my readiness to deploy and stay in the mili- tary. Thank you for this program!!!! (MFLC participant) Subgroup differences No significant subgroup differences emerged among MFLC participants, but there was a sig- nificant difference by active- duty status among Military OneSource participants. Compared to active- duty members and their families, a larger percentage of reserve and guard members and their families agreed or strongly agreed that they wanted to stay in the military longer as a result of non- medical counseling (38 percent and 48 percent, respectively; see Table C3.5 in Appendix C). Chapter Summary The results reported in this chapter suggest that non- medical counseling reduced prob lem severity and facilitated prob lem resolution among the majority of participants. Participants Agree/strongly agree Neither agree nor disagree Disagree/strongly disagree 48% 41% 34% 39% 18% 21% 0 10 20 30 40 50 60 70 80 90 100 Military OneSourceMFLC I wanted to stay in the military longer (or I wanted to remain a military family for a longer period of time). NOTE: ns = 939 for MFLC and 999 for Military OneSource. MFLC and Military OneSource estimates for each question were generated in separate regression models. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non-response. RAND RR1861-3.6 Figure 3.6 Average Estimated Probability of Perceived Impact of Non- Medical Counseling on Willingness to Stay in the Military, Wave 1 Severity and Overall Prob lem Resolution 33 reported short- term improvements, which were maintained over time by the majority of par- ticipants. There were no significant subgroup differences in short- term prob lem resolution for Military OneSource, but for MFLC, males and individuals presenting with child- related prob- lems were less likely to experience prob lem resolution. Three months after counseling, the majority of participants experienced a reduction in prob lem severity relative to severity before counseling. However, a subset of participants did not experience long- term prob lem resolution after receiving non- medical counseling. There were no significant group differences for MFLC over the long term but for Military OneSource officers and their family members were more likely to experience prob lem resolu- tion compared to enlisted individuals and their family members. Overall, a small proportion of participants did not experience a reduction in prob lem severity as a result of non- medical counseling, especially in the short term. Responses to open- ended questions suggest potential barriers to prob lem resolution, including counselor’s lack of understanding of military culture, poor counselor- participant rapport, and a mismatch between counselor expertise and partici- pant needs; these issues will be further explored in Chapter Eight. Non- medical counseling did not have a significant impact on feeling more prepared for deployment, reintegration after deployment, or participants’ desire to stay in the military. It is pos si ble that the lack of frequent and lengthy deployments during the study period contributed to these perceptions as only about 8 percent reported deployment- related concerns as their reason for seeking non- medical counseling. In the next chapter we examine the extent to which non- medical counseling results in a reduction of stress and anxiety over time. 35 CHAPTER FOUR Resolution of Stress and Anxiety As noted in Chapter One, both ser vice members and their families may experience periods of heightened stress and anxiety as a result of the military lifestyle, including frequent moves, deployment and reintegration, separation from one’s family, and heavier workloads with fewer breaks for both the ser vice member and the family members left to run the house hold (Hosek, Kavanagh, and Miller, 2006; Clemens and Milsom, 2008; Denning, Meisnere, and Warner, 2014; Castro, Kintzle, and Hassan, 2015). Upon return from deployment, challenges with reintegration into family and civilian life may also produce feelings of stress and anxiety (Hosek, Kavanagh, and Miller, 2006; Hassan et al., 2010; Koenig et al., 2014; Castro, Kintzle, and Hassan, 2015). Stress and anxiety affect every one at some point, and can impact levels of productivity as well as military and family readiness. Military non- medical counseling programs are designed to help individuals with stress management, giving them tools and strategies to maintain control when life’s demands become excessive. This chapter examines the extent to which non- medical counseling affects problem- related stress and anxiety. Note that the anxiety results reported in this chapter are not indica- tive of anxiety disorder per se, but are based on self- reported anxiousness. Statistically signifi- cant differences among subgroups are discussed in the text and subgroup differences are tabulated in Tables C4.1– C4.5 in Appendix C). Key findings from this chapter include: • The frequency with which participants’ prob lems caused them to report feeling stressed or anxious was significantly reduced following non- medical counseling. • Over 70 percent of individuals experienced a reduction in the frequency of feeling stressed or anxious as a result of their prob lem. • Improvements were generally maintained three months after receipt of counseling. Over 80 percent reported a reduction in feeling stressed or anxious as a result of their prob lem compared to how they felt before receiving counseling. • Reported levels of stress in participants’ work life and personal life were significantly lower following non- medical counseling. Over 60 percent of individuals reported that they experienced less or much less stress in their work life, and over 65 percent of indi- viduals reported that they experienced less or much less stress in their personal life after initiating non- medical counseling. 36 An Evaluation of U.S. Military Non-Medical Counseling Programs Short- Term Changes in Stress and Anxiety In the survey administered at Wave 1, shortly after participants initiated non- medical counsel- ing, we asked participants to retrospectively assess how often their concern made them feel stressed or anxious before receiving counseling and also assess how often their concern made them feel stressed or anxious after initiating counseling. Respondents rated frequency on a five- point scale ranging from “very frequently” to “never,” but we have collapsed it to a three- point scale for purposes of reporting. After initiating non- medical counseling, there was a decrease in the proportion of individu- als reporting that their concern caused frequent or very frequent stress or anxiety (Figure 4.1). Prior to non- medical counseling, about 80 percent of individuals reported that the concern caused frequent or very frequent stress or anxiety. After initiating non- medical counseling, this proportion dropped to between 23 percent and 38 percent among those who sought MFLC and Military OneSource ser vices, respectively. Responses to open- ended survey questions reit- erated these findings: I believe that the tools that I was provided there by the counselors have helped me out in many ways. It helped allow me to prob lem solve much easier. Also has helped me manage my stress. (MFLC participant) 6% 12% 82% 33% 44% 23% 0 20 40 60 80 100 Before counseling Shortly after counseling Before counseling Shortly after counseling M FL C M il it a ry O n e S o u rc e 4% 21% 12% 41% 84% 38% NOTE: The experience of stress or anxiety was assessed at Wave 1. The experience of stress or anxiety before counseling was retrospectively reported. The experience of stress or anxiety after counseling captured perceptions at the time of the survey. ns = 2,370 for MFLC and 2,513 for Military OneSource. MFLC and Military OneSource estimates were generated in separate regression models. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non-response. RAND RR1861-4.1 Never/rarely Occasionally Frequently/very frequently Figure 4.1 Average Estimated Probability of Frequency of Stress and Anxiety Before and After Non- Medical Counseling, Wave 1 Resolution of Stress and Anxiety 37 When I met with the MFLC I did not expect much. I was happily surprised to get real answers and advice. The week leading up to our meeting I had trou ble sleeping. I had devel- oped an eye twitch and was grinding my teeth. Afterwards I felt as if a huge weight was taken from me. I am truly grateful for what the MFLC program does for soldiers. (MFLC participant) It just seems like he adds more stuff to my plate which does not stress me out less or help with anxiety or frustration. I know it is up to me to put forth the effort and change from within myself. I truly don’t know what I need. (Military OneSource participant) To analyze short- term changes in stress or anxiety, we examined the proportion of partici- pants who reported improved or worsened frequency of stress or anxiety relative to those who reported the same level of severity before and after initiating counseling. The analy sis tests whether the proportion of participants getting better or worse differs from what one would expect from chance alone. Results indicated that both MFLC and Military OneSource participants were significantly more likely to experience a reduction in the frequency of stress and anxiety after counseling than would be expected by chance alone. As shown in Figure 4.2, about 80 percent of MFLC participants and 71 percent of Military OneSource participants reported a reduction in the frequency of stress and anxiety. About 20–30 percent of participants experienced a similar frequency in stress and anxiety and only about 2 percent of MFLC and Military OneSource participants reported an increase in the frequency of experiencing stress and anxiety. 1% 2% 19% 27% 80% 71% 0 10 20 30 40 50 60 70 80 90 Military OneSourceMFLC NOTE: ns = 2,370 for MFLC and 2,513 for Military OneSource. Within-person changes in the experience of stress or anxiety before and after counseling, both measured at Wave 1. MFLC and Military OneSource estimates were generated in separate regression models. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non-response. RAND RR1861-4.2 More frequent Stayed the same Less frequent Figure 4.2 Average Estimated Probability of Short- Term Changes in Stress and Anxiety, Wave 1 38 An Evaluation of U.S. Military Non-Medical Counseling Programs Subgroup Differences Our results showed some significant differences among subgroups in the amount of stress expe- rienced prior to non- medical counseling and in reported short- term resolution of stress and anxiety. Statistically significant subgroup differences are reported in the following sections. Before Counseling We observed subgroup differences in the frequency with which individuals felt stressed or anx- ious as a result of their concern before seeking non- medical counseling (see Tables C4.1 and C4.2 in Appendix C). Among MFLC participants, after adjusting for other variables in the regression model, women were more likely than men to experience frequent stress or anxiety (86 and 76 percent, respectively). There were also significant differences in the frequency of stress and anxiety before counseling by prob lem type, with 85 percent of those experiencing family or relationship concerns reporting frequent or very frequent stress and anxiety; followed by about 80 percent of those with deployment concerns, loss or grief, and more general stress or emotional concerns; 77 percent of those with education or employment concerns; and 72 percent with child issues or concerns. Among Military OneSource participants, women were more likely than men to experi- ence frequent or very frequent stress or anxiety before counseling (88 percent compared to 79 percent of men), as were younger individuals (88 percent of those aged 19–24, 85 percent of those aged 25–40, and 81 percent of those aged 41 and older). Among those seeking Mili- tary OneSource ser vices, there were also differences by ser vice affiliation, with Marines and their families experiencing stress and anxiety more often than those affiliated with other ser- vices (88 percent of Marines and their families reported frequent or very frequent stress or anxiety, compared to 86 percent of Navy, 84 percent of Army, and 81 percent of Air Force participants and their families). In Short- Term Resolution of Stress and Anxiety Analy sis revealed several subgroup differences in whether feelings of stress or anxiety were resolved in the short term after participants initiated non- medical counseling (see Tables C4.3 and C4.4 in Appendix C). Among MFLC participants, there were differences again by gender. Although women were more likely to report a higher frequency of stress and anxiety before counseling, they were more likely to report an improvement after counseling (83 percent reported an improvement related to 77 percent of men). Significant differences were also observed by ser vice affiliation, with Marines and their families less likely than those affiliated with other ser vices to report a reduction in the frequency of stress and anxiety (74 percent com- pared to 81–84 percent in other ser vices). Fi nally, significant differences were observed among individuals who received ser vices from an MFLC at their installation. Those receiving ser vices from an embedded MFLC more often reported a reduction in the frequency of stress and anxi- ety than those receiving ser vices from MFLC counselors who were not embedded (84 and 79 percent, respectively). Among Military OneSource participants, the only significant difference in reported short- term resolution of stress and anxiety was by gender. About 74 percent of women reported a reduction in the frequency of stress and anxiety, relative to 67 percent of men. Resolution of Stress and Anxiety 39 Short- Term Changes in the Level of Stress at Work and in One’s Personal Life In addition to asking about the frequency with which individuals were experiencing stress and anxiety in general, we asked two additional questions related to changes in the level of stress at Wave 1. One question asked participants to rate the level of stress in their work life since they started receiving non- medical counseling ser vices (e.g., much less than before, about the same, much more than before). A parallel question asked participants to rate the level of stress in their personal life. After initiating non- medical counseling ser vices, individuals reported reductions in the level of stress they experienced at work. Over 70 percent of MFLC participants and almost 60 percent of Military OneSource participants reported that they experienced less or much less stress than they did prior to seeking non- medical counseling ser vices (Figure 4.3). Similarly, close to 80 percent of MFLC participants and almost 65 percent of Military OneSource participants reported that they experienced less or much less stress in their personal life than they did prior to seeking non- medical counseling ser vices. About 5 percent of indi- viduals, however, reported an increase in stress in their personal life after counseling. One significant subgroup difference emerged for changes in stress in one’s personal life. Among Military OneSource participants, over 30 percent of those with deployment- related prob lems reported experiencing much less stress in their personal life than they had before receiving non- medical counseling ser vices. In contrast, 10–13 percent of participants with 3% 3% 25% 38% 43% 43% 28% 16% 0 10 20 30 40 50 60 Military OneSourceMFLC RAND RR1861-4.3 NOTE: ns = 1,998 for MFLC and 2,210 for Military OneSource. Changes in level of stress at work was measured by a single item assessed at Wave 1. MFLC and Military OneSource estimates were generated in separate regression models. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non-response. More than before About the same Less than before Much less than before Figure 4.3 Average Estimated Probability of Changes in Level of Stress at Work After Non- Medical Counseling, Wave 1 40 An Evaluation of U.S. Military Non-Medical Counseling Programs other types of prob lems reported much less stress in their personal lives than before receiving non- medical counseling. Open- ended responses provide additional insight into the effectiveness of non- medical counseling in participants’ work and personal life. The counseling definitely helps with stresses brought on by the highly demanding military way of life. (Military OneSource participant) It’s really easy to feel a connection with the MFLC which is why most Soldiers that I have referred as well as myself leave our appointments with them feeling relief if not just a small bit. The MFLC has made the amount of work and personal stress drop drastically. I hope this program never goes away. (MFLC participant) [I was] able to help cope and deal with the conflicts in our marriage in a more healthy way. [We have] better communication, and it is easier to deal with the stresses of daily life. (Mili- tary OneSource participant) I have really seen improvement in my mental clarity and emotional state since I have been doing sessions with the MFLC. Before I started see the counselor I was a frazzled mother of 2 under 2 years of age, feeling like I was spiraling out of control. Now I feel much more 3% 5% 19% 31% 51% 51% 27% 13% 0 10 20 30 40 50 60 Military OneSourceMFLC RAND RR1861-4.4 NOTE: ns = 2,316 for MFLC and 2,479 for Military OneSource. Changes in level of stress in personal life was measured by a single item assessed at Wave 1. MFLC and Military OneSource estimates were generated in separate regression models. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non-response. More than before About the same Less than before Much less than before Figure 4.4 Average Estimated Probability of Changes in Level of Stress in Personal Life After Non- Medical Counseling, Wave 1 Resolution of Stress and Anxiety 41 confident, in control, and I can see the positive side of things. I have laughed more. I have danced more. I really feel like my marriage and role as a wife and mother have come full circle. (MFLC participant) Long- Term Changes in Stress and Anxiety The Wave 2 survey used the same mea sures of stress and anxiety. This survey included both the question about how often the non- medical concern made the individual feel stressed or anx- ious and the two questions about rating the level of stress in one’s work and personal life. This analy sis was limited to the participants who completed both the Wave 1 and Wave 2 surveys (ns = 436 for MFLC and 617 for Military OneSource). As noted earlier in the chapter, individuals were asked to rate how often their non- medical concern made them feel stressed or anxious. As shown in Figure 4.5, across both programs, average frequency of experiencing stress or anxiety decreased over time, especially among MFLC participants. After three months, average frequency of experiencing stress or anxiety continued to decline among Military OneSource and MFLC participants. Compared to rat- ings of stress or anxiety shortly after initiating counseling, after three months about 40 percent of participants reported a similar frequency (42 percent for MFLC and 41 percent for Mili- tary OneSource), and about 40 percent reported a continued reduction in the frequency of 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.0 Before counseling Shortly after counseling Three months after counseling Le ss s tr e ss M o re s tr e ss NOTE: Average ratings were calculated for those who completed both Wave 1 (before and after counseling ratings) and Wave 2 (three months after counseling) surveys. ns = 436 for MFLC and 617 for Military OneSource. MFLC and Military OneSource estimates were generated in separate regression models. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non-response. RAND RR1861-4.5 MFLC Military OneSource Figure 4.5 Average Estimated Frequency of Stress or Anxiety over Time 42 An Evaluation of U.S. Military Non-Medical Counseling Programs feeling stressed or anxious (37 percent for MFLC, 44 percent for Military OneSource). About 20 percent of the sample, however, reported an increase in the frequency with which they felt stressed or anxious as a result of their non- medical concern (21 percent for MFLC, 16 percent for Military OneSource). Although about 20 percent of the sample did not maintain their short- term reduction in stress or anxiety, the majority of MFLC and Military OneSource participants reported signifi- cant improvements in the frequency of feeling stressed or anxious after three months relative to how they felt before counseling. Compared to ratings of stress or anxiety before counseling, about 85 percent of individuals reported a reduction in the frequency of feeling stressed or anxious, about 10 percent reported a similar level, and only 3 percent reported an increase in the frequency of feeling stressed or anxious after three months. There were no significant differences by subgroup for reporting an increased frequency of feeling stressed or anxious over time. Another way to look at long- term changes in stress or anxiety is to examine the percent of participants who experienced stress or anxiety frequently/very frequently, occasionally, or never/rarely across time. Figure 4.6 is similar to Figure 4.1, but reports responses from the three- month follow-up at Wave 2. Numbers vary slightly from what is presented in Figure 4.1 as this figure includes responses only from those who completed both surveys. When exam- ined over time, there is a continued reduction in the frequency of stress and anxiety for both MFLC and Military OneSource participants. Three months after counseling, just over 31% 40% 21% 34% 5% 44% 39% 4% 41% 44% 8% 25% 22% 12% 38% 22% 87% 84% Before counseling Shortly after counseling Three months after counseling Before counseling Shortly after counseling Three month after counseling M FL C M il it a ry O n e S o u rc e 0 20 40 60 80 100 NOTE: Frequency of stress or anxiety ratings were calculated for those who completed both Wave 1 (before and after counseling ratings) and Wave 2 (three months after counseling) surveys. ns = 436 for MFLC and 617 for Military OneSource. MFLC and Military OneSource estimates were generated in separate regression models. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non-response. Rows may not add to 100% due to rounding. RAND RR1861-4.6 Never/rarely Occasionally Frequently/very frequently Figure 4.6 Average Estimated Probability of Frequency of Stress or Anxiety over Time Resolution of Stress and Anxiety 43 20 percent still reported frequent or very frequent experiences of stress and anxiety compared to more than 80 percent before counseling. Long- Term Changes in the Level of Stress at Work and in One’s Personal Life As noted earlier in this chapter, in addition to asking about the frequency with which individu- als were experiencing stress and anxiety in general, we asked two additional questions related to changes in participants’ level of stress relative to how they felt before counseling. We describe the results for these questions at Wave 2, reported three months following counseling. Three months after counseling, a little over 40 percent of MFLC and Military OneSource participants reported that their level of stress at work was less than it was before counseling, and an additional 31 percent and 26 percent of MFLC and Military OneSource participants, respectively, reported that they experienced much less stress at work than they did before coun- seling (Figure 4.7). A small proportion of participants, however, reported that their level of stress at work was higher three months after counseling than it was before counseling (5 percent for MFLC and 7 percent for Military OneSource). There were no significant subgroup differ- ences in changes in stress at work over time. Similarly, three months after counseling over 45 percent of MFLC and Military One- Source participants reported that the level of stress in their personal life was less than it was before counseling, and an additional 31 percent and 25 percent of MFLC and Military 5% 7% 24% 26% 41% 42% 31% 26% 0 10 20 30 40 50 60 Military OneSourceMFLC RAND RR1861-4.7 NOTE: ns = 403 for MFLC and 483 for Military OneSource. Changes in level of stress at work was measured by a single item assessed at Wave 2. MFLC and Military OneSource estimates were generated in separate regression models. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non-response. More than before About the same Less than before Much less than before Figure 4.7 Average Estimated Probability of Changes in Level of Stress at Work After Non- Medical Counseling, Wave 2 44 An Evaluation of U.S. Military Non-Medical Counseling Programs OneSource participants, respectively, reported that they experienced much less stress in their personal life than they did before counseling (Figure 4.8). Despite improvements for many, about 9 percent of MFLC participants and 6 percent of Military OneSource participants reported that the level of stress in their personal life was higher three months after counseling than it was before counseling. There were no significant subgroup differences in changes in the level of stress in one’s personal life over time. Chapter Summary Results suggest that the frequency with which individuals reported feeling stressed or anxious as a result of their prob lem was reduced for the majority of participants following non- medical counseling, and these improvements were maintained and, for some, continued to improve over time. In the short term, women were significantly more likely than men to experience a reduction in feelings of stress and anxiety, for both the MFLC and Military OneSource pro- grams. Among MFLC participants, those receiving ser vices from MFLC counselors embedded in their unit were more likely to experience a reduction of stress and anxiety compared to those receiving ser vices from other MFLC counselors, and Marines and their families were least likely to experience a reduction in stress and anxiety relative to individuals affiliated with other ser vices. We detected no subgroup differences over the long term for either program. Changes 9% 6% 16% 21% 45% 48% 31% 25% 0 10 20 30 40 50 60 Military OneSourceMFLC NOTE: ns = 459 for MFLC and 586 for Military OneSource. Changes in level of stress in personal life was measured by a single item assessed at Wave 2. MFLC and Military OneSource estimates were generated in separate regression models. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non-response. RAND RR1861-4.8 More than before About the same Less than before Much less than before Figure 4.8 Average Estimated Probability of Changes in Level of Stress in Personal Life After Non- Medical Counseling, Wave 2 Resolution of Stress and Anxiety 45 in the level of stress at work and in one’s personal life were also observed, with at least 60 percent reporting that their level of stress was less or much less than it was before seeking non- medical counseling ser vices. While the majority of individuals did experience a reduction in stress and anxiety following non- medical counseling, approximately 20 percent of participants reported frequent or very frequent feelings of stress and anxiety in their work or personal life, suggesting that they may not have benefited as much from non- medical counseling ser vices. 47 CHAPTER FIVE Interference with Work and Daily Life The prob lems that ser vice members and their families experience not only cause them stress, but also can disrupt their work and daily life routines. We examined how MFLC and Military OneSource participants’ concerns affected three aspects of daily life: whether they interfered with work, interfered with daily routines, or made it difficult to cope with day- to- day demands. Statistically significant differences among subgroups are discussed in the text and subgroup differences are tabulated in Tables C5.1– C5.10 in Appendix C. Key findings from this chapter include: • Following non- medical counseling, there was a statistically significant decrease in the fre- quency with which participants’ prob lems were found to interfere with work or daily routines, and a decrease in difficulty coping with day- to- day demands. • Compared to how they felt before counseling, over 55 percent of individuals reported that their prob lems caused less interference with work in the short term, and over 65 percent reported less interference with work three months after counseling. • Compared to how they felt before counseling, over 65 percent reported decreased inter- ference with daily routines in the short term, and over 74 percent reported decreased interference with daily routines in the three months after counseling. • Compared to how they felt before counseling, over 60 percent of individuals reported less difficulty coping with day- to- day demands over the short term, and over 71 percent reported less difficulty coping with day- to- day demands in the three months after coun- seling. Short- Term Changes in Prob lem Interference with Work At Wave 1, respondents reported on the extent to which the prob lem for which they sought counseling interfered with their work both prior to receiving non- medical counseling and after initiating counseling. As shown in Figure 5.1, before counseling a little over 40 percent of MFLC and Military OneSource participants reported that their prob lem interfered very fre- quently or frequently with work, and about equal proportions reported that their prob lem interfered occasionally (30 percent) or rarely or never (30 percent). After initiating non- medical counseling, only 9 percent of MFLC and 14 percent of Military OneSource reported that their prob lem interfered with work very frequently or frequently. Furthermore, the percentage of respondents reporting that their prob lem either never or rarely interfered with work about doubled after counseling. 48 An Evaluation of U.S. Military Non-Medical Counseling Programs To analyze short- term changes in prob lem interference with work, we examined the pro- portion of participants who reported more or less frequency relative to those who reported the same level of frequency before and after initiating counseling, mea sured at Wave 1. Results indicated that both MFLC and Military OneSource participants were significantly likely to experience less prob lem interference with work after counseling than would be expected by chance alone. As shown in Figure 5.2, prob lems interfered with work less frequently for 66 percent of MFLC participants and 55 percent of Military OneSource participants after counseling. About 32 percent of MFLC and 42 percent of Military OneSource participants reported the same level of prob lem interference with work after counseling. Three percent of MFLC and 4 percent of Military OneSource participants reported an increase in prob lem interference with work. The positive impact of non- medical counseling on prob lems interfering with work is sup- ported by open- ended survey responses. Respondents highlighted the stress and anxiety they experienced, and the ways in which counseling supported them with the demands of their jobs in the military. Marines need the MFLC. We are constantly stressed out. . . . If it wasn’t for my MFLCs I wouldn’t be able to do my job every day. I wouldn’t be able to carry out normal duties. I don’t cry in the bathroom anymore. I can face my fears. (MFLC participant) 0 20 40 60 80 100 Before counseling Shortly after counseling Before counseling Shortly after counseling M FL C M il it a ry O n e S o u rc e 68% 56% 30% 23% 30% 27% 9% 29% 30% 43% 41% 14% Never/rarely Occasionally Frequently/very frequently NOTE: Problem interference with work was assessed at Wave 1. Interference with work before counseling was retrospectively reported. Problem interference with work after counseling captured perceptions at the time of the survey. ns = 2,378 for MFLC and 2,513 for Military OneSource. MFLC and Military OneSource estimates were generated in separate regression models. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non-response. RAND RR1861-5.1 Figure 5.1 Average Estimated Probability of Ratings of Prob lem Interference with Work Before and After Non- Medical Counseling, Wave 1 Interference with Work and Daily Life 49 My anxiety was really bad. . . . For the first time in my life I understood how people can slip into thoughts of suicide and depression (I was not there but now I understand how emotional issues, life changes, and stress affect how you think and see the world). I am very thankful. After being able to talk to someone, the improvement to my life was almost instant and I don’t have to worry about my career which I hold dear. I actually feel normal again. I am on top of things at work. It’s been life changing. (Military OneSource participant) Subgroup Differences Before Non- Medical Counseling Among MFLC participants, we observed no significant subgroup differences in ratings of prob- lem interference with work before counseling. However, we did observe significant differences by ser vice, component, and prob lem type among Military OneSource participants (see Table C5.1 in Appendix C). Among Military OneSource participants, after adjusting for other variables in the regres- sion model, the majority of Marines and their families reported that their issues interfered with work frequently or very frequently (50 percent) before receiving counseling. A smaller propor- tion of individuals affiliated with the Army, Navy, or Air Force reported that their prob lems interfered with work frequently or very frequently (42, 44, and 34 percent, respectively). The difference between active- duty and guard and reserve components is accounted for by the 46 percent of guard and reserve participants and their families who reported that their prob lem 55% 66% 42% 32% 4%3% 0 10 20 30 40 50 60 70 80 90 100 Military OneSourceMFLC NOTE: Within-person changes in problem interference with work before and after counseling, both measured at Wave 1. ns = 2,378 for MFLC and 2,513 for Military OneSource. MFLC and Military OneSource estimates were generated in separate regression models. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non-response. RAND RR1861-5.2 More frequent The same frequency Less frequent Figure 5.2 Average Estimated Probability of Short- Term Changes in Prob lem Interference with Work, Wave 1 50 An Evaluation of U.S. Military Non-Medical Counseling Programs interfered with work frequently or very frequently, compared to a relatively lower 40 percent of active- duty participants and their families. The difference by prob lem type is largely driven by the 55 percent of participants who reported that education or employment issues frequently or very frequently interfered with work before counseling. In comparison, 31–43 percent of participants with other prob lem types reported that their prob lem interfered with work frequently or very frequently before counseling. In Short- Term Resolution of Prob lem Interference with Work Analy sis revealed several significant subgroup differences in short- term changes in prob lem interference with work among MFLC and Military OneSource participants (see Tables C5.2 and C5.3 in Appendix C). Among MFLC participants, subgroup differences emerged for ser vice affiliation and gender. Navy participants and their families demonstrated a larger decrease in prob lem inter- ference with work (76 percent) compared to participants affiliated with other ser vices, which ranged from 58 percent to 67 percent. Between genders, men were more likely to have the same frequency of prob lem interference with work before and after initiating counseling compared to women (35 percent compared to 30 percent). Women were more likely to report decreases in frequency with which their prob lem interfered with work (68 percent of women compared to 62 percent of men). About 2 percent of women and 3 percent of men reported increased fre- quency of prob lem interference with work. Among Military OneSource participants, subgroup differences emerged for ser vice member status and gender. Ser vice members seemed to benefit more than family members in terms of prob lem interference with work: compared to before receiving counseling, prob- lem interference with work decreased for 57 percent of ser vice members compared to 51 percent of family members. In addition, almost 40 percent of ser vice members reported no change in how frequently their prob lem interfered with work compared to 45 percent of family members. Regarding gender differences, men were more likely than women to have the same fre- quency of prob lem interference with work before and after receiving counseling (46 percent compared to 39 percent). Women were more likely than men to report decreases in frequency of prob lem interference with work (58 percent and 50 percent, respectively). About 3 percent of women and 4 percent of men reported that the frequency with which prob lem interference with work increased after receiving counseling. It is impor tant to note that, although most ser- vice members are men, the analyses calculate subgroup differences controlling for other vari- ables in the model. So the gender differences reported here are in de pen dent of the significant ser vice member differences found in the same model. Long- Term Changes in Prob lem Interference with Work The Wave 2 survey used the same mea sure to assess whether participants’ prob lems interfered with their work over time. We asserted that if long- term prob lem resolution is successful, reductions in prob lem interference ratings after counseling would be maintained or would fur- ther decline over time. This analy sis was limited to the participants who completed both Wave 1 and Wave 2 surveys (ns = 614 for MFLC and 878 for Military OneSource). Interference with Work and Daily Life 51 As shown in Figure 5.3, across both programs, average frequency of interference with work decreased over time, especially among MFLC participants. After three months, average frequency of interference with work continued to improve among Military OneSource partici- pants and reductions reported shortly after initiating counseling were maintained among MFLC participants. Compared to ratings of prob lem interference with work shortly after participants initiated counseling, about 78 percent of MFLC and 81 percent of Military OneSource partici- pants reported the same level or less interference with work after three months. A significant number of Military OneSource participants demonstrated continued improvement over time. This suggests that short- term decreases in prob lem interference with work were maintained or continued for most participants. Compared to ratings of prob lem interference with work before counseling, 72 percent of MFLC and 65 percent of Military OneSource participants had reduced interference with work after three months. About 19 percent of MFLC and 25 percent of Military OneSource partici- pants reported that prob lem interference with work after three months was similar to interference before receiving counseling. About 10 percent of MFLC and Military OneSource participants reported that their prob lem interfered with work more frequently than it did before counseling. Results revealed no significant subgroup differences in long- term prob lem interference with work for MFLC or Military OneSource participants. Another way to look at long- term changes is to examine the percent of participants who experienced prob lem interference with work frequently/very frequently, occasionally, or 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.0 Before counseling Shortly after counseling Three months after counseling Le ss i n te rf e re n ce M o re i n te rf e re n ce NOTE: Average ratings were calculated for those who completed both Wave 1 (before and after initial counseling) and Wave 2 (three months after counseling) surveys. ns = 431 for MFLC and 594 for Military OneSource. MFLC and Military OneSource estimates were generated in separate regression models. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non-response. RAND RR1861-5.3 MFLC Military OneSource Figure 5.3 Average Estimated Frequency of Prob lem Interference with Work over Time 52 An Evaluation of U.S. Military Non-Medical Counseling Programs never/rarely across time. Figure 5.4 is similar to Figure 5.1, but includes responses from the Wave 2 survey. Numbers vary slightly from what is presented in Figure 5.1 as this figure includes responses only from those who completed both surveys. When examined over time, the frequency with which prob lems interfered with work declined after counseling for both MFLC and Military OneSource participants, and then remained steady for MFLC partici- pants over the next three months. Military OneSource participants reported a continued decrease in frequency of prob lem interference with work over time: three months after counsel- ing, only 7–8 percent still reported frequent or very frequent prob lem interference with work. Short- Term Changes in Interference with Daily Routines Similar to interference at work, respondents reported in the Wave 1 survey the extent to which their prob lem interfered with their daily routines before and after they initiated non- medical counseling. As shown in Figure 5.5, 56 percent of MFLC and Military OneSource partici- pants reported that before receiving counseling their prob lems interfered very frequently or frequently with their daily routines. About 26 percent reported that it interfered occasionally, and about 17 percent reported rarely or never. After initiating non- medical counseling, 11 percent of MFLC and 18 percent of Military OneSource participants reported that their prob lem interfered with daily routines very frequently or frequently. Furthermore, the per- centage whose prob lem rarely or never interfered with daily routines increased to 61 percent Before counseling Shortly after counseling Three months after counseling Before counseling Shortly after counseling Three months after counseling M FL C M il it a ry O n e S o u rc e 0 20 40 60 80 100 68% 73% 69% 28% 23% 32% 56% 27% 9% 21% 30% 32% 24% 45% 7% 38% 12% 8% NOTE: Frequency of problem interference with work was calculated for those who completed both Wave 1 (before and shortly after counseling) and Wave 2 (three months after counseling) surveys. ns = 431 for MFLC and 594 for Military OneSource. MFLC and Military OneSource estimates were generated in separate regression models. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non-response. Rows may not add to 100% due to rounding. RAND RR1861-5.4 Never/rarely Occasionally Frequently/very frequently Figure 5.4 Average Estimated Probability of Frequency of Prob lem Interference with Work over Time Interference with Work and Daily Life 53 of MFLC participants and 46 percent of Military OneSource participants after counseling was initiated. As shown in Figure 5.6, ratings of the extent to which the prob lem interfered with the participant’s daily routines decreased in frequency for 74 percent of MFLC and 65 percent of Military OneSource participants. About 24 percent of MFLC and 32 percent of Military One- Source participants reported the same frequency of prob lem interference with daily routines before and after initiating counseling. About 2 percent of MFLC and 3 percent of Military OneSource participants reported an increase in frequency with which prob lems interfered with daily routines. When describing strengths of the Military OneSource and MFLC programs, some par- ticipants mentioned in open- ended responses the ways in which non- medical counseling helped them cope with prob lems that interfered with their daily routines and family life. Having someone on hand who both understands the military/aviation culture and the effects it has on family life immediately creates an atmosphere of understanding. This immediacy allowed me and my wife to get straight to the point. Our MFLC’s in depth knowledge allowed for all three of us to flow through the prob lems that we were facing with ease. This facilitated a very rapid healing pro cess for me and my wife. I cannot express how instrumental our counselor was in aiding my immediate return to duty. I also was given some very helpful tools to deal with similar issues in the future. (MFLC participant) Figure 5.5 Average Estimated Probability of Ratings of Prob lem Interference with Daily Routines Before and After Non- Medical Counseling, Wave 1 0 20 40 60 80 100 Before counseling Shortly after counseling Before counseling Shortly after counseling M FL C M il it a ry O n e S o u rc e 61% 46% 18% 28% 17% 36% 26% 11% 27% 18% 56% 56% NOTE: Problem interference with daily routines was assessed at Wave 1. Problem interference with daily routines after counseling captured perceptions at the time of the survey. ns = 2,381 for MFLC and 2,513 for Military OneSource. MFLC and Military OneSource estimates were generated in separate regression models. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non-response. RAND RR1861-5.5 Never/rarely Occasionally Frequently/very frequently 54 An Evaluation of U.S. Military Non-Medical Counseling Programs Subgroup Differences Before Non- Medical Counseling Among MFLC participants, at Wave 1 we observed significant differences in ratings of inter- ference with daily routines before counseling by gender and prob lem type. Military OneSource participants demonstrated significant differences by ser vice affiliation and age (see Tables C5.4 and C5.5 in Appendix C). Women who obtained counseling through the MFLC program were more likely to state that their prob lems interfered with daily routines frequently or very frequently (58 compared to 52 percent, respectively) before receiving counseling. Men were more likely to report that their prob lems interfered with daily routines never or rarely (22 percent compared to 17 percent of women). Among MFLC participants, those experiencing prob lems with “loss or grief ” or “ family or relationships” were likely to report that their prob lem interfered with daily routines fre- quently or very frequently (62 percent and 58 percent, respectively). For the Military OneSource program, Navy and Marine participants and their families had the highest rate of interference with daily routines before receiving counseling, with around 59 percent of the participants reporting frequent or very frequent interference. In addition, Mili- tary OneSource participants aged 41 and older were less likely to report that their prob lem inter- fered with their daily routines frequently or very frequently (51 percent compared to 58 percent of 18–24 year olds and 58 percent of 25–40 year olds) before receiving counseling. Figure 5.6 Average Estimated Probability of Short- Term Changes in Prob lem Interference with Daily Routines, Wave 1 3%2% 32% 24% 65% 74% 0 10 20 30 40 50 60 70 80 90 100 Military OneSourceMFLC NOTE: Within-person changes in problem interference with daily routines before and after counseling. ns = 2,381 for MFLC and 2,513 for Military OneSource. MFLC and Military OneSource estimates were generated in separate regression models. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non-response. RAND RR1861-5.6 Less frequent The same frequency More frequent Interference with Work and Daily Life 55 In Short- Term Resolution of Prob lem Interference with Daily Routines We observed no significant differences in changes in ratings of prob lem interference with daily routines by subgroups among Military OneSource participants at Wave 1. Among MFLC par- ticipants, we observed a significant difference in changes by gender (see Table C5.6 in Appen- dix C). Compared to women, men were more likely to have the same frequency of prob lem interference with daily routines before and after initiating counseling (27 percent compared to 23 percent, respectively). Women were more likely than men to report a decrease in frequency of prob lem interference with work (76 percent compared to 70 percent of men). About 2 percent of women and men reported increased frequency of prob lem interference with work. Long- Term Changes in Prob lem Interference with Daily Routines The Wave 2 survey used the same mea sure of prob lem interference with daily routines to assess whether participants’ prob lems interfered with their daily routines over time. Successful long- term prob lem resolution would be evidenced by maintenance of reductions in reported post- counseling prob lem interference with daily routines after counseling or further reduction of interference with daily routines. This analy sis was limited to the participants who completed both Wave 1 and Wave 2 surveys (ns = 434 for MFLC and 594 for Military OneSource). As shown in Figure 5.7, across both programs, average frequency of interference with daily routines decreased over time, especially among MFLC participants. After three months, Figure 5.7 Average Estimated Frequency of Prob lem Interference with Daily Routines over Time 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.0 Before counseling Shortly after counseling Three months after counseling Le ss i n te rf e re n ce M o re i n te rf e re n ce NOTE: Average ratings were calculated for those who completed both Wave 1 (before and after counseling ratings) and Wave 2 (three months after counseling) surveys. ns = 434 for MFLC and 594 for Military OneSource. MFLC and Military OneSource estimates were generated in separate regression models. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non-response. RAND RR1861-5.7 MFLC Military OneSource 56 An Evaluation of U.S. Military Non-Medical Counseling Programs average frequency of interference with daily routines continued to improve among Military OneSource participants and reductions captured shortly after initiating counseling were main- tained among MFLC participants. About 76 percent of MFLC and 78 percent of Military One- Source participants reported the same level or less interference with daily routines after three months. A significant number of Military OneSource participants also demonstrated continued improvement over time. This suggests that short- term decreases in prob lem interference with daily routines were maintained or continued to decrease over time for most participants. Compared to ratings of interference with daily routines before counseling, 80 percent of MFLC and 74 percent of Military OneSource participants had reduced prob lem interference with daily routines after three months. About 14 percent of MFLC and 18 percent of Military OneSource participants reported that prob lem interference with daily routines after three months was similar to interference before receiving counseling. About 7 percent of MFLC and Military OneSource participants reported that their prob lem interfered with daily routines more frequently after three months than it did before receiving counseling. Another way to look at long- term changes is to examine the percent of participants who experienced prob lem interference with daily routines frequently/very frequently, occasionally, or never/rarely across time. Figure 5.8 is similar to Figure 5.5, but includes responses from the Wave 2 survey. Numbers vary slightly from what is presented in Figure 5.5 as this figure includes responses only from those who completed both surveys. When examined over time, Figure 5.8 Average Estimated Probability of Frequency of Prob lem Interference with Daily Routines over Time Before counseling Shortly after counseling Three months after counseling Before counseling Shortly after counseling Three months after counseling M FL C M il it a ry O n e S o u rc e 0 20 40 60 80 100 59% 62% 60% 13% 29% 18% 46% 29% 12% 27% 28% 36% 29% 58% 11% 55% 18% 11% NOTE: Frequency of problem interference with daily routines was calculated for those who completed both Wave 1 (before and shortly after counseling ratings) and Wave 2 (three months after counseling) surveys. ns = 434 for MFLC and 594 for Military OneSource. MFLC and Military OneSource estimates were generated in separate regression models. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non-response. Rows may not add to 100% due to rounding. Never/rarely Occasionally Frequently/very frequently RAND RR1861-5.8 Interference with Work and Daily Life 57 there is a reduction in the frequency of interference with daily routines for both MFLC and Military OneSource participants. MFLC participants reported similar interference with daily routines shortly after initiating counseling and after three months, while Military OneSource participants continued to report a decline in interference with daily routines over time. Three months after counseling, 11 percent of MFLC and Military OneSource participants still reported frequent or very frequent prob lem interference with daily routines. Subgroup Differences in Long- Term Changes Results revealed no significant subgroup differences in long- term changes in prob lem interfer- ence with daily routines for MFLC participants. For Military OneSource participants, ratings of prob lem interference with daily routines significantly differed over time by ser vice member status (see Table C5.7 in Appendix C). Ratings of prob lem interference with daily routines shortly after initiating counseling were maintained or had decreased for 74 percent of ser vice members after three months, compared to 83 percent of family members. However, roughly equal percentages of family and ser vice members had reduced long- term interference in daily routines relative to before receiving counseling (72 and 75 percent, respectively), suggesting that differences in maintenance of short- term gains were counterbalanced by overall improve- ment by both groups in the long term. Short- Term Changes in Difficulty Coping with Day- to- Day Demands Respondents reported at Wave 1 how often their prob lem made it difficult to cope with day- to- day demands before they received non- medical counseling and after initiating counseling. As shown in Figure 5.9, about 50 percent of MFLC and Military OneSource participants reported that their prob lems frequently or very frequently made it difficult to cope with day- to- day demands before receiving counseling. After initiating non- medical counseling, 10 percent of MFLC and 17 percent of Military OneSource participants reported that their prob lem made it difficult to cope with day- to- day demands frequently or very frequently. Fur- thermore, the percentage whose prob lem rarely or never made it difficult to cope with day- to- day demands increased from 26 to 65 percent of MFLC participants and from 24 to 51 percent of Military OneSource participants. In open- ended responses, participants reiterated the value of non- medical counseling for helping them handle day- to- day demands. I am so profoundly grateful that Military OneSource is available. As a result of these ser vices, which are still ongoing, I feel more fit in both my personal and professional life, and only regret that I did not take advantage of them sooner. (Military OneSource participant) As shown in Figure 5.10, the extent to which the prob lem made it difficult for partici- pants to cope with day- to- day demands decreased in frequency for 69 percent of MFLC and 60 percent of Military OneSource participants. About 28 percent of MFLC and 37 percent of Military OneSource participants reported the same level of difficulty coping with day- to- day demands before and after initiating counseling. About 2 percent of MFLC and 3 percent of Military OneSource participants reported an increase in difficulty coping with day- to- day demands. 58 An Evaluation of U.S. Military Non-Medical Counseling Programs Subgroup Differences Before Non- Medical Counseling Among MFLC participants, we observed significant differences in difficulty coping with day- to- day demands before counseling by gender and prob lem type, and Military OneSource par- ticipants demonstrated significant differences by ser vice affiliation and gender (see Tables C5.8 and C5.9 in Appendix C). Among MFLC participants, women were more likely than men (54 and 44 percent, respec- tively) to report frequent or very frequent difficulty coping with day- to- day demands. Among MFLC participants with diff er ent prob lem types, those seeking help with child issues were less likely to say that their prob lem made it difficult to cope with day- to- day demands compared to participants with other prob lem types (36 percent compared to 46–58 percent for other prob- lem types). Similar to MFLC participants, women seeking Military OneSource ser vices were more likely to report frequent or very frequent difficulty coping with day- to- day demands compared to men (52 and 46 percent, respectively). Among participants affiliated with diff er ent ser vices, Air Force participants and their families were less likely to report frequent or very frequent dif- ficulty coping with day- to- day demands compared to participants affiliated with other ser vices (43 percent compared to 52–54 percent for other ser vices). Figure 5.9 Average Estimated Probability of Ratings of Difficulty Coping with Day- to- Day Demands, Wave 1 65% 51% 26% 26% 24% 31% 23% 10% 27% 50% 49% 17% 0 20 40 60 80 100 Before counseling Shortly after counseling Before counseling Shortly after counseling M FL C M il it a ry O n e S o u rc e NOTE: Difficulty coping with day-to-day demands assessed at Wave 1. Difficulty coping with day-to-day demands after counseling captured perceptions at the time of the survey. ns = 2,382 for MFLC and 2,516 for Military OneSource. MFLC and Military OneSource estimates were generated in separate regression models. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non-response. Rows may not add to 100% due to rounding. RAND RR1861-5.9 Never/rarely Occasionally Frequently/very frequently Interference with Work and Daily Life 59 In Short- Term Resolution of Difficulty Coping with Day- to- Day Demands For both MFLC and Military OneSource, we observed significantly diff er ent short- term changes by gender. Across both programs, compared to women, men were more likely to have the same difficulty coping with day- to- day demands before and after initiating counseling (26 percent of women compared to 33 percent of men for MFLC; 35 percent of women com- pared to 40 percent of men for Military OneSource). Women were more likely than men to experience an improvement in their ability to cope with day- to- day demands (72 percent com- pared to 65 percent, respectively, for MFLC; 62 percent compared to 56 percent of men, respec- tively, for Military OneSource). Long- Term Changes in Difficulty Coping with Day- to- Day Demands The Wave 2 survey used the same postcounseling mea sure of difficulty coping with day- to- day demands to assess whether the ability to cope changed over the long term. We again examined whether short- term changes in difficulty coping were maintained after three months (i.e., did not change or less difficulty over time), followed by whether ratings of difficulty coping before counseling decreased in the three months after receiving counseling. As shown in Figure 5.11, across both programs, average frequency of interference with day- to- day demands decreased shortly after initiating counseling, especially among MFLC participants. After three months, average frequency of interference with day- to- day demands Figure 5.10 Average Estimated Probability of Difficulty Coping with Day-to-Day Demands, Wave 1 3%2% 37% 28% 60% 69% 0 10 20 30 40 50 60 70 80 90 100 Military OneSourceMFLC NOTE: Within-person changes in difficulty coping with day-to-day demands before and after counseling. ns = 2,382 for MFLC and 2,516 for Military OneSource. MFLC and Military OneSource estimates were generated in separate regression models. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non-response. RAND RR1861-5.10 Less frequent The same frequency More frequent 60 An Evaluation of U.S. Military Non-Medical Counseling Programs continued to improve among Military OneSource participants and reductions captured shortly after initiating counseling were maintained among MFLC participants. About 76 percent of MFLC and 79 percent of Military OneSource participants reported the same level or less dif- ficulty coping with day- to- day demands after three months. A significant number of Military OneSource participants demonstrated continued improvement over time. This suggests that short- term decreases in difficulty coping with day- to- day demands were maintained or contin- ued to decrease over time for most participants. Compared to ratings of difficulty coping with day- to- day demands before counseling, 72 percent of MFLC and 71 percent of Military OneSource participants reported experiencing less difficulty coping after three months. About 19 percent of MFLC and Military OneSource participants reported that difficulty coping with day- to- day demands after three months was similar to before receiving counseling. About 9 percent of MFLC and Military OneSource participants reported more frequent difficulties coping with day- to- day demands after three months compared to before they received counseling. Another way to look at long- term changes is to examine the percent of participants who experienced prob lem interference with day- to- day demands frequently/very frequently, occa- sionally, or never/rarely across time. Figure 5.12 is similar to Figure 5.8, but includes responses from the Wave 2 survey. Numbers vary slightly from what is presented in Figure 5.8 as this figure includes responses only from those who completed both surveys. When examined over time, there is a reduction in the frequency of difficulty coping with day- to- day demands for Figure 5.11 Average Estimated Frequency of Difficulty Coping with Day- to- Day Demands over Time 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.0 Before counseling Shortly after counseling Three months after counseling Le ss d if fi cu lt y M o re d if fi cu lt y NOTE: Average ratings were calculated for those who completed both Wave 1 (before and after counseling ratings) and Wave 2 (three months after counseling) surveys. ns = 433 for MFLC and 594 for Military OneSource. MFLC and Military OneSource estimates were generated in separate regression models. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non-response. RAND RR1861-5.11 MFLC Military OneSource Interference with Work and Daily Life 61 both MFLC and Military OneSource participants. MFLC participants reported similar diffi- culty coping shortly after initiating counseling and after three months, while Military One- Source participants continued to report a decline in difficulty coping with day- to- day demands. Three months after counseling, 9–11 percent of participants still reported frequent or very fre- quent difficulty coping with day- to- day demands. Subgroup Differences in Long- Term Changes There were no significant subgroup differences in long- term changes in coping with day- to- day demands for Military OneSource participants, but long- term changes differed among MFLC participants with diff er ent prob lem types (see Table C5.10 in Appendix C). This difference was driven by participants with child- related prob lems: compared to ratings of difficulty before receiv- ing counseling, almost 39 percent of participants with child- related prob lems demonstrated improved coping with day- to- day demands after three months, compared to 67 to 86 percent of participants with other prob lem types. Chapter Summary The results reported in this chapter demonstrate that participants’ prob lems interfered less with their work and daily lives following non- medical counseling, both in the short and long term. Figure 5.12 Average Estimated Probability of Frequency of Difficulty Coping with Day- to- Day Demands over Time Before counseling Shortly after counseling Three months after counseling Before counseling Shortly after counseling Three months after counseling M FL C M il it a ry O n e S o u rc e 0 20 40 60 80 100 62% 67% 66% 23% 28% 24% 50% 25% 10% 23% 27% 33% 25% 52% 11% 48% 17% 9% NOTE: Frequency of difficulty coping with day-to-day demands was calculated for those who completed both Wave 1 (before and shortly after counseling) and Wave 2 (three months after counseling) surveys. ns = 433 for MFLC and 594 for Military OneSource. MFLC and Military OneSource estimates were generated in separate regression models. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non-response. Rows may not add to 100% due to rounding. Never/rarely Occasionally Frequently/very frequently RAND RR1861-5.12 62 An Evaluation of U.S. Military Non-Medical Counseling Programs While MFLC participants reported short- term improvements that were maintained over the long term by the majority of participants, Military OneSource participants reported more modest short- term improvements but experienced continued improvement over time. For many of the outcomes examined, women experienced significantly less interference in their work and daily life for both programs. Furthermore, individuals affiliated with the Navy, compared to other ser vices (for MFLC only) and ser vice members, compared to family members (for Military OneSource only) experienced greater prob lem resolution at work. These findings provide addi- tional evidence that non- medical counseling facilitated short- and long- term prob lem resolu- tion among the majority of participants. 63 CHAPTER SIX Connection to Ser vices and Referrals In addition to actively helping participants cope with the stress and impact of their prob lems, non- medical counseling serves as a conduit for connecting participants to ser vices for which they are eligible and referrals to medical or behavioral health ser vices when needed. This chapter examines the extent to which participants in non- medical counseling were connected to addi- tional ser vices, how satisfied participants were with those referrals, and whether the program followed up with them to make sure they had connected with ser vices. Importantly, each ques- tion was examined among participants who reported that the question was applicable to their prob lem (i.e., they did not indicate that the question was “not applicable”). The number of respondents reporting that a question was not applicable to their prob lem varied widely, rang- ing from 33 to 62 percent. Statistically significant differences among subgroups are discussed in the text and subgroup differences are tabulated in Tables C6.1– C6.4 in Appendix C. Key findings from this chapter among participants who reported that each question was applicable include: • Of the 34 percent of MFLC and 37 percent of Military OneSource participants who reported that they needed support and ser vices outside the program, over 65 percent indi- cated that they had been connected to those ser vices. • About 45 percent of participants reported that they needed referrals to medical ser vices, and a little over half of those participants agreed that their counselor had connected them with medical ser vices. Of the 38 percent of MFLC and 46 percent of Military OneSource participants who reported needing referrals to physical health ser vices, only around 37 percent agreed that they had been connected with physical health ser vices they would not have connected with on their own. • A larger number of Military OneSource participants (67 percent) reported that they needed referrals to mental health ser vices, and 69 percent of those participants agreed that they had been connected with mental health ser vices they would not have connected with on their own. • Over 81 percent of non- medical counseling participants who reported that their coun- selor referred them to outside ser vices were satisfied or very satisfied with program follow- up to make sure they connected with recommended ser vices. Connection to Ser vices Outside of Non- Medical Counseling At Wave 1, participants were asked about their use of other resources to help with their prob- lem (e.g., family or friends, religious or faith- based community), and the connections their 64 An Evaluation of U.S. Military Non-Medical Counseling Programs counselor provided to ser vices outside of non- medical counseling, including general support and ser vices, medical care (physical and psychological), and community ser vices. We found that 40 percent of MFLC participants and 38 percent of Military OneSource participants had sought additional support from other individuals or providers for their prob- lem. Of those who had sought additional support, 54 percent of MFLC and 61 percent of Mili- tary OneSource participants sought help from one additional source, and 43 percent of MFLC and 37 percent of Military OneSource participants sought help from two or three additional sources. The most frequently cited sources of additional help sought by MFLC and Military OneSource participants are shown in Table 6.1. About half of MFLC and Military OneSource participants sought help from extended family members or friends for their prob lem, and about a third sought help from a religious or faith- based community. Although there may be a concern about duplication of ser vices, the varied nature, emphasis, and approach of these sup- ports are likely quite diff er ent (e.g., support of friends as compared to one’s faith leader as com- pared to a non- medical counselor) and this minimizes this concern. However, between 11 percent and 12 percent of participants sought help from both Military OneSource and MFLC. Given that the approaches of these two programs are quite similar, it is not clear why individuals felt the need to seek ser vices from both non- medical counseling programs. About a quarter of Military OneSource and 31 percent of MFLC participants who sought additional help for their prob lem reported seeing a private counselor or specialist. However, the timing (e.g., before or after MFLC/Military OneSource ser vices) and nature (e.g., a result of an MFLC/ Military OneSource referral) of this additional help is unclear. To assess counselor- initiated connections to general outside resources, we asked partici- pants the extent to which they agreed with the statement “My counselor connected me to out- side support and ser vices.” About 34 percent of MFLC and 37 percent of Military OneSource participants indicated that this question was not applicable to their prob lem. Of those who responded that it was applicable, 76 percent of MFLC and 65 percent of Military OneSource participants agreed or strongly agreed that their counselor had connected them with outside support and ser vices (see Figure 6.1). About 9 percent of MFLC and 16 percent of Military Table 6.1 Percent of Participants Using Support Ser vices in Addition to Non- Medical Counseling to Address Their Prob lem, Wave 1 MFLC (%) Military OneSource (%) Private counselor or specialist 31.0 24.9 Military family support program 9.8 6.6 Military OneSource 11.3 — MFLC — 12.0 Religious or faith- based community 33.3 32.1 Extended family members or friends 50.9 54.1 Other 20.8 14.5 NOTE: Among individuals who reported seeking support from individuals or providers other than MFLC (n = 991) or Military OneSource (n = 1,027), respectively. Percentages are weighted to be representative of the MFLC and Military OneSource non- medical counseling population. Connection to Ser vices and Referrals 65 OneSource participants disagreed or strongly disagreed that they had been connected to out- side support and ser vices. To assess counselor- initiated connections specifically to medical resources, we asked the extent to which they agreed with the statement “My counselor connected me to medical ser- vices.” Fifty- five percent of MFLC and 53 percent of Military OneSource participants indi- cated that this question was not applicable to their prob lem. Of those who responded that it was applicable, 58 percent of MFLC and 54 percent of Military OneSource participants agreed or strongly agreed that their counselor had connected them with medical ser vices (see Figure 6.1). About 16 percent of MFLC and 22 percent of Military OneSource participants disagreed or strongly disagreed that they had been connected to medical ser vices. In addition to the general question about connection with medical ser vices, we asked par- ticipants whether they had been “connected with physical health care providers that I would not have on my own” and whether they had been “connected with mental health care providers that I would not have on my own.” About 38 percent of MFLC and 46 percent of Military OneSource participants indicated connection with a physical health provider was relevant for addressing their concern. Of these, roughly equal proportions of participants indicated that they agreed or strongly agreed (36 percent of MFLC and 38 percent of Military OneSource) or neither agreed nor disagreed (35 percent of MFLC and 38 percent of Military OneSource) that they had connected with physical health providers with the help of MFLC or Military Figure 6.1 Average Estimated Probability of Connection to Ser vices Outside of Non- Medical Counseling, Wave 1 0 10 20 30 40 50 60 70 80 90 100 MFLC Military OneSource MFLC Military OneSource 22%24% 54% 16% 25% 58% 16% 19% 65% 9% 15% 76% My counselor connected me to outside support and services My counselor connected me to medical services Agree/strongly agree Neither agree nor disagree Disagree/strongly disagree NOTE: ns = 1,531 and 990 for MFLC; 1,488 and 1,015 for Military OneSource, respectively. MFLC and Military OneSource estimates were generated in separate regression models. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non-response. RAND RR1861-6.1 66 An Evaluation of U.S. Military Non-Medical Counseling Programs OneSource counselors (see Figure 6.2). About 29 percent of MFLC and 24 percent of Military OneSource participants disagreed or strongly disagreed that they had connected with physical health providers with the help of the counselors. As shown in Figure 6.2, participants were more likely to agree that they had connected with mental health providers with the help of MFLC or Military OneSource counselors. About 44 percent of MFLC participants and 67 percent of Military OneSource participants reported that this question was applicable to their prob lem. Of those, 47 percent of MFLC and 69 percent of Military OneSource participants agreed or strongly agreed with this statement, while 23 percent of MFLC and 13 percent of Military OneSource participants disagreed or strongly disagreed. Non- medical counselors also connect individuals with community- based resources. In response to the question about how much they agreed with the statement that, because of non- medical counseling, they “connected with additional community ser vices that I would not have on my own,” 56 percent of MFLC and 39 percent of Military OneSource participants stated they agreed or strongly agreed. About 18 percent of MFLC and 23 percent of Military OneSource participants disagreed or strongly disagreed with this statement, and 26 percent of MFLC and 38 percent of Military OneSource participants neither agreed or disagreed (about 50 percent of MFLC and Military OneSource participants indicated that this question was not applicable to their problem). For both MFLC and Military OneSource participants, significant subgroup differ- ences emerged by ser vice member status for connections with outside support and ser vices Figure 6.2 Average Estimated Probability of Connection to Physical and Mental Health Providers Due to Non- Medical Counseling, Wave 1 0 10 20 30 40 50 60 70 80 90 100 MFLC Military OneSource MFLC Military OneSource 13% 18% 69% 23% 31% 47% 24% 38%38% 29% 35%36% I connected with mental health care providers that I would not have on my own I connected with physical health care providers that I would not have on my own Agree/strongly agree Neither agree nor disagree Disagree/strongly disagree NOTE: ns = 713 and 855 for MFLC; 839 and 1,476 for Military OneSource, respectively. MFLC and Military OneSource estimates were generated in separate regression models. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non-response. RAND RR1861-6.2 Connection to Ser vices and Referrals 67 (see Tables C6.1 and C6.2 in Appendix C). Compared to family members, ser vice members were more likely to agree or strongly agree with the statement “My counselor connected me to outside support and ser vices” (73 percent compared to 80 percent for MFLC; 60 percent com- pared to 68 percent for Military OneSource, respectively). While open- ended responses mentioned the value of referrals offered by non- medical coun- selors as one of the strengths of the program, responses also highlighted logistical difficulties participants experienced with trying to obtain referrals from non- medical counselors. Some of the comments highlight related challenges of the program, including frequent rotation of MFLC counselors and a lack of continuity between military ser vice providers (discussed fur- ther in Chapter Seven). [A strength of the program is] their considerable ability to highlight and pinpoint specific issues and refer clients to other sources for more targeted treatment. (MFLC participant) [A strength of the program is that it is] easy to get referrals. (Military OneSource participant) My MFLC recommended referral for par tic u lar testing for my son and sent me to my PCM [primary care man ag er] for that referral. It took 2 months to get a referral because the PCM didn’t understand what I was asking for and the MFLC was no longer at the base to be able to contact for assistance or guidance with the referral. Therefore I feel one of the greatest chal- lenges is the disconnect between mental health and medical health. (MFLC participant) They need to know how to talk to people, how to be impartial, and how to refer customers to adequate help. (MFLC participant) Program Follow- Up with Connections to Outside Ser vices Although many participants did not perceive that their counselor had connected them with outside ser vices, those who were referred to outside ser vices generally said that their counselor followed up with them to make sure that the connection was made. In response to the question of how much they agreed with the statement that “My counselor [or Military OneSource call center] followed up with me to make sure I was able to connect with the outside supports and ser vices they recommended,” 74 percent of MFLC and 76 percent of Military OneSource par- ticipants agreed or strongly agreed. About 12 percent of MFLC and 11 percent of Military OneSource participants disagreed or strongly disagreed with this statement, and 14 percent of MFLC and 13 percent of Military OneSource participants neither agreed nor disagreed (about 37 percent of MFLC and 33 percent of Military OneSource participants indicated that this question was not applicable to their prob lem). Furthermore, over 81 percent of non- medical counseling participants were satisfied or very satisfied with program follow-up to make sure they connected with recommended ser vices (see Figure 6.3). Subgroup Differences Significant subgroup differences emerged for satisfaction with counselor follow-up on con- necting with recommended ser vices (see Tables C6.3 and C6.4 in Appendix C). Among MFLC participants, participants seeing counselors embedded within the unit tended to be more satisfied with counselor follow-up than those whose counselor was not embedded 68 An Evaluation of U.S. Military Non-Medical Counseling Programs (85 percent compared to 80 percent were satisfied or very satisfied, 10 percent compared to 14 percent were neither satisfied nor dissatisfied, and 5 percent compared to 7 percent were dis- satisfied or very dissatisfied). Among Military OneSource participants, ser vice members tended to be more satisfied than family members: 85 percent of ser vice members and 81 percent of family members were satisfied or very satisfied with counselor (or Military OneSource) follow-up for connection with recommended ser vices. Almost 10 percent of ser vice members and 12 percent of family members were neither satisfied nor dissatisfied with follow-up, and 5 percent of ser vice mem- bers compared to 7 percent of family members were dissatisfied or very dissatisfied with coun- selor or program follow-up for connection with recommended ser vices. Chapter Summary The results reported in this chapter suggest that there was considerable variation in the extent to which non- medical counseling participants were connected with support and ser vices out- side of the program, but, when recommendations were made, the vast majority of participants were satisfied with program follow-up to make sure they connected with recommended ser- vices. Among participants who reported that each question was applicable, over 65 percent of non- medical counseling participants indicated that their counselor had connected them with support and ser vices outside the program, although smaller percentages indicated that they Figure 6.3 Average Estimated Probability of Satisfaction with Program Follow- Up on Connections to Recommended Outside Ser vices, Wave 1 Satisfied / very satisfied Neither satisfied or dissatisfied Dissatisfied / very dissatisfied 81% 84% 13% 11% 6% 6% 0 10 20 30 40 50 60 70 80 90 100 Military OneSourceMFLC Counselor follow-up to make sure I connected with services that they had recommended NOTE: ns = 1,448 for MFLC and 1,587 for Military OneSource. MFLC and Military OneSource estimates were generated in separate regression models. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non-response. RAND RR1861-6.3 Connection to Ser vices and Referrals 69 were connected to medical ser vices or physical health ser vices they would not have connected with on their own. Military OneSource participants were likely to agree that they had been connected with mental health ser vices they would not have connected with on their own. Over 81 percent of non- medical counseling participants were satisfied or very satisfied with program follow-up to make sure they connected with recommended ser vices, and MFLC participants seeing counselors embedded within the unit tended to be more satisfied with counselor follow- up than those whose counselor was not embedded. About a quarter of participants who sought additional help for their prob lem reported also seeing a private counselor or specialist. Although the timing and nature of this additional help is unclear, the fact that participants sought help from other counselors raises questions about the severity and nature of their prob lem, includ- ing whether participants with serious mental health prob lems are screened out of non- medical counseling and directed to more appropriate sources of care. Note that each question examined in this chapter was analyzed for those participants who reported that the question was applicable to their prob lem (i.e., they did not indicate that the question was “not applicable”), and the number of respondents reporting that a question was not applicable to their prob lem varied widely, ranging from 33 to 62 percent. This suggests that only participants who needed connections to outside ser vices answered the questions. How- ever, it is pos si ble that those who did not need outside ser vices answered the questions anyway, perhaps indicating that they did not agree that they had been connected to outside ser vices. This could partly account for the lower ratings of agreement with these questions relative to participants’ higher levels of satisfaction with follow-up on these connections. The next chapter further explores participants’ experiences with non- medical counseling programs and with the counselors themselves. 71 CHAPTER SEVEN Experiences with MFLC and Military OneSource Programs MFLC and Military OneSource are meant to increase access to high- quality ser vices and help individuals connect to needed ser vices that will help them to address their prob lems (see Figure 2.1 for the full logic model). Earlier chapters in this report examined the reported effectiveness of these ser vices on outcomes related to prob lem resolution and impact of the prob lem on one’s work and family life. This chapter examines the experiences individuals had with these non- medical coun- seling programs. At the program level, we examine perceptions related to ease of access, confi- dentiality, continuity of care, and overall satisfaction as mea sured by willingness to use ser vices again or recommend them to others. Statistically significant differences among subgroups are dis- cussed in the text and subgroup differences are tabulated in Tables C7.1– C7.4 in Appendix C. While there is slight variability between the two programs, key findings across both MFLC and Military OneSource include the following: • Over 90 percent of individuals reported that they were satisfied or very satisfied with the speed of being connected to a counselor and ease with which they could make an appoint- ment. • Over 90 percent of participants were satisfied or very satisfied with the level of confiden- tiality received. • Over 90 percent of individuals reported being satisfied or very satisfied with the continu- ity of care they received. • Over 90 percent of participants reported that they would be likely or highly likely to use non- medical counseling ser vices again. • Despite positive perceptions from the majority of participants, between 1 percent and 7 percent of participants reported being dissatisfied or very dissatisfied on the above pro- gram dimensions. Ease of Access In Wave 1, respondents reported on their satisfaction with the speed at which they were con- nected to counseling staff, as well as how easy it was to make an appointment with their coun- selor that fit their schedule. Speed of Connecting to Counseling Ser vices Over 90 percent of individuals reported that they were satisfied or very satisfied with the speed of being connected to a counselor. About 1 percent of MFLC participants and 3 percent of Military OneSource participants reported being dissatisfied or very dissatisfied with the speed 72 An Evaluation of U.S. Military Non-Medical Counseling Programs of which they were connected to a counselor (Figure 7.1). There were no subgroup differences related to the speed of connecting to non- medical ser vices. The high level of satisfaction was reiterated in the open- ended survey responses. It is quicker to get together with an MFLC counselor than it is to get in with a psychiatrist. It is very nice to be able to speak to someone right away. (MFLC participant) Military OneSource was able to find a counselor that specialized in what I was looking for and near me. It would have taken me hours/days to figure it out. I called very late in the eve- ning and was able to speak to someone right away. I got the contact info for a counselor and left a message for them. They called back the next morning even though it was a weekend and was able to get an appointment very quickly. (Military OneSource participant) Despite the majority of participants being satisfied with the speed of ser vices, not every- one was equally satisfied. Given that individuals often reach out in time of crisis, it is not sur- prising that individuals with wait times of several weeks or more expressed much higher dissatisfaction. The counselors that I have been in contact with did not seem to have the appropriate time available to schedule appointments. I have had to wait in excess of 3 or more weeks for the first appointment, and many times more than 2 weeks in between appointments. (Military OneSource participant) Figure 7.1 Average Estimated Probability of Satisfaction with the Speed of Connecting to Non- Medical Counseling Ser vices, Wave 1 1% 3%3% 4% 17% 25% 79% 67% 0 10 20 30 40 50 60 70 80 90 100 Military OneSourceMFLC NOTE: ns = 2,165 for MFLC and 2,314 for Military OneSource. MFLC and Military OneSource estimates were generated in separate regression models. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non-response. RAND RR1861-7.1 Dissatisfied or very dissatisfied Neither satisfied nor dissatisfied Satisfied Very satisfied Experiences with Non- Medical Counseling Programs 73 Ease of Making Appointments That Fit with Participant Schedule In addition to capturing perceptions on the length of time it took to connect to non- medical counseling ser vices, we also asked participants about the extent to which they felt they were able to make appointments with their counselor to fit their schedule (Figure 7.2). Over 90 percent of non- medical counseling participants felt that it was easy to make an appointment that worked with their schedule, with 79 percent of MFLC and 60 percent of Military One- Source participants strongly agreeing with the statement “It was easy to make appointments with my counselor to fit my schedule.” About 2 percent of MFLC and 5 percent of Military OneSource participants, however, disagreed or strongly disagreed that it was easy to make con- ve nient appointments. While there were no significant differences by subgroups for Military OneSource, MFLC participants whose counselors were embedded in their unit were more likely to agree that it was easy to make an appointment, as compared to those whose counselors were not embedded (see Table C7.1 in Appendix C). Beyond the ability to schedule appointments at con ve nient times, open- ended responses indicate that participants appreciated the flexibility to meet with counselors at con ve nient loca- tions to them, either in their communities (Military OneSource) or at a place on base or some- where else of their choosing (MFLC). This is a huge advantage to those who are not near a military installation where medical ser vices are readily available. I enjoy the non- medical approach too because this has become a major concern within the military community. (Military OneSource participant) Figure 7.2 Average Estimated Probability of Ease of Making Appointments, Wave 1 2% 5% 2% 5% 17% 31% 79% 60% 0 10 20 30 40 50 60 70 80 90 100 Military OneSourceMFLC NOTE: ns = 2,328 for MFLC and 2,492 for Military OneSource. MFLC and Military OneSource estimates were generated in separate regression models. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non-response. Disagree or strongly disagree Neither agree nor disagree Agree Strongly agree RAND RR1861-7.2 74 An Evaluation of U.S. Military Non-Medical Counseling Programs A major advantage using the MFLC system is that they are very easy to work with. My appointments are made within the time that I need them and locations are con ve nient for me. (MFLC participant) However, as 10 percent of Military OneSource survey respondents indicated, some par- ticipants did not agree that they were able to easily schedule counseling ser vices, particularly given the hectic schedules of military life. [A weakness of the MFLC program is the] restrictions of coordinating a regular civilian appointment schedule with a chaotic and fluid military schedule. (MFLC participant) It was difficult to get an appointment scheduled after leaving numerous providers voice- mails, getting calls returned saying they’re not taking new patients, or they didn’t have the hours we needed. (Military OneSource participant) Confidentiality One of the hallmarks of these two non- medical counseling programs is the confidential nature of ser vices being offered. As such, we asked individuals to rate their level of satisfaction with the confidentiality of personal and family information held by the program. Over 95 percent of MFLC participants and over 90 percent of Military OneSource participants were satisfied or very satisfied with the level of confidentiality received (Figure 7.3). One percent of clients in both programs, however, reported being dissatisfied or very dissatisfied. There were no sub- group differences in the level of satisfaction. In the open- ended responses, confidentiality was mentioned frequently as the primary reason for participants’ choice of non- medical counseling and their interest in continued use. [A strength of the program is] the fact that MFLC counselors are not plugged into the same healthcare recording systems as medical ser vices which leads me to believe confidentiality is better and makes me feel more comfortable about using the ser vice. (MFLC participant) The major strengths are having confidentiality outside of your duty station to get the assis- tance needed. There’s no fear of your supervision/leadership getting in your business while you work through some of life’s events. (Military OneSource participant) However, open- ended responses summarizing weaknesses of the programs revealed that concerns about a lack of confidentiality are still a major factor and can influence participants’ perceptions of both programs. Counselors need to make sure the patient feels that every thing is confidential (close the door) for privacy. (Military OneSource participant) The location of the MFLC in the [a specific building on base]. . . . Entering the room doesn’t feel very private. . . . It might be a barrier for some, to enter a room with such a high flow of traffic. (MFLC participant) Experiences with Non- Medical Counseling Programs 75 Continuity of Care Individuals were also asked to report on their level of satisfaction with continuity of care, which included seeing the same counselor for each session or another counselor who knew about the individual’s concern and what had been discussed during a previous counseling ses- sion. Individuals reported on whether the counselor or a member of the program staff reached out if an individual missed a scheduled appointment. For both MFLC and Military One- Source, just over 90 percent of individuals reported being satisfied or very satisfied with the continuity of care they received (Figure 7.4). Significant subgroup differences were observed for both MFLC and Military One- Source (see Tables C7.2 and C7.3 in Appendix C). For MFLC, participants whose counselor was embedded in their unit were more likely to report being very satisfied with the continuity of care compared to those whose counselors were not embedded. For Military OneSource, there was a significant difference in continuity of care by presenting prob lem. Close to 80 percent of individuals with deployment concerns were very satisfied with the continuity of care received. Between 60 percent and 65 percent of individuals with education and employ- ment prob lems, family or relationship issues, loss or grief, or general stress, anxiety or emo- tional prob lems reported being very satisfied with the continuity of care. For individuals with child- related prob lems, only 45 percent reported being highly satisfied with the continuity of care provided. Figure 7.3 Average Estimated Probability of Satisfaction with the Confidentiality of Personal and Family Information, Wave 1 1% 1%3% 6% 18% 31% 78% 62% 0 10 20 30 40 50 60 70 80 90 100 Military OneSourceMFLC NOTE: ns = 2,175 for MFLC and 2,267 for Military OneSource. MFLC and Military OneSource estimates were generated in separate regression models. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non-response. RAND RR1861-7.3 Dissatisfied or very dissatisfied Neither satisfied nor dissatisfied Satisfied Very satisfied 76 An Evaluation of U.S. Military Non-Medical Counseling Programs Open- ended responses provided more detail on the ways in which programs maintained continuity of care. We discussed the prob lem, pos si ble solutions, and plan for the next step forward to include follow-up sessions. Continuity is extremely impor tant so being able to stay with the same counselor made a big impact. (MFLC participant) It was a fast and seamless pro cess. There was great communication with the text messages, email, and follow-up to ensure I had scheduled an appointment. (Military OneSource participant) While the majority of participants were satisfied with the continuity of care they received through MFLC and Military OneSource, there was a significant subset of respondents who were not satisfied. Weaknesses mentioned in open- ended responses provide some insight into the reasons why roughly 10 percent of participants were not satisfied with the continuity of the program. While we cannot directly compare the frequency of themes mentioned in open- ended responses between programs, this issue was more commonly mentioned by Military OneSource participants. My only complaint is that when we move (as we often do) finding a new counselor means explaining my entire life story again. I don’t even know if there is a work- around for this, and maybe it’s best to repeat things and gain other perspectives, but I do feel like a lot of time is spent the first session or two repeating things I told a previous counselor. (Military OneSource participant) Figure 7.4 Average Estimated Probability of Satisfaction with the Continuity of Care, Wave 1 3% 3%5% 6% 21% 30% 71% 62% 0 10 20 30 40 50 60 70 80 90 100 Military OneSourceMFLC NOTE: ns = 1,969 for MFLC and 2,184 for Military OneSource. MFLC and Military OneSource estimates were generated in separate regression models. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non-response. RAND RR1861-7.4 Dissatisfied or very dissatisfied Neither satisfied nor dissatisfied Satisfied Very satisfied Experiences with Non- Medical Counseling Programs 77 No notes taken so on more detailed issues some of the information is lost or forgotten. (MFLC participant) Related to concerns with continuity of care, respondents, particularly those who sought counseling through MFLC, were concerned about the impact of frequently rotating counselors from installation to installation. In fact, the most frequently mentioned weakness of the MFLC program was a lack of stability of MFLC counselors, one that seemed to influence participants’ perceptions of the value of the program as a whole. The major disadvantage is MFLC counselors rotate a lot. I would like to see the same coun- selor for all of my session because I already have a rapport with them. (MFLC participant) There’s a policy to move our MFLCs after a year. We’ve had some outstanding counselors who have become strong members of the team. I hate losing them after they’ve established trust and rapport. (MFLC participant) In addition to overall continuity of care, individuals also provided feedback related to outreach by the program or counselor after a missed appointment. About half of participants (59 percent of MFLC and 50 percent of Military OneSource) reported being very satisfied with follow-up from program staff if they missed an appointment (Figure 7.5). Between 6 percent and 7 percent, however, were dissatisfied with the follow-up. There were no significant group differences in the level of satisfaction among MFLC or Military OneSource participants. Figure 7.5 Average Estimated Probability of Satisfaction with Follow- Up After Missed Appointment, Wave 1 6% 7% 14% 15% 21% 28% 59% 50% 0 10 20 30 40 50 60 70 80 90 100 Military OneSourceMFLC NOTE: ns = 1,144 for MFLC and 1,107 for Military OneSource. MFLC and Military OneSource estimates were generated in separate regression models. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non-response. RAND RR1861-7.5 Dissatisfied or very dissatisfied Neither satisfied nor dissatisfied Satisfied Very satisfied 78 An Evaluation of U.S. Military Non-Medical Counseling Programs Future Use and Recommendation of Program to Others Anticipated Future Use of Program As an overall indicator of program satisfaction, we asked individuals how likely it is that they would use non- medical counseling the next time they experienced a non- medical prob lem. Over 90 percent of participants reported that they would be likely or highly likely to use non- medical counseling ser vices again if the need arose (91 percent for MFLC and 93 percent for Military OneSource) (Figure 7.6). Approximately 5 percent were not sure and about 3 percent said that they would not likely use non- medical counseling ser vices in the future. There were no significant differences by subgroup in the reported likelihood of future program use. In response to the open- ended question about strengths of the program, participants took the opportunity to affirm their plans for future use. My counselor knew me and counseled me in a way I responded well to. Appointments were flexible and encouraged me to come back. I would definitely use an MFLC again when I needed support. (MFLC participant) The support was excellent and would use the ser vices again if needed. (Military OneSource participant) Participants also noted that they appreciated the fact that the non- medical counseling ser vices were offered to them free of charge. Many reported that this eliminated the financial Figure 7.6 Average Estimated Probability of Likelihood of Future Program Use, Wave 1 3% 2% 6% 5% 15% 13% 76% 80% 0 10 20 30 40 50 60 70 80 90 100 Military OneSourceMFLC NOTE: ns = 2,314 for MFLC and 2,432 for Military OneSource. MFLC and Military OneSource estimates were generated in separate regression models. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non-response. RAND RR1861-7.6 Unlikely or very unlikely Not sure Likely Highly likely Experiences with Non- Medical Counseling Programs 79 barrier that they had faced when trying to access similar ser vices elsewhere and, as a result, they were able to get the ser vices they needed. I would not have sought counseling ser vices without Military OneSource because my civil- ian medical insurance does not cover it until our deductible is met, and then only covers half of the cost. I wouldn’t take money from our family bud get for myself like that. I also had no idea (as a professional in the community on the civilian side) how to access any lower- cost or free ser vices. (Military OneSource participant) Despite positive experiences by many, other participants reported that they did not intend to use MFLC or Military OneSource ser vices again. Reasons provided in these responses reflect other concerns identified in survey data, including issues with access, while others reflect a general lack of confidence in the efficacy of the program. It is such a pain to receive treatment through Military OneSource. The initial phone call takes entirely too long, and they’ll only send the names of up to three providers at a time. I then have to research those three providers, decide if they’re worthy, and then call back and request three more if I don’t like them. This is time consuming, mentally draining, and an effective barrier to me wanting to find treatment. . . . I will never utilize Military One- Source again for myself or for my family. (Military OneSource participant) The same stuff that caused the stress is still pres ent after the counselor left and will continue to be pres ent until this duty is over. So why talk about it with someone about your prob- lems, if you know your prob lems won’t change. I’m not a threat to myself so there is no need in the future for me to talk with a counselor again. (MFLC participant) Likelihood of Recommending Non- Medical Counseling to Others We also asked how likely individuals would be to refer a friend to non- medical counseling ser- vices. Although this question was asked of Military OneSource only due to the highly confi- dential nature of the MFLC program, some MFLC participants noted in their open- ended responses that they do recommend MFLC ser vices to others. Among Military OneSource participants, about 95 percent reported that they would be likely (11 percent) or highly likely (84 percent) to recommend Military OneSource to a friend in need of ser vices. About 3 percent were not sure and about 2 percent reported that they would be unlikely to recommend Mili- tary OneSource ser vices. I am a HUGE advocate of the MFLC program and recommend their ser vices whenever I can. (MFLC participant) If it was just my husband and I were just talking to each other, it was difficult to move past the issue we each wanted to address and go parallel, but our counselor was able to help us communicate better. . . . I recommend the ser vice to anyone who is suffering from marital prob lems. (Military OneSource participant) There were significant differences in the likelihood of recommending Military OneSource ser vices among ser vice members and family members, and this was driven largely by differ- ences in the extent to which they reported being “highly likely” to recommend Military 80 An Evaluation of U.S. Military Non-Medical Counseling Programs OneSource ser vices (86 percent of ser vice members and 80 percent of family members), with little difference in the proportion reporting that they would not recommend ser vices (1 percent of ser vice members and 2 percent of family members; see Table C7.4 in Appendix C). Chapter Summary Overall, participants were generally pleased with the ease with which they were able to access ser vices, confidentiality of ser vices, and continuity of care. Among MFLC participants in par- tic u lar, those working with an embedded MFLC counselor reported significantly higher satis- faction along several program domains. However, not all participants had an equally positive experience or perception of non- medical counseling ser vices. Findings, particularly open- ended responses, point to the need for MFLC and Military OneSource leadership to assess where additional counselors may be warranted to alleviate stress on the system and ensure every one can access ser vices within a reasonable time frame. Other findings suggest that peri- odic reminders to counselors about confidentiality, and the appearance of confidentiality, may be warranted as this is a hallmark of the program and a continued concern for many. Results also suggest that program leadership may wish to examine concerns related to the continuity of care, reported by about 10 percent of the population, as this lack of continuity may serve as a barrier to faster prob lem resolution. For example, there were significant differences among Military OneSource participants by prob lem type, with those presenting with child- related issues reporting the lowest level of continuity. Despite these concerns, about 90 percent of indi- viduals noted that they would be likely to use non- medical counseling ser vices again if the need arose. 81 CHAPTER EIGHT Perceptions of Non- Medical Counselors In addition to the perceptions of the non- medical programs (Chapter Seven), we also asked individuals to report on their perceptions of their counselors. Feedback on issues of profession- alism, clarity of communication, cultural competency (i.e., sensitive to cultural/language dif- ferences of participants, understanding of military culture), knowledge of the presenting prob- lem, and whether the counselor met the client needs may help to further strengthen non- medical counseling programs and the experiences of individuals seeking ser vices. Statistically signifi- cant differences among subgroups are discussed in the text and subgroup differences are tabu- lated in Tables C8.1– C8.7 in Appendix C. While there is slight variability between the two programs, key findings across both MFLC and Military OneSource include the following: • Over 90 percent of participants reported being very satisfied with the level of profession- alism of the counseling staff. • Over 95 percent of participants strongly agreed that their counselor listened to them care- fully and 90 percent agreed or strongly agreed that their counselor spent enough time with them. • Over 75 percent of participants agreed or strongly agreed that their counselor addressed their cultural, language, or religious concerns. • Over 75 percent of participants agreed or strongly agreed that their counselor understood military culture. • Over 90 percent of participants agreed or strongly agreed that their counselor was knowl- edgeable about their presenting prob lem. • Over 75 percent of participants were satisfied or highly satisfied with the number of mate- rials and resources received, and 80 percent were satisfied or highly satisfied with the types of materials and resources provided. • About 90 percent of participants agreed or strongly agreed that their counselor provided the ser vices they needed to address their non- medical prob lems and related concerns. Professionalism Professionalism was assessed with two questions, including the extent to which participants felt the counselor showed interest in their questions and concerns, and their satisfaction with the level of professionalism of counseling staff. 82 An Evaluation of U.S. Military Non-Medical Counseling Programs Counselor Showed Interest About 84 percent of MFLC and 70 percent of Military OneSource participants strongly agreed that their counselor showed interest in their questions and concerns (Figure 8.1). While there were no group differences for MFLC, for Military OneSource there were significant differences by gender and rank (see Table C8.1 in Appendix C). More women than men strongly agreed that their counselor showed interest in their concerns (72 percent compared to 66 percent, respec- tively). Also, a higher proportion of officers and their families strongly agreed that their coun- selor showed interest in their questions and concerns compared to enlisted respondents and their families (73 as compared to 68 percent, respectively). Level of Professionalism Approximately 80 percent of MFLC participants and 65 percent of Military OneSource par- ticipants reported being very satisfied with the level of professionalism of the counseling staff (Figure 8.2). It is impor tant to note, however, that between 4 percent and 8 percent reported either feeling neutral or dissatisfied with the level of professionalism, suggesting that there may be a need for additional training or oversight for some counselors. While there were no signifi- cant differences by subgroups for Military OneSource, for MFLC, those working with a MFLC counselor who was embedded in their unit reported significantly higher levels of satisfaction than those working with MFLC counselors who were not embedded (84 percent as compared to 78 percent, respectively; see Table C8.2 in Appendix C). Figure 8.1 Estimated Share Agreeing That Counselor Showed Interest in Questions and Concerns, Wave 1 1% 2%1% 2% 14% 26% 84% 70% 0 10 20 30 40 50 60 70 80 90 100 Military OneSourceMFLC NOTE: ns = 2,379 for MFLC and 2,540 for Military OneSource. MFLC and Military OneSource estimates were generated in separate regression models. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non-response. RAND RR1861-8.1 Disagree or strongly disagree Neither agree nor disagree Agree Strongly agree Perceptions of Non- Medical Counselors 83 Open- ended responses frequently included the value of having access to a professional resource through Military OneSource and MFLC, and participants mentioned the profession- alism of the counselors they met with as strengths of the MFLC and Military OneSource programs. I really like using MFLC because of the assistance they give and how professional and knowl- edgeable they are. They assess situations in a calm manner that helps deal with stressful situa- tions and give valuable information to take with me as I leave. I find their guidance extremely helpful due to the stressful life of being in the military. I wish more military members would seek out their help. (MFLC participant) This is the best benefit of my 24 years of ser vice. I am very thankful for the professional- ism and promptness of both Military OneSource and our counselor. (Military OneSource participant) However, responses to open- ended questions also revealed that some participants experi- enced inconsistency in the professionalism of the counselors they saw, including some extreme cases of unprofessional be hav ior on the part of counselors. A subset of responses, predomi- nantly from Military OneSource participants but including MFLC participants as well, included recommendations that counselor per for mance reviews emphasize the importance of professionalism. Figure 8.2 Estimated Share with Satisfaction with Level of Professionalism, Wave 1 2% 3%2% 5% 17% 29% 79% 64% 0 10 20 30 40 50 60 70 80 90 100 Military OneSourceMFLC NOTE: ns = 2,202 for MFLC and 2,300 for Military OneSource. MFLC and Military OneSource estimates were generated in separate regression models. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non-response. RAND RR1861-8.2 Dissatisfied or very dissatisfied Neither satisfied nor dissatisfied Satisfied Very satisfied 84 An Evaluation of U.S. Military Non-Medical Counseling Programs This par tic u lar counselor was a joke. She was unprofessional she would discuss other clients in front of you. Give negative attitude about people who are wanting and needing helping. Made an appointment and she never showed up nor did she call. (MFLC participant) There were some definite positives with the first counselor I saw, but I needed to find a new one due to unprofessional be hav iors. (Military OneSource participant) Communication We asked participants several questions about the communication skills of their counselor. Participants were asked the extent to which they agreed that their counselor listened carefully, spent enough time with them, and explained things in a way that was easy to understand. Par- ticipants were also asked whether they left their counselor’s office with all of their questions answered. Counselor Listened Carefully Approximately 95 percent of MFLC and Military OneSource participants agreed or strongly agreed that their counselor listened to them carefully, but about 1–3 percent disagreed with this statement (Figure 8.3). While there we no subgroup differences among MFLC partici- pants, among Military OneSource participants, ser vice members and women were more likely Figure 8.3 Estimated Share Agreeing That Counselor Listened to Them Carefully, Wave 1 1% 3%1% 2% 14% 26% 84% 69% 0 10 20 30 40 50 60 70 80 90 100 Military OneSourceMFLC NOTE: ns = 2,380 for MFLC and 2,538 for Military OneSource. MFLC and Military OneSource estimates were generated in separate regression models. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non-response. RAND RR1861-8.3 Disagree or strongly disagree Neither agree nor disagree Agree Strongly agree Perceptions of Non- Medical Counselors 85 to strongly agree that their counselor listened to them carefully (72 percent of ser vice members as compared to 65 percent of family members; 72 percent of women compared to 66 percent of men; see Table C8.3 in Appendix C). Through their open- ended responses, participants mentioned the listening skills of coun- selors as one of the most notable strengths of non- medical counseling programs. It offers an opportunity to identify my personal and work- related grievances with a patient and tactful human being with actual listening and communication skills. (MFLC participant) She listened and identified the real need. Because of my personality, she was truthful and got to the need so more time could be spent. She didn’t give homework, but things to think about until the next session that were on point. (Military OneSource participant) However, a small subset of survey respondents indicated that they did not agree that their counselors listened carefully to them during their sessions. Open- ended responses related to weaknesses of MFLC and Military OneSource provide insight into the issues that some par- ticipants had with counselors’ listening skills. I felt she wasn’t qualified because in the same session she would ask the same question sev- eral times, which made me feel like she wasn’t listening. This was a huge concern for me because as a counselor, I feel like active listening is the main skill one needs to succeed. (MFLC participant) I was not happy with the provider of my non- medical counseling. I felt she did not listen to me at all and I will not be returning to her. (Military OneSource participant) Counselor Spent Enough Time with Participant In relation to how much time the counselor spent with the participant, about 81 percent of MFLC and 63 percent of Military OneSource participants strongly agreed that their counselor spent enough time with them to address their concern (Figure 8.4). For MFLC, participants were more likely to strongly agree if their counselor was embedded in their unit (86 percent) compared to those where their counselor was not embedded in their unit (80 percent). For Military OneSource, ser vice members (66 percent as compared to 58 percent of family mem- bers) and women (67 percent as opposed to 59 percent of men) were more likely to strongly agree that their counselor spent enough time with them. Respondents described the amount of time that counselors spent with them as one of the program’s strengths through their open- ended responses. The counselor spent hours at a time with me, didn’t take sides or push me to do things I didn’t want to do, and showed that he actually cared. (MFLC participant) When I saw a provider at mental health I felt that they were eager to diagnose and prescribe, but going to a non- medical provider through Military OneSource for the exact same issues, I felt that the Military OneSource was more open to talking through some of the prob lems I was facing and really took the time to understand what I was struggling with, without pathologizing every thing. (Military OneSource participant) 86 An Evaluation of U.S. Military Non-Medical Counseling Programs Between 5 percent and 10 percent of respondents, however, did not agree that their coun- selors spent enough time with them. Responses detailing weaknesses of MFLC and Military OneSource provided some insight into the situations in which respondents were concerned about the amount of time they spent with par tic u lar counselors. My counselor doesn’t seem inviting to talk to. . . . I feel that a counselor should be inviting because many people would like to talk, but may not have the courage to take that first step like myself. She did not seem to dig when asking about personal information. . . . This seems to be a waste of time and money for what turned into a 10–15 minute visit to each Marine. . . . I also feel that the next counselor should spend more time talking with the individual asking more questions and building good rapport. (MFLC participant) Our sessions with our counselor were absolutely too short. . . . When you’ve been in the military for 10 years with a half dozen deployments, it takes awhile to give our com- plete history and background and touch on the issues AND have time for the counselor to give us tools. We had so much ‘material’ to communicate, our counselor wouldn’t have time to actually help us sort things out before the end of our appointment . . . causing us, many times, to leave even more disgruntled with each other than when we entered. (Mili- tary OneSource participant) Figure 8.4 Estimated Share Agreeing That Counselor Spent Enough Time with Them, Wave 1 2% 5%3% 5% 15% 27% 81% 63% 0 10 20 30 40 50 60 70 80 90 100 Military OneSourceMFLC NOTE: ns = 2,375 for MFLC and 2,531 for Military OneSource. MFLC and Military OneSource estimates were generated in separate regression models. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non-response. RAND RR1861-8.4 Disagree or strongly disagree Neither agree nor disagree Agree Strongly agree Perceptions of Non- Medical Counselors 87 Information Was Explained in a Way That Was Easy to Understand When participants were asked about whether information was explained to them in a way that made it easy for them to understand, just over 80 percent of MFLC and about two- thirds of Military OneSource participants strongly agreed (Figure 8.5). About 3 percent of MFLC and 7 percent of Military OneSource participants either felt neutral or did not agree that that they received information in a way that was easy to understand. One participant shared her positive experiences: The counselor that I am seeing has an open mind and the ability to listen and understand how I am feeling and why. There have been several occasions that I was guided through the mix of thoughts and emotions and was able to better understand them and why I was having them. My counselor is very approachable, friendly and kind. I feel very comfortable with her and that I can talk about anything. She also does not sugar coat things but she is still kind in the words that she uses. (MFLC participant) Subgroup differences for this item were similar to other communication items (see Tables C8.4 and C8.5 in Appendix C). Participants working with an embedded MFLC counselor were more likely to strongly agree that their counselor explained things in a way that made it easy to understand (85 percent relative to 80 percent for non- embedded MFLC counselors). For Military OneSource, ser vice members and women were also more likely to strongly agree that the counselor explained things in a way that made it easy to understand (69 percent of Figure 8.5 Estimated Share Agreeing That Counselor Explained Things in a Way That Was Easy to Understand, Wave 1 1% 3%2% 4% 16% 27% 81% 66% 0 10 20 30 40 50 60 70 80 90 100 Military OneSourceMFLC NOTE: ns = 2,367 for MFLC and 2,524 for Military OneSource. MFLC and Military OneSource estimates were generated in separate regression models. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non-response. RAND RR1861-8.5 Disagree or strongly disagree Neither agree nor disagree Agree Strongly agree 88 An Evaluation of U.S. Military Non-Medical Counseling Programs ser vice members compared to 62 percent of family members, and 69 percent of women com- pared to 63 percent of men). Left Counselor’s Office with Questions Answered We asked individuals to report on the extent to which they felt their questions had been answered when they left their counselor’s office. Consistent with other mea sures of com- munication presented in this section, a strong majority agreed or strongly agreed that they left their counselor’s office with all of their questions answered. Of MFLC participants, 77 percent strongly agreed that their questions had been adequately answered and 62 percent of Military OneSource strongly agreed with this statement (Figure 8.6). Again, there was a small minority (2 percent of MFLC and 4 percent of Military OneSource) who disagreed or strongly disagreed with this statement, indicating that they did not feel their questions were answered. There were no subgroup differences for MFLC participants in the level of agreement with this statement, but Military OneSource participants differed by gender and ser vice member status (see Table C8.6 in Appendix C). For Military OneSource, ser vice members and women were more likely to strongly agree that their questions had been adequately answered (64 percent of ser vice members compared to 57 percent of family members, and 65 percent of women com- pared to 58 percent of men). Figure 8.6 Estimated Share Who Left Counselor’s Office with All of Their Questions Answered, Wave 1 2% 4%4% 8% 17% 26% 77% 62% 0 10 20 30 40 50 60 70 80 90 100 Military OneSourceMFLC NOTE: ns = 2,354 for MFLC and 2,497 for Military OneSource. MFLC and Military OneSource estimates were generated in separate regression models. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non-response. RAND RR1861-8.6 Disagree or strongly disagree Neither agree nor disagree Agree Strongly agree Perceptions of Non- Medical Counselors 89 Open- ended responses confirmed that participants were generally satisfied with the abil- ity of their counselors to answer the questions they brought to the appointment. I felt that the areas I had (albeit minor) concern were addressed, my questions answered, and my quality of life (which was already good) was improved further. (MFLC participant) Cultural Competency For non- medical counseling to be effective, it must provide ser vices in a way that aligns with and is respectful of the culture, background, language, or religion of the individual seeking the ser vices. Cultural competency also includes a strong understanding of military culture, and the unique experiences and stressors facing ser vice members and their families. To assess the cultural competency of counselors within MFLC and Military OneSource, we asked individuals to report on two aspects: the extent to which the participant felt their counselor addressed their cultural, language, or religious concerns, and whether the counselor understood military culture. Cultural, Language, or Religious Concerns About 81 percent of MFLC and 76 percent of Military OneSource participants agreed or strongly agreed with the statement “My counselor addressed my cultural, language or religious concerns” (Figure 8.7). While about 15 percent felt neutral about the statement, 3 percent of Figure 8.7 Estimated Share Agreeing That Counselor Addressed Cultural, Language, or Religious Concerns, Wave 1 3% 6% 15% 18% 21% 30% 60% 46% 0 10 20 30 40 50 60 70 80 90 100 Military OneSourceMFLC NOTE: ns = 1,383 for MFLC and 1,450 for Military OneSource. MFLC and Military OneSource estimates were generated in separate regression models. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non-response. RAND RR1861-8.7 Disagree or strongly disagree Neither agree nor disagree Agree Strongly agree 90 An Evaluation of U.S. Military Non-Medical Counseling Programs MFLC and 6 percent of Military OneSource participants disagreed or strongly disagreed with this statement. While there were no subgroup differences for MFLC, among Military OneSource participants, officers and their families were more likely than enlisted ser vice members and their families to strongly agree that their counselor addressed their cultural, language, or religious con- cerns (51 percent compared to 44 percent, respectively; see Table C8.7 in Appendix C). Respondents were somewhat divided about whether or not counselors addressed their cultural, religious, or language concerns. Some participants felt as though counselors were well trained and sensitive to cultural competency issues, while others had concerns about their counselor’s level of sensitivity. I also appreciate . . . the separation of religion and counseling, as my husband and I sub- scribe to a diff er ent set of beliefs than the prominent set in this area, and (in religious coun- seling settings) do not appreciate the disrespect of being evangelized while sorting through our differences. It has been very freeing to speak to a counselor who prioritizes our personal needs over any religious motivation. (MFLC participant) Counselor understands my issue and is helping me to walk through it. She understands my cultural and moral background and keeps on guiding me to success despite my challenges. I feel very comfortable. (Military OneSource participant) [Counseling] seemed to be more ‘Christian’ then I wanted. I was able to pull out things that could help me in the examples he gave me. I feel like general religious references would be fine, but hinting at or ga nized religion as a solution was a bit much for me. (MFLC participant) In the military, there are a lot of international couples so counselors need to understand about the culture differences and language barriers and have knowledge about them. (MFLC participant) Understood Military Culture One of the concerns often expressed by ser vice members seeking ser vices is that providers, par- ticularly in the civilian population, often don’t understand military culture. Given the wide variation in type and location of providers, we asked MFLC and Military OneSource partici- pants to rate the extent to which their counselor understood military culture. Among MFLC participants, 25 percent agreed and 69 percent strongly agreed that their counselor understood military culture (Figure 8.8). Among Military OneSource participants, 34 percent agreed and 44 percent strongly agreed that their counselor understood military culture. However, 2 percent of MFLC and 6 percent of Military OneSource participants disagreed or strongly disagreed that their counselor understood military culture. There were no subgroup differences for either MFLC or Military OneSource in the assessment of their counselor’s understanding of military culture. Open- ended responses on the strengths and weaknesses of the program support these data. While having an understanding of military culture was noted as a strength of non- medical counseling programs for some, others felt this was an area that could be improved upon. The MFLC offers an out that a Marine normally does not have. Someone that (needs to/ does) understand the lingo, gets the Jarhead things we go through and understands the chaotic but structured way we do things. If you need someone to listen or to talk to, or to seek help with something, the last person you want to say it to is one of your se niors or Perceptions of Non- Medical Counselors 91 one of your subordinates and depending on the work environment your peers may not be suitable either. That is where the MFLC pays off. They are a trusted, certified, command endorsed, reputable source for young and old Jarheads. (MFLC participant) The situation my husband and I are in with the Navy is very unique and has caused a lot of stress for over a year in both our professional and personal life. Having a Military OneSource counselor and the third party resource to talk to who has knowledge of military life and culture has been so helpful to my emotional well- being. (Military OneSource participant) The only challenge I ran into was the knowledge of the military and my job in par tic u lar. That is not something I would expect them to know but have to explain the situation and how the chain of command was not helping and the difference between a crew boss and a supervisor along with other tedious things like rec ords and the weekly evals [evaluations] that we receive was the only thing that I felt held me back a bit. (MFLC participant) Not too significant, but [one weakness is] the lack of understanding of military culture. . . . Civilian counselors would benefit from some education. (Military OneSource participant) Knowledge of the Presenting Prob lem and Adequacy of Resources In addition to assessing the level of professionalism, clear communication, and cultural com- petency of the counselor, we assessed participant perceptions of their counselor’s knowledge of Figure 8.8 Estimated Share Agreeing That Counselor Understood Military Culture, Wave 1 2% 6%5% 16% 25% 34% 69% 44% 0 10 20 30 40 50 60 70 80 90 100 Military OneSourceMFLC NOTE: ns = 2,311 for MFLC and 2,526 for Military OneSource. MFLC and Military OneSource estimates were generated in separate regression models. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non-response. RAND RR1861-8.8 Disagree or strongly disagree Neither agree nor disagree Agree Strongly agree 92 An Evaluation of U.S. Military Non-Medical Counseling Programs their presenting prob lem and the adequacy of the resources provided to address the partici- pants concerns. Counselor Knowledge of Presenting Prob lem Individuals were asked two separate but related questions about counselor knowledge. The first asked participants to rate the extent to which they agreed with the following statement, “My counselor was knowledgeable in the area of my specific concern.” About 95 percent of MFLC participants agreed (17 percent) or strongly agreed (78 percent) that their counselor was knowledgeable (Figure 8.9). Similarly, about 90 percent of Military OneSource participants agreed (27 percent) or strongly agreed (63 percent) that their counselor was knowledgeable about their presenting prob lem. There were no subgroup differences in the perception of coun- selor knowledge. The second question asked participants to report their level of satisfaction with their counselor’s knowledge about their non- medical concerns. Over 90 percent of MFLC partici- pants were satisfied (21 percent) or very satisfied (71 percent) with the level of their counselor’s knowledge (Figure 8.10). Similarly, about 89 percent of Military OneSource participants were satisfied (33 percent) or very satisfied (56 percent) with the level of their counselor’s knowledge. There were no subgroup differences for MFLC or Military OneSource in level of satisfaction related to their counselor’s knowledge about their non- medical concern. Open- ended responses reiterate the patterns observed in the survey data showing that participants generally agree that non- medical counselors have sufficient knowledge to help Figure 8.9 Estimated Share Agreeing That Counselor Was Knowledgeable in the Area of Their Concern, Wave 1 2% 3%3% 7% 17% 27% 78% 63% 0 10 20 30 40 50 60 70 80 90 100 Military OneSourceMFLC NOTE: ns = 2,369 for MFLC and 1,587 for Military OneSource. MFLC and Military OneSource estimates were generated in separate regression models. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non-response. RAND RR1861-8.9 Disagree or strongly disagree Neither agree nor disagree Agree Strongly agree Perceptions of Non- Medical Counselors 93 with their prob lems. However, some participants described a lack of counselor knowledge as one of the main weaknesses of the program. He had great knowledge on every thing I spoke about. He provided me with tools to lower stress levels and build better communication with family. (MFLC participant) When my family situation became acute Military OneSource was there immediately and stayed connected until they connected me with assistance. It was the care and lifeline that I needed and am very thankful as is my family because the tools and resources I learned also benefit them. (Military OneSource participant) Difficult issues . . . didn’t seem to be rectified with counselor due to either lack of knowl- edge or diff er ent perspective/way of dealing with things. Aspects [ were] helpful but not very much. (MFLC participant) It seemed that our counselor did not receive specialized training in our specific situation and was not as helpful as I had expected. (Military OneSource participant) Number and Types of Resources Provided Individuals were asked to report on their level of satisfaction related to the types of resources and materials received by the counselor, whether materials were relevant to the participant’s concern, and the number of resources provided. Overall, participants were satisfied with the types of materials provided and felt that they were relevant to their needs (Figure 8.11). About Figure 8.10 Estimated Share with Satisfaction with Level of Counselor Knowledge, Wave 1 3% 4%5% 7% 21% 33% 71% 56% 0 10 20 30 40 50 60 70 80 90 100 Military OneSourceMFLC NOTE: ns = 2,164 for MFLC and 2,274 for Military OneSource. MFLC and Military OneSource estimates were generated in separate regression models. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non-response. RAND RR1861-8.10 Dissatisfied or very dissatisfied Neither satisfied nor dissatisfied Satisfied Very satisfied 94 An Evaluation of U.S. Military Non-Medical Counseling Programs 89 percent of MFLC participants reported being satisfied (24 percent) or very satisfied (65 percent) with the types of materials and 82 percent of Military OneSource participants reported being satisfied (33 percent) or very satisfied (49 percent). About 3 percent of MFLC and 5 percent of Military OneSource participants, however, reported being dissatisfied or very dissatisfied with the types of resources and materials provided. There were no subgroup differ- ences in the level of satisfaction with the types of resources provided for either MFLC or Mili- tary OneSource participants. In addition to reporting on their level of satisfaction related to the types of resources and materials provided, and whether those aligned with their current needs and presenting prob- lem, participants reported on their level of satisfaction related to the number, or amount, of resources and materials provided by their counselor. About 86 percent of MFLC and 78 percent of Military OneSource participants were satisfied or highly satisfied with the number of resources and materials (Figure 8.12). However, about 4 percent of MFLC and 6 percent of Military OneSource participants reported not being satisfied. Due to how the question was worded, however, it is not clear whether individuals who were dissatisfied would have preferred more or fewer resources or materials. There were no subgroup differences in the level of satisfac- tion related to the number of resources provided by non- medical counselors. Open- ended responses provide more insight into the types of resources counselors pro- vided and how well they worked for participants. [We] thought our marriage was over and the MFLC helped us recover and grow stronger, and recommended relationship materials. . . . Overall we regained our marriage and got Figure 8.11 Estimated Share with Satisfaction with the Types of Materials Provided, Wave 1 3% 5% 8% 13% 24% 33% 65% 49% 0 10 20 30 40 50 60 70 80 90 100 Military OneSourceMFLC NOTE: ns = 1,812 for MFLC and 1,732 for Military OneSource. MFLC and Military OneSource estimates were generated in separate regression models. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non-response. RAND RR1861-8.11 Dissatisfied or very dissatisfied Neither satisfied nor dissatisfied Satisfied Very satisfied Perceptions of Non- Medical Counselors 95 better as individuals and improved our communication and relationship skills. (MFLC participant) My counselor was able to relieve some of the stress I was experiencing by giving me self- care tools and new stress reduction techniques to try out. (Military OneSource participant) She gave us no materials to help us and only a vague referral as to where a certain building on post was that could help us. (MFLC participant) Our counselor did not provide us with any materials or exercises that we could have used as a couple. (Military OneSource participant) Met Client Needs Overall A final question related to counselor quality asked participants to rate the extent to which they agreed with the statement “My counselor provided the ser vices I needed.” About 93 percent of MFLC participants agreed (16 percent) or strongly agreed (77 percent) with this statement (Figure 8.13). Among Military OneSource participants, 88 percent agreed (27 percent) or strongly agreed (61 percent) that their counselor provided the ser vices they needed to address their non- medical prob lems and related concerns. A small minority, however, disagreed or strongly dis- agreed with this statement (3 percent of MFLC participants and 5 percent of Military OneSource Figure 8.12 Estimated Share with Satisfaction with the Number of Resources Provided, Wave 1 4% 6% 11% 16% 25% 34% 61% 44% 0 10 20 30 40 50 60 70 80 90 100 Military OneSourceMFLC NOTE: ns = 1,781 for MFLC and 1,697 for Military OneSource. MFLC and Military OneSource estimates were generated in separate regression models. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non-response. RAND RR1861-8.12 Dissatisfied or very dissatisfied Neither satisfied nor dissatisfied Satisfied Very satisfied 96 An Evaluation of U.S. Military Non-Medical Counseling Programs participants) and about 4 percent and 7 percent of MFLC and Military OneSource participants, respectively, neither agreed nor disagreed with this statement, suggesting that non- medical coun- selors did not meet the needs of about 10 percent of individuals who sought ser vices. There were no significant subgroup differences for either MFLC or Military OneSource. Chapter Summary This chapter provides impor tant insights into the experiences participants had while interact- ing with non- medical counselors. Counselor professionalism, clear communication, cultural competency, and knowledge and handling of presenting prob lems can have a significant impact on both the efficacy of the program to address prob lems and the perception of MFLC and Military OneSource more broadly. While the majority did have a positive experience with their counselor, approximately 10 percent had concerns, and in some cases they were serious con- cerns. Across the dimensions assessed, there were a number of significant subgroup differences. Among MFLC participants, counselors embedded within the participant’s unit generally received higher ratings than counselors who were not embedded. Among Military OneSource participants, women and ser vice members were more likely to report higher satisfaction with their counselor than men or family members, respectively. Determining which counselors are performing well and which may be in need of additional training and oversight was outside of the scope of this proj ect. However, these findings point to the need for more regular feedback on counselor per for mance so that concerns that do arise can be quickly addressed. Figure 8.13 Estimated Share Agreeing Counselor Provided the Ser vices They Needed, Wave 1 3% 5%4% 7% 16% 27% 77% 61% 0 10 20 30 40 50 60 70 80 90 100 Military OneSourceMFLC NOTE: ns = 2,331 for MFLC and 2,500 for Military OneSource. MFLC and Military OneSource estimates were generated in separate regression models. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non-response. RAND RR1861-8.13 Disagree or strongly disagree Neither agree nor disagree Agree Strongly agree 97 CHAPTER NINE Summary and Conclusions This report detailed research evaluating non- medical counseling provided through two large programs under the DoD— MFLC and Military OneSource— with the purpose of better understanding the impact of non-medical counseling on military ser vice members and their families. The study focused on the extent to which participants report that their prob lems were resolved following non- medical counseling, the degree to which program participants were able to connect with other ser vices, and participants’ experiences with counseling. For each research question, we examined whether there were notable differences by provider or client characteristics (e.g., prob lem type, ser vice, gender). Although the MFLC and Military One- Source studies were conducted as separate evaluations, high- level findings about the potential impact of and experiences with non- medical counseling can be drawn by examining results across both studies; these findings may help to inform policy decisions. The previous chapters contain additional details about the potential impact of each program, which may help to inform programmatic changes. Key high- level findings from the study include the following: • In general, most people who used non- medical counseling experienced a reduction in prob lem severity and its impact on their lives over the short and long term. • There was a statistically significant decrease in the frequency with which a participant’s prob lem interfered with work or daily routines following non- medical counseling, and a decrease in stated difficulty coping with day- to- day demands. • Most non- medical counseling participants were connected with support and ser vices out- side of the program— although not necessarily to support they would not have found on their own. • Across most mea sures, over 90 percent of participants expressed favorable perceptions of non- medical counseling programs. • Over 90 percent of participants expressed favorable perceptions of the professionalism and knowledge of non- medical counselors, thought that their counselor listened to them and spent enough time with them, and agreed that their counselor provided the ser vices they needed to address their prob lem. • Despite positive perceptions from the majority of participants, between 1 percent and 7 percent of participants reported being dissatisfied or very dissatisfied with non- medical counseling, and about 15 percent continued to rate their prob lem as severe or very severe, suggesting that there is room for improvement. In addition to the survey questions, participants were also given the opportunity to com- plete open- ended questions related to the strengths or weaknesses of non- medical counsel- ing. Two of the most commonly mentioned strengths related to the non- military counseling 98 An Evaluation of U.S. Military Non-Medical Counseling Programs environment were appreciation of confidentiality and ability to seek ser vices without engaging the chain of command. Participants also reported that they appreciated non- medical counsel- ing as a “forum to discuss issues” and noted that it was particularly helpful to have a neutral party from whom to seek advice and guidance. Some individuals, however, noted a preference for more sessions or more continuity in non- medical counselors over time, so that they could continue to work together as opposed to “starting over” with a new counselor. Another common weakness noted by participants was a broader lack of awareness about non- medical counseling within military- connected individu- als, suggesting that additional work could be done to disseminate information about the availability of non- medical counseling through these programs for ser vice members and their families. Lack of awareness was a par tic u lar theme for comments about the MFLC program. Given the limited lit er a ture on non- medical counseling programs, this is one of the first studies of the effectiveness of non- medical counseling for addressing participants’ prob lems. Other research has found that specific treatments were effective in improving mental health symptoms such as distress, anxiety, and depression (e.g., Army Center for Enhanced Per for- mance, Battlemind), and a few studies have found that military support programs for families are effective for improving parenting (Meadows, Tanielan, and Karney, 2016) and child (Chandra et al., 2011) outcomes. But the current study is one of the first to examine the short- and long- term outcomes and experiences of ser vice members and their families seeking non- medical counseling. The findings for this study can therefore serve as a starting point for establishing future benchmarks for judging the success of other non- medical counseling programs. The overall pattern of results from this study, though not causal, suggests that the pro- grams are largely effective in helping program participants resolve their prob lems. The majority of participants of these programs reported reductions in prob lem severity, stress and anxiety, and less prob lem interference with work and their personal lives after counseling. For most participants, these improvements were sustained or continued to improve in the three months after initiation of counseling ser vices. In addition, most participants were satisfied with the way the program connected them to applicable outside ser vices and resources (including medi- cal or behavioral health ser vices), and had positive perceptions of their experiences with the non- medical counseling programs and with their own counselor. Given the challenges that ser vice members and their families face (e.g., Lara- Cinisomo et al., 2011; Tanielian et al., 2014) and the need in this population for short- term, confidential ser vices for resolving non- clinical prob lems (Castro, Kintzle, and Hassan, 2015), results from the current study suggest that non- medical counseling provided through the MFLC and Military OneSource programs serve a key role in helping military families cope with the common stresses of military life. Even though the majority of participants experienced prob lem resolution and had positive perceptions of the programs and counselors, non- medical counseling was not universally suc- cessful. A small but impor tant proportion of participants did not experience a reduction in prob lem severity, stress and anxiety, and prob lem interference with work and their personal lives as a result of non- medical counseling. Across several of the outcomes, men were less likely than women to experience prob lem resolution and had less positive perceptions of their coun- selors (although these differences were often small in magnitude, they were statistically signifi- cant). In addition, participants who sought non- medical counseling for child- related prob lems reported lower levels of prob lem resolution and lower satisfaction with the continuity of care than those participants with other types of prob lems. Additional research is needed to investigate why Summary and Conclusions 99 these participants reported not being able to resolve their prob lems through non- medical coun- seling. Furthermore, a small proportion of participants reported that their counselor did not connect them to support and ser vices outside of non- medical counseling, and a small minority (between 1 percent and 7 percent of participants) expressed dissatisfaction with the program or their counselor. We make specific recommendations below for how program man ag ers can address these issues by improving counseling consistency and quality across counselors and strengthening connections to other ser vices. Limitations This study is limited in impor tant ways that constrain the strength of the conclusions that can be drawn from the results. First, the study did not include a control group that received no treatment or a diff er ent type of treatment; as a result, we cannot draw causal conclusions about the effectiveness of the program. Without a control group to compare against, it is unclear whether participants in the study would have resolved their prob lems on their own. However, given the diversity of needs and likely approaches offered by non- medical counselors to MFLC and Military OneSource participants, the focus of this study was not to assess the clinical effec- tiveness of specific interventions or treatments that were offered within the non- medical coun- seling sessions. Rather, the objective was to assess whether the availability of non- medical counseling programs to ser vice members and their families resulted in prob lem resolution and outcomes particularly relevant for military and family readiness, including reduction in stress and anxiety and reduced interference with work and daily life. While a randomized controlled trial is widely accepted as the gold standard for assessing the clinical effectiveness of a specific treatment, it is most appropriate for assessing causal influences at an individual level in a highly controlled context (World Health Organ ization, 2004). However, preventive and health pro- motion programs such as these are designed for diverse groups of individuals in need of a range of ser vices, so time series designs such as this one, where individuals serve as their own control over time, are valuable strategies for developing evidence of program effectiveness (World Health Organ ization, 2004). Because this is the first study to assess changes in participant outcomes over time, it is difficult to assess whether the observed changes over time are consistent with, better, or worse than other non- medical counseling programs. However, this study can serve as a useful bench- mark for future monitoring and evaluation of these programs over time. Another limitation of this study is that we were not able to collect a baseline assessment of prob lem severity or impact (i.e., mea sured before participants received counseling). Instead, we asked participants at Wave 1 to retrospectively assess precounseling levels of prob lem sever- ity and impact. It is pos si ble that the retrospective assessments of severity and impact were biased, although it is unclear which direction the bias would have occurred— toward perceiv- ing more severity prior to counseling or less severity. Given that identification of potential study participants was initiated by their first non- medical counseling session, obtaining a true baseline was not pos si ble. While we sought to overcome this limitation and minimize recall bias by inviting participants as soon after their first non- medical session as pos si ble (in most cases within a week), individuals varied in the time between invite and survey completion. Those that waited for the last reminder, for example, took the survey about a month after their initial non- medical counseling session. 100 An Evaluation of U.S. Military Non-Medical Counseling Programs It is also impor tant to recognize that the type and intensity of counseling given at each session likely varied between participants and across programs. Furthermore, there was vari- ability in the number of counseling sessions used by participants up to the maximum of 12. Follow-up analy sis on the relationship between number of non- medical counseling sessions and prob lem severity revealed, however, that the observed relationship between non- medical counseling and reduced severity occurred after the first 1–3 sessions and then tended to level off, suggesting that the number of sessions with a counselor may not be a strong explanatory factor for observed patterns. Response rates for both MFLC and Military OneSource were low, but not aty pi cal for studies of military ser vice members and their families (Miller and Aharoni, 2015). Low response rates can raise concerns about sample bias and representativeness of the study population rela- tive to the broader non- medical counseling population. However, comparisons to population- level characteristics of all program users who met eligibility criteria for the study revealed that study participants were representative of the population on demographic characteristics and prob lem type. In addition, where there were differences between the sample and population characteristics, we adjusted the data to be representative of the population. Numerous studies have found that sample representativeness, and not the response rate, is the key indicator of a biased sample (see Miller and Aharoni, 2015). Policy Implications Non-medical counseling provided through MFLC and Military OneSource was designed and implemented to provide short- term, solution- focused counseling to address general conditions of living and military lifestyle. Despite the face validity of these programs, to date there has been little empirical evidence of their effectiveness or the perception of these ser vices among those who have accessed them. Findings from this study, though not causal, suggest that non- medical counseling is associated with reductions in prob lem severity, and stress and anxiety both at work and at home, and that these improvements are generally maintained over time. These findings suggest the following implications for OSD policy: 1. Non-medical counseling should continue to be offered to ser vice members and families through the MFLC and Military OneSource programs. Non-medical counseling provided through MFLC and Military OneSource is a key component of the suite of ser vices and programs offered by the DoD. As our findings indicate, ser vice members and their families felt they derived considerable benefit from these programs in an environment that is compatible with their military obligations and that they would benefit from the continued availability of these programs. Furthermore, the program- matic changes suggested below would help strengthen the program to benefit those for whom non- medical counseling has been less effective in resolving their prob lems. 2. Steps should be taken to increase awareness of the program. Although we did not formally assess awareness of the program among military families, in the open- ended items participants noted that the awareness of these programs in the broader military community may be limited, suggesting that more work could be done to further dis- seminate information about the availability of these ser vices. This is especially true of the MFLC program. Such dissemination should go beyond direct awareness campaigns Summary and Conclusions 101 to ser vice members and families to include efforts to further engage chain of command and installation leadership, particularly for locations where MFLC ser vices are avail- able. Although participants did not note lack of command support as a concern or bar- rier, there may be more that leadership could be doing to actively support engagement with non- medical counseling programs. This may include periodic reminders of the availability of such support during “off- peak” times, such as two to three months after return from deployment, when non- medical counseling needs may be high but the dis- semination of information on resources is low (e.g., after postdeployment briefings have ended). 3. Expansion of the program should be informed by additional research that was beyond the scope of this proj ect. For the MFLC program in par tic u lar, program and counselor perceptions were consistently higher for individuals working with counselors embedded within units, the number of which may be worth expanding. However, find- ings suggest that there is a need for more research on how to strengthen ser vice delivery. Data from this report provide less input on opportunities for within- site expansion (e.g., adding non- medical counselors to an existing footprint). By design, we did not collect information on the counselor or location of ser vices and, as such, are unable to identify locations where con ve nient appointment times were more difficult to obtain, for exam- ple. Because this study focused on individual and couples sessions, additional studies may be warranted to similarly examine the effectiveness of other activities or modes of delivery (e.g., groups, ser vices specific for children). Additionally, before expanding the program, it would be impor tant to better understand how well non- medical counseling fits into the larger military health system, and specifically behavioral health. For exam- ple, does this type of counseling offset demand for more traditional behavioral health or clinical ser vices, either by preventing psychological prob lems from escalating in severity or by providing a substitute treatment for less severe psychological prob lems? Are individuals who seek non- medical counseling those who would have alternatively accessed the military health system more formally, or would they have gone without care? Part of this assessment would involve research demonstrating the cost- effectiveness of non- medical counseling programs relative to other solutions. We strongly recom- mend that the DoD conduct this kind of cost- effectiveness research before determining the scope of any expansion of these programs. Programmatic Implications Findings in Chapter Seven suggest that many individuals were satisfied with the program, their counselor, and the non- medical counseling ser vices they received. However, it was also clear that not every one had a positive experience. These findings suggest the following implica- tions for programmatic improvement: 4. Provide opportunities for ongoing support, guidance, and training for counsel- ors. A small minority of participants reported that they were dissatisfied with a number of counselor characteristics, including professionalism, communication, cultural com- petency, knowledge, and treatment of the presenting prob lem. These concerns, expressed through survey responses and open- ended items, along with the number of participants 102 An Evaluation of U.S. Military Non-Medical Counseling Programs whose prob lem severity, stress, or prob lem interference with their daily lives did not improve with counseling, suggest that counselors might benefit from more opportuni- ties to receive support and guidance from other non- medical counselors or from super- visors with more experience in the military community. This could include regularly scheduled case review sessions where counselors and supervisors provide advice on cur- rent participant cases; provision of guidance on how to set up client expectations for brief, solution- focused treatment and make the most efficient use of time; mentoring of new counselors by more experienced counselors; sharing best practice documents or tips; and provision of ongoing training with a toolkit to address prob lems using multiple counseling techniques. These activities could be done telephonically, virtually via web- based platform, or in person. Continuity in training may be particularly impor tant for counselors who are isolated from other military counselors (e.g., the only MFLC coun- selor assigned to a base; Military OneSource counselors with solo practices). These activities may also help to provide consistent counselor support and supervision and standardize high- quality non- medical counseling approaches and experiences across counselors. Findings also suggest the need for additional training on how to handle child- related concerns (implication 5), and how to strengthen referrals and connections to other ser- vices (implication 8). 5. Strengthen non- medical counseling for child- related concerns. For this study, we did not include children or counselors that provided ser vices to children and youth. However, many participants sought non- medical counseling through MFLC and Mili- tary OneSource for child- related prob lems. These participants, on average, reported lower levels of prob lem resolution and lower satisfaction with the continuity of care. This suggests a need to focus on how child- related issues are handled in non- medical counseling for adults. By nature, these prob lems may be more complex and require additional providers (e.g., education professionals, Child and Youth Ser vices counselors), as well as a specialized understanding of child and youth development that many adult counselors may not have. Programs may benefit from working to strengthen delivery of ser vices for individuals presenting with child- related concerns, potentially through warm handoffs to counselors who hold this more specialized level of training. 6. Identify ways to systematically collect counselor- level feedback and incorporate findings into per for mance review. While we did not collect information on individ- ual counselors for the purposes of this study, both the MFLC and Military OneSource programs may benefit from systematically collecting counselor- level feedback to estab- lish whether identified concerns are more prevalent for a given counselor or location. For example, some participants expressed concerns about confidentiality and the appear- ance of confidentiality by their counselor, and participant feedback would help identify counselors who need additional instruction or reminders about maintaining confiden- tiality. While Military OneSource does currently conduct quality improvement surveys and encourages feedback, MFLC does not, due to the confidential nature of the pro- gram. While this does pose a barrier, feedback on the counselor and program overall is critical for continued program improvement. Programs should develop a confidential procedure for participants to provide feedback. 7. Strengthen continuity of care. Satisfaction with continuity of care varied significantly across respondents. While most participants were satisfied, others noted a preference for Summary and Conclusions 103 greater continuity of care. This was particularly true for the MFLC program, where counselors were more likely to rotate prior to the full resolution of an individual’s prob- lem. This rotation often resulted in a need to start over with a new counselor, which was viewed as inefficient and disrupting of pro gress. Program officials should consider extend- ing MFLC assignment periods to provide less frequent rotations, and arrange for warm handoffs of cases from current counselors to incoming counselors. Frequent MFLC rotations were originally implemented to allow additional confidentiality for MFLC users, but it is unclear whether rotations actually help preserve confidentiality. Program officials should weigh whether the trade- off of possibly compromised confidentiality for less continuity of care is worthwhile. Even if current MFLC rotation schedules are maintained, additional accommodation should be provided for out going counselors to brief incoming counselors about their current caseload. In doing so, current counseling participants would be able to continue their trajectory of care without having to rein- form the incoming counselor of their prob lem and pro gress to date. 8. Strengthen screening and connections to other ser vices. Survey results and open- ended comments from participants suggest that non- medical counseling could benefit from strengthening connections to other ser vices. In some cases, the line between prob- lems that can be treated effectively through non- medical counseling and those that may require more specialized mental or behavioral health ser vices may be difficult to discern. For example, about a quarter of participants who sought additional help for their prob- lem reported seeing a private counselor or specialist, raising questions about the severity and nature of their prob lem. Future research and counselor training should focus on the pro cess by which those with diagnosable mental health conditions are screened and referred to ensure timely access to the most appropriate treatment for their concerns (e.g., through the military medical mental health care system, TRICARE, or other pro- viders of professional mental health care). Connection to other ser vices could benefit those participants who do not have a clinical need, but whose prob lem severity, stress, or prob lem interference with their daily lives did not improve with counseling. In addi- tion, results suggest the need to strengthen the continuity of care during the referral pro cess for both clinical and more specialized non- medical supports. On average, percep- tions of continuity of care were lower among individuals whose prob lems may require referrals or working with multiple professionals (e.g., child- related prob lems, stress), suggesting that programs may be improved by establishing a more formalized warm handoff and follow-up procedure to ensure continuity of care. 9. Conduct research to better understand how to strengthen ser vice delivery. Despite improvements in severity, stress, and anxiety among many participants, about 20 percent reported that they did not experience a reduction in prob lem severity as a result of non- medical counseling, and between 11 percent and 12 percent sought help from both MFLC and Military OneSource for the same concern. While this evaluation did not assess the types of counseling approaches or supports provided to participants, a stron- ger, more detailed understanding of what happens during a non- medical counseling session may provide insight into areas for improvement or gaps that are not being ade- quately addressed. This includes an assessment of whether those who did not experience improvements in prob lem severity would gain value from traditional behavioral health ser vices. The outcome mea sures included in this study were general by design (e.g., prob lem resolution, interference at work or daily life), but these findings point to a need 104 An Evaluation of U.S. Military Non-Medical Counseling Programs to examine in more detail what happens within a counseling session to ensure that approaches are evidence- based and appropriate and delivered as intended. More insight may also be gained by examining alignment of non- medical counseling approaches with the presenting prob lem and by looking at outcomes more specific to the presenting prob lem. Collectively, these analyses may inform more specific training needs. Conclusions Non- medical counseling ser vices offered through the MFLC and Military OneSource programs are a key component of the broader support offered to military ser vice members and their families. Findings from this study suggest that, overall, the programs are providing short- term, confidential, solution- focused counseling to address general conditions of living and military lifestyle. Participants reported reductions in prob lem severity and stress and anxiety at work and in their personal life after counseling, and, in most cases, these improvements were sus- tained or continued to improve in the three months after initiation of counseling ser vices. While many participants reported that their prob lem was resolved following counseling, non- medical counseling was not universally successful and a small minority expressed dissatisfac- tion with the program or their counselor. Collectively, these findings point to a number of key policy and programmatic recommendations that can be used by the OSD to further strengthen these programs. 105 APPENDIX A Data Collection, Weighting, and Analytic Approach In this appendix we provide additional information on data collection, weighting of the sample to be reflective of the larger population eligible for non- medical counseling ser vices, and our analytic approach. This appendix expands upon information provided in Chapter Two. All methods, procedures, and instruments used in the study were approved by the R AND Human Subject Protection Committee. The survey instruments are licensed by the DoD Washington Headquarters Ser vices in December 2010 (Rec ord Control Schedule DD- P&R [OT] 2562 and DD- P&R [OT] 2580). Identification of Eligible Participants and Introduction to the Study MFLC Individuals interested in MFLC ser vices may call an MFLC directly to make an appointment or they may simply walk into the counselor’s office without a prior appointment. Because no personally identifiable information is kept by the program to facilitate direct recruitment by R AND NDRI, individual MFLC counselors were tasked with recruiting participants for the study. At the end of counseling sessions that met study eligibility, counselors introduced the study to participants using a script developed by R AND NDRI: We want to know how well this program is working for you so that we can improve it. To help us, the R AND Corporation, a nonprofit research organ ization, is conducting an in de- pen dent study of the MFLC program. They would like to send you more information about their study. This study will also help to highlight the importance of these ser vices for you and your family. After reading the script, MFLC counselors handed participants a card where participants could indicate whether they did or did not want additional information about the study. It was made clear to potential participants that this card did not indicate consent, but simply an inter- est in learning more about the study. Each card was stamped with randomly assigned unique ID number. This number was entered in the online reporting form that MFLC counselors use to capture information about the session. This ID allowed us to link survey results for consenting participants to administra- tive data about their non- medical counseling session, while ensuring that the strict confidential nature of the program was kept intact. If participants indicated that they did want more information, there was a space for them to include their email address on the card. If participants did not want more information, they 106 An Evaluation of U.S. Military Non-Medical Counseling Programs checked “no” and did not provide an email address. To ensure confidentiality of participants and their interest in the study, participants placed their cards in envelopes, sealed them, and either returned them to the counselor for shipment to R AND or dropped them in the mail themselves (all envelopes were postage paid). Once cards were received by R AND, the ID number, “yes” or “no” response, and email address (if “yes”) were entered into a secure data- base. Those participants who were interested in the study were contacted via email and invited to participate (the average time between card receipt by R AND and solicitation email was six days). MFLC counselors were trained, and reminded on an ongoing basis, of eligibility criteria for the study to ensure fidelity to study protocols. Military OneSource For Military OneSource, initial introduction to the study occurred through the Military One- Source triage con sul tants when individuals first contacted Military OneSource. Triage con sul- tants assessed individuals’ needs and their eligibility for non- medical counseling ser vices. Once the con sul tant determined that the individual was eligible for non- medical counseling ser vices, the con sul tants read a script that introduced the study and asked about their interest in learn- ing more. If the individual indicated interest, their email address was recorded and saved in a separate, secure database accessible to R AND NDRI researchers. Interested participants were emailed an invitation for the study approximately one week after attending their first non- medical counseling session.1 Recruitment Emails for Interested Military OneSource and MFLC Participants Interested Military OneSource and MFLC participants received email invitations to partici- pate in the study using the same procedure. The email reinforced the confidential nature of the study and asked for participants’ help in understanding whether the respective program worked well and helped them resolve their prob lem or issue. The email contained a link to the survey and a randomly assigned login code for respondents to input at the survey website. Participants affirmed their consent to participate in the study on the first screen after logging into the online survey. Reminder emails were sent to non- respondents at three, seven, fourteen, and twenty- one days after the initial invitation email. Respondents who consented to the study and completed the Wave 1 survey were emailed an invitation to complete the Wave 2 survey. (Survey instruments are described in the follow- ing appendix.) This email was sent three months following the participant’s initial consent to participate in the study. As with the Wave 1 survey, reminder emails were sent to non- respondents at three, seven, fourteen, and twenty- one days after the initial follow-up invitation email. 1 We initially emailed interested Military OneSource participants within two to three days of their first contact with Military OneSource counselors, but some respondents reported on the survey that they did not feel that they had enough experience with their counselor to properly evaluate their ser vices. We therefore extended this period to one week. Data Collection, Weighting, and Analytic Approach 107 Study Population and Sample Weights for Tables One potential threat to the generalizability of study results is that the group of survey respon- dents may differ in impor tant ways from the target population. For example, if women were more likely to respond to the survey than men, and if women and men have differing average responses for key survey questions, reporting raw counts of survey outcomes may result in biased estimates. In order to address this concern, we received administrative data on several key client characteristics: a three- category age variable ( under 25; 25–40; 41 and above), whether the respondent was a ser vice member (as opposed to a spouse or other family member), ser vice affiliation (Air Force, Army, Marines, Navy, or Coast Guard), component affiliation (active or reserve), and officer/enlisted status (self or sponsoring family member). We also included an indicator of the category for the V code of the primary presenting prob lem.2 V codes that represented subcategories of prob lems (e.g., “marital and partner prob lems, unspeci- fied”) were collapsed into their larger overall prob lem domains (e.g., “ family or relationship prob lems”). Two prob lem domains with fewer respondents— employment assistance and edu- cation assistance prob lems— were combined into an “education or employment” prob lem domain. For the data reported in this report, we performed a pro cess called raking that pro- duces statistical weights to ensure that the distributions of weighted client characteristics equal the distributions of the characteristics in the population. The raking pro cess was performed using the “survey” package in R. Moreover, we used raking to account also for item non- response. Rather than calculating a single set of weights for all of the survey questions, we calculated separate sets of weights for each survey item. That is to say, even though a given number of individuals may have responded to the baseline survey, not every one of those respondents answered each individual survey question. Therefore, we produced weights so that the weighted distributions of client charac- teristics for respondents to each question equal the distributions in the target population. Although we believed (before looking at the data) that the weighted tables should be more accurate, we did examine unweighted tables that did not include any adjustments for differen- tial survey or item non- response. Comparisons of the unweighted and weighted tables for individual survey questions showed that the two versions of the estimates were generally quite similar: individual cell percentages were almost always within a few percentage points of each other when comparing the weighted and unweighted percentages. This is due to some combi- nation of the respondents being similar in their characteristics to the population, and because clients whose characteristics were underrepresented in the population nonetheless responded to the survey questions in a similar manner to those who were overrepresented. See Tables A.1 and A.2 for a comparison between demographic characteristics of the sample and the eligible population. While we believe that we weighted for characteristics that were likely to induce se lection bias, we emphasize that our weighting approach only accounts for the variables that were included in raking (as listed above). It is pos si ble that there are other client characteristics that should have been included in the weighting pro cess (if they were available for the full popula- 2 V codes, as described in the ICD-9- CM “Official Guidelines for Coding and Reporting, Supplementary Classification of Factors Influencing Health Status and Contact with Health Ser vices,” are used by providers to classify patient visits when circumstances other than a disease or injury result in an encounter with a provider (e.g., relationship distress, parent- child relational prob lem; Kostick, 2011). 108 An Evaluation of U.S. Military Non-Medical Counseling Programs tion and for the sample). While concerns related to unobserved confounding cannot ever be fully eliminated, the fact that weighting on observed potential confound ers only resulted in small changes in the survey estimates may be reason to believe that weighting on unobserved potential confound ers would only result in relatively minor changes, too. Further, it is pos si ble that the outcome mea sures themselves are predictive of the probabil- ity that an individual responded to the survey, which could bias the results. For example, if individuals who were displeased with the non- medical counseling ser vices were more moti- vated to respond to the survey, we would expect even the weighted tables to reflect a more negative overall sentiment than would be found if all clients had responded to the survey. However, we will see that the survey responses for many of the questions were almost uni- formly positive. For such survey items, se lection effects that could change overall, qualitative conclusions would have to be exceptionally strong. Table A.1 Comparison of MFLC Population to Study Sample Characteristic Population (%) Sample (%) Age 18–24 35.0 18.6 25–40 56.7 71.6 41 and over 8.2 9.8 Ser vice affiliation Army 60.3 49.0 Marines 20.3 14.4 Air Force 16.8 31.7 Navy 2.3 3.8 Other 0.3 1.2 Rank (self or sponsoring family member) Enlisted 84.1 78.5 Officer 15.9 21.5 Ser vice member status Family member 37.6 57.2 Ser vice member 62.4 42.8 Component affiliation Active duty 98.1 85.3 Guard or reserve 1.9 14.7 Prob lem type Education or employment 18.3 12.1 Family or relationship 49.9 66.7 Loss or Deployment 10.1 6.9 Stress, anxiety, or emotional prob lems 21.7 14.3 Data Collection, Weighting, and Analytic Approach 109 Quantitative Methods In our analyses, we do not have any control group, or a group that was unexposed to non- medical counseling ser vices. Consequently, we are not able to make any claims about whether the program “works” or not. For example, we are unable to make a determination as to whether more clients found prob lem resolution than would have been the case if they had not had access to the non- medical counseling ser vices. Even so, we are able to assess whether there is evidence of differences in survey outcomes by client- level characteristics, and whether there is evidence of change over time. We divide our models into two types: cross- sectional models that describe a response at a single point in time, and models of changes over time. Table A.2 Comparison of Military OneSource Population to Study Sample Characteristic Population (%) Sample (%) Age 18–24 12.9 6.8 25–40 72.6 69.6 41 and over 14.5 23.6 Ser vice affiliation Army 37.2 34.7 Marines 9.8 7.5 Air Force 21.3 21.9 Navy 17.8 19.1 Other 13.9 16.7 Rank (self or sponsoring family member) Enlisted 80.5 68.7 Officer 19.5 31.3 Ser vice member status Family member 28.9 35.7 Ser vice member 71.1 64.3 Modality In person 92.3 89.4 Other (e.g., phone, online chat) 7.7 10.6 Gender Women 48.8 56.8 Men 51.2 43.2 Prob lem type Education or employment 2.8 3.5 Family or relationship 64.4 67.4 Loss or deployment 4.7 5.1 Stress, anxiety, or emotional prob lems 28.0 24.0 110 An Evaluation of U.S. Military Non-Medical Counseling Programs All models that control for client- level characteristics contain the following covariates: gender; a three- category age variable ( under 25 years; 25–40 years; 41 years and above); whether the respondent was a ser vice member (as opposed to spouse or other family member); ser vice affiliation (Air Force, Army, Marines, Navy, or Coast Guard); component affiliation (active; reserve); officer or enlisted (self or sponsoring family member); and, in the case of MFLC, whether the counselor was embedded in the sponsoring ser vice member’s unit or not. We also included an indicator of the category for the V code of the primary presenting prob lem. Some of the covariates have missing data ele ments. Although the rates of missingness are generally modest, excluding observations that have any missing covariate values would sub- stantially reduce our available sample size and may bias results (e.g., Schafer, 1999). Accord- ingly, we performed multiple imputation to account for missing data at both Wave 1 (used in the cross- sectional models described below) and Wave 2 (used in the models examining change over time described below). Multiple imputation produces completed datasets so that data from all respondents to a par tic u lar question may be used in estimating the model. The mul- tiple imputation pro cess produces several complete datasets, and models are estimated on each completed dataset. By producing multiple completed datasets, the technique is able to express additional uncertainty due to the missing data in confidence intervals and p- values. The result- ing estimates from each model are combined according to Rubin’s (1987) rules. We used the “mi” package in R to perform the multiple imputation to create 20 completed datasets. We used the “micombine.chisquare” function from the “miceadds” package in R to combine chi- squared p- values for the multiply imputed datasets, and we used the “MIcombine” function in the “mitools” package in R to combine regression coefficient estimates and calculate 95 percent confidence intervals. Cross- Sectional Models Our primary model for the outcome variables of interest are ordered categorical models called proportional odds logistic regression models, which we fit using the “polr” function in the “MASS” package in R (Venables and Ripley, 2002). For these models, if the outcome categories Y are labeled k = 1, . . . , K, a repre sen ta tion of the model is given by Pr(Yi ≤ k) = exp(αk − xi β)/ (1 + exp(α k − x i β)). Here, α k are “cutpoints” that determine the relative probabilities of the outcome categories for a given set of covariates. From the model we can see that if, say, men have a higher probability of reporting the “worst” outcome for a given outcome mea sure than other wise identical women (e.g., rating their satisfaction with counselor knowledge as “very dissatisfied,” as mea sured through the covariates x i ), the model assumes that men also have a higher probability of reporting the worst or second worst category (e.g., rating their satisfaction as “dissatisfied”) compared to the other wise identical women. For ease of interpretation in tables and figures, we translate the fitted pa ram e ter values into marginal averages (i.e., averages that adjust for covariates included in the model). To calculate these, for each imputed dataset we generated the fitted probabilities and averaged the fitted probabilities from the imputed models across individuals. Fi nally, to calculate the estimated percentages included in the tables and figures, we averaged fitted probabilities across the imputed datasets. Additionally, we calculated p- values related to excluding a characteristic from the model. For example, we consider whether ser vice affiliation explains a significant amount of variation in the outcome scale. Low p- values (typically p < 0.05) suggest a significant association between the characteristic in question and the outcome probabilities. However, we kept in mind that we were performing dozens of such tests, and that we would expect approximately one in 20 com- Data Collection, Weighting, and Analytic Approach 111 parisons to be “significant” by chance alone (if there were no true, under lying differences). For this reason, we opted for a more stringent p- value (p < 0.01) for reporting of significant associa- tions. Even with the more stringent cutoff, we would expect some false positives due to chance alone given the large number of tests. Hence, we view the “significant” subgroup differences as exploratory findings that merit future surveillance rather than immediate action. Moreover, highlighted differences should be interpreted as associations rather than causal effects; it is pos- si ble that other unmea sured factors are driving apparent associations. Even so, these signifi- cance tests are useful for highlighting groups of respondents that may be experiencing more or less favorable outcomes than others. Changes over Time We also considered several methods for analyzing change over time. The simplest version of our analy sis does not include any covariates: it simply asks whether there is evidence that indi- viduals tend to report an improvement for a par tic u lar mea sure over time. If there were no systematic change over time, we would expect roughly the same number of individuals to improve as to worsen. On the other hand, if a significantly greater number of individuals report improvements than the number who report a worsening, we have evidence that there was systematic change over the time period in question. More specifically, we focused on the total number of individuals that reported an improvement for a par tic u lar question, which we denoted m. We then calculated the probability that the number of individuals who saw an improvement was greater than or equal to m (out of the number who reported a change), plus the probability that the number of individuals who saw a worsening was greater than or equal to m, if there were in fact no trend over time. (This assumes that the number of individuals who improved is greater than or equal to the number who worsened; if the opposite is true, m would be defined as the number who worsened.) As stated above, evidence of a change over time does not necessarily mean that the non- medical counseling program is responsible for that change. We might expect more prob lems to improve over time than to get worse, even if individuals were not able to access counseling ser vices. Even so, this approach allowed us to quantify the evidence that there was a change over time, even if we could not statistically iden- tify the root cause of that change. We also considered models that describe differences in a scale of changes. We began by cal- culating the change between a mea sure at one time point versus another. In most cases, reported worsening was rare. Because of this we used the following categories: Worsen, Stay same, Improve 1 point, Improve 2 points, etc. We then applied the ordered categorical model described above to describe this ordered outcome. Qualitative Methods Survey respondents had the option to provide open- ended responses to two questions assessing the perceived strengths and weaknesses of the non- medical counseling program (“What do you see as the major advantages or strengths of non- medical counseling offered by Military and Family Life Counseling [Military OneSource]?”; “What do you see as the major concerns or challenges related to non- medical counseling offered by Military and Family Life Counseling [Military OneSource]?”). Researchers used an iterative pro cess to develop a code book and code the strength and weakness responses according to recurring themes, based on the method for 112 An Evaluation of U.S. Military Non-Medical Counseling Programs coding open- ended survey questions described in Ryan and Bernard (2003). This approach involves reading text for themes and subthemes, determining a manageable list of codes to capture themes, building hierarchies of codes (code book), and applying the code book to a full dataset. The procedure for open- ended coding involved four research team members— two coders, a team leader, and a proj ect leader— who met on a weekly or biweekly basis to review the cur- rent coding scheme, develop new codes to reflect newly observed themes, consolidate or elimi- nate codes that seemed to be less common or overlapping, resolve any coding discrepancies to ensure consistent coding, and discuss the data collection timeline. The procedure led to two separate code books— one for the MFLC open- ended responses and one for the Military One- Source open- ended responses. Separate code books were necessary to account for the program- matic differences between the MFLC and Military OneSource programs. However, the team attempted to preserve consistency across the two code books as much as pos si ble by using the same codes for common themes pres ent across the programs (e.g., confidentiality, counselor skills, stigma, lack of follow- up). Two team members coded the MFLC and Military OneSource responses in de pen dently (one specifically coded MFLC responses and the other specifically coded Military OneSource responses). To check for intercoder reliability, the percent agreement score and Cohen’s kappa score was calculated for a sample set of MFLC and Military OneSource responses coded by both coders. Adequate reliability was determined with a percent agreement score of 85.5 percent and a kappa of 0.85. The score calculations were followed by a team discussion of coding dis- crepancies and strategies to maintain consistency. Additionally, ongoing discussions and itera- tion during the coding pro cess preserved consistency. The qualitative analy sis team calculated the frequency of each code and when pos si ble, collapsed low frequency codes (n < 7) with an overlapping existing code or under a new code. The team then transferred the final code books, open- ended responses, and select demographic data and survey responses to the qualitative data analy sis program Dedoose (version 7.0.23). 113 APPENDIX B Survey Instruments B.1 Wave 1 Survey Instructions on screen: We are interested in learning more about your recent experience with non- medical counseling through Military OneSource. We use the term “non- medical” to mean ser vices that relate to behavioral concerns, stress reduction, educational and other non- clinical issues. SECTION 1: PROB LEM TYPE PT1: Have you ever received non- medical counseling from a Military OneSource non- medical counselor for any of the following concerns? Check all that apply per row. 1. Yes, this was my most recent issue/concern 2. Yes, I have connected with a Military OneSource counselor about this in the past 3. I have never contacted a Military OneSource counselor about this issue a. Child issues (e.g., academic issues, behavioral concerns) 1 2 3 b. Family or relationship issues 1 2 3 c. Conflict resolution or anger management 1 2 3 d. Exceptional family member support 1 2 3 e. Stress, anxiety, or emotional prob lems 1 2 3 f. Deployment concerns or support 1 2 3 g. Reintegration concerns or support 1 2 3 h. Relocation/PCS concerns or support 1 2 3 i. Wounded warrior concerns or support 1 2 3 j. Loss or grief 1 2 3 k. Personal financial management 1 2 3 l. Employment assistance 1 2 3 m. Education assistance (for self or spouse) 1 2 3 n. Care for disabled or el derly adult 1 2 3 o. Other topic (specify__________) 1 2 3 Instructions on screen: For these next questions, please think about how your concern affected you or your family BEFORE you connected with Military OneSource. 114 An Evaluation of U.S. Military Non-Medical Counseling Programs PT2: Thinking about your most recent concern (e.g., behavioral, family), before you connected with Military OneSource for non- medical counseling, how would you rate the severity of your concern? Select one. 1. Low 2. Moderate 3. Severe 4. Very severe 9. Don’t know PT3: Think about how your concern made you feel before you reached out to a Military One- Source counselor. How often did the concern . . . ? For each item in the table below, select one response per row. 1. Very frequently 2. Frequently 3. Occasionally 4. Rarely 5. Never a. Make you feel stressed or anxious? 1 2 3 4 5 b. Interfere with your work? 1 2 3 4 5 c. Interfere with other daily routines? 1 2 3 4 5 d. Make it difficult to cope with day- to- day demands? 1 2 3 4 5 PT4: Thinking about your most recent concern, in addition to the Military OneSource coun- selors, did you also seek support from other individuals or providers? Select one. 1. Yes 0. No [skip to SR1] PT5: What other support ser vices helped you with this concern? Check all that apply. a. Private counselor or specialist b. Military family support program c. Military and Family Life Counseling d. Religious, or faith- based community e. Extended family members or friends f. Other? (Specify) ___________________ g. Don’t know SECTION 2: SERVICE RECEIPT AND PROB LEM RESOLUTION Instructions on screen: We are interested in learning more about your experience with the Military OneSource counselor and the ways in which your counselor has helped you address your non- medical concern. For the following questions, please think about your interactions with the Military OneSource counselor for your most recent non- medical concern. Survey Instruments 115 SR1 [Military OneSource only]: How did you meet with your counselor? 1. I met in- person with a counselor 2. I talked to a counselor over the telephone 3. I chatted online with a counselor 4. I met over a video link with a counselor SR2: Please rate the extent to which you agree or disagree with the following statements. Select one response per row. 1. Strongly agree 2. Agree 3. Neither agree nor disagree 4. Disagree 5. Strongly disagree 9. Not applicable a. My counselor showed interest in my questions and concerns. 1 2 3 4 5 9 b. My counselor listened to me carefully. 1 2 3 4 5 9 c. My counselor spent enough time with me. 1 2 3 4 5 9 d. My counselor explained things in a way that was easy for me to understand. 1 2 3 4 5 9 e. I left my counselors office with all of my questions answered. 1 2 3 4 5 9 f. My counselor was knowledgeable in the area of my specific concern. 1 2 3 4 5 9 g. My counselor provided the ser vices I needed. 1 2 3 4 5 9 h. My counselor connected me to outside support and ser vices. 1 2 3 4 5 9 i. My counselor connected me to medical ser vices. 1 2 3 4 5 9 j. My counselor (or Military OneSource call center) followed up with me to make sure I was able to connect with the outside supports and ser vices they recommended. 1 2 3 4 5 9 SR3: Please rate the extent to which you agree or disagree with the following statements. Select one response per row. NUMBER 1. Strongly agree 2. Agree 3. Neither agree nor disagree 4. Disagree 5. Strongly disagree 9. Not applicable a. My counselor addressed my cultural, language, or religious concerns. 1 2 3 4 5 9 b. My counselor understood military culture. c. It was easy to make appointments with my counselor to fit my schedule. 1 2 3 4 5 9 d. It was hard for me to get to my appointments with my counselor (e.g., due to lack of child care, transportation, office hours that didn’t work with my schedule). 1 2 3 4 5 9 116 An Evaluation of U.S. Military Non-Medical Counseling Programs PR1: How many Military OneSource sessions have you had to date related to this non- medical concern? 1. One 2. Two 3. Three 4. Four 5. Five 6. Six or more 7. Don’t know PR2: How would you rate the severity of this concern now? Select one. 1. Low 2. Moderate 3. Severe 4. Very severe 9. Don’t know PR3: Now that you have received non- medical counseling from Military OneSource, please rate how often this concern . . . ? Select one response per row. 1. Very frequently 2. Frequently 3. Occasionally 4. Rarely 5. Never a. Makes you feel stressed or anxious? 1 2 3 4 5 b. Interferes with your work? 1 2 3 4 5 c. Interferes with other daily routines? 1 2 3 4 5 d. Makes it difficult to cope with day- to- day demands? 1 2 3 4 5 PR4: Since receiving non- medical counseling ser vices from Military OneSource, how would you rate the level of stress in your work life? 1. Much less than before 2. Less than before 3. About the same as before 4. More than before 5. Much more than before 9. Not applicable PR5: Since receiving non- medical counseling ser vices from Military OneSource, how would you rate the level of stress in your personal life? 1. Much less than before 2. Less than before Survey Instruments 117 3. About the same as before 4. More than before 5. Much more than before 9. Not applicable PR6: Please rate the extent to which you agree or disagree with the following statements. Because of non- medical counseling provided by Military OneSource: 1. Strongly agree 2. Agree 3. Neither agree nor disagree 4. Disagree 5. Strongly disagree 9. Not applicable a. I connected with physical health care providers that I would not have on my own. 1 2 3 4 5 9 b. I connected with mental health care providers that I would not have on my own. 1 2 3 4 5 9 c. I connected with additional community ser vices that I would not have on my own. 1 2 3 4 5 9 d. I felt more prepared for deployment. 1 2 3 4 5 9 e. My family felt more prepared for deployment. 1 2 3 4 5 9 f. Reintegration after deployment was made easier. 1 2 3 4 5 9 g. My children felt better supported in school. 1 2 3 4 5 9 h. I wanted to stay in the military longer (or I wanted to remain a military family for a longer period of time). 1 2 3 4 5 9 PR7: Please describe your level of satisfaction with the following areas? Select one response per row. 1. Very satisfied 2. Satisfied 3. Neither satisfied nor dissatisfied 4. Dissatisfied 5. Very dissatisfied 9. Not applicable a. Continuity of care—(For example, seeing the same counselor for each session or another counselor who knew about my concern and what we had discussed during previous counseling sessions) 1 2 3 4 5 9 b. Counselor (or Military OneSource call center) follow-up to make sure I connected with ser vices that they had recommended 1 2 3 4 5 9 c. Counselor or program follow-up with me if I missed an appointment 1 2 3 4 5 9 d. Confidentiality of personal and family information 1 2 3 4 5 9 e. The types of resources and materials they gave to me (the materials were relevant to my concerns) 1 2 3 4 5 9 f. The number of resources and materials they gave to me 1 2 3 4 5 9 g. Counselor knowledge about my non- medical concerns 1 2 3 4 5 9 h. Professionalism of counseling staff 1 2 3 4 5 9 i. Speed with which I was connected to counseling staff 1 2 3 4 5 9 118 An Evaluation of U.S. Military Non-Medical Counseling Programs PR8: How likely is it that you will use Military OneSource the next time you have a non- medical concern? 1. Highly likely 2. Likely 3. Not sure 4. Unlikely 5. Very unlikely PR9 [Military OneSource only]: How likely is it that you would tell a friend to call Military OneSource for ser vices? 1. Highly likely 2. Likely 3. Not sure 4. Unlikely 5. Very unlikely PR10: What do you see as the major advantages or strengths of non- medical counseling offered by Military OneSource? [Open ended] Please do not include any personally identifiable information. PR11: What do you see as the major concerns or challenges related to non- medical counseling offered by Military OneSource? [Open ended] Please do not include any personally iden- tifiable information. Instructions on screen: If you have not been satisfied with your experience with Military One- Source, we encourage you to reach out to them directly by calling: 1-800-342-9647. This will allow Military OneSource to become aware of the specific situation, and to allow for better help with any prob lem you may have experienced. SECTION 3: PERSONAL INFORMATION Instructions on screen: This last set of questions asks a few questions about you so we can have a better understanding of who completed this survey. PI1: What is your gender? Select one. a. Male b. Female PI2: What is your military affiliation? Select one. a. Active duty b. Reserve c. National Guard d. Veteran e. Spouse/family member [skip to PI4] Survey Instruments 119 PI3. What is your ser vice? a. Army b. Navy c. Marine Corps d. Air Force e. Coast Guard PI4: What is your current relationship status? Select one. a. Married b. Separated c. Divorced d. Widowed e. Single, living with partner f. Single PI5: How many children do you have? Select one. a. None b. 1 c. 2 d. 3 e. 4 f. 5 or more PI6: What is the highest grade or year of school that you completed? Select one. a. Less than a High School Diploma/Equivalent (GED) b. High School Diploma/Equivalent (GED) c. Vocational/Technical Program After High School But No Vocational/Technical Diploma d. Vocational/Technical Diploma After High School e. College Coursework But No Degree f. Associate’s Degree g. Bachelor’s Degree h. Gradu ate or Professional Degree i. Other? (Specify) ___________________ Instructions on screen: Thank you for taking the time to fill out this impor tant survey. B.2 Wave 2 Survey Instructions on screen: About three months ago you completed a survey on the web asking about a recent experience you had with non- medical counseling through Military One- Source and how the issue/concern you sought help with had been addressed. We use the term 120 An Evaluation of U.S. Military Non-Medical Counseling Programs “non- medical” to mean ser vices that relate to behavioral concerns, stress reduction, educa- tional and other non- clinical issues. The issue/concern you indicated that you received counseling for was: [FILL IN PT1 = 1 RESPONSES FROM BASELINE] We are interested in learning more about your experiences with this issue/concern in the three months since you completed the initial survey. PR2: How would you rate the severity of this concern now? Select one. 1. Low 5. Moderate 6. Severe 7. Very severe 9. Don’t know PR3: Now that you have received non- medical counseling from Military OneSource, please rate how often this concern . . . ? Select one response per row. 1. Very frequently 2. Frequently 3. Occasionally 4. Rarely 5. Never a. Makes you feel stressed or anxious? 1 2 3 4 5 b. Interferes with your work? 1 2 3 4 5 c. Interferes with other daily routines? 1 2 3 4 5 d. Makes it difficult to cope with day- to- day demands? 1 2 3 4 5 PR4: Since receiving non- medical counseling ser vices from Military OneSource, how would you rate the level of stress in your work life? 1. Much less than before 2. Less than before 3. About the same as before 4. More than before 5. Much more than before 9. Not applicable PR5: Since receiving non- medical counseling ser vices from Military OneSource, how would you rate the level of stress in your personal life? 1. Much less than before 2. Less than before 3. About the same as before 4. More than before 5. Much more than before 9. Not applicable Survey Instruments 121 Instructions on screen: We are interested in learning more about your experience with the Military OneSource counselor and the ways in which your counselor has continued to help you address your non- medical concern. PR1: How many Military OneSource sessions have you received in the last three months related to your initial non- medical concern? 1. One 2. Two 3. Three 4. Four 5. Five 6. Six or more 7. Don’t know 8. I did not meet with a Military OneSource counselor in the past three months. SR1 [Military OneSource only]: How did you meet with your counselor? Check all that apply. 1. I met in- person with a counselor 5. I talked to a counselor over the telephone 6. I chatted online with a counselor 7. I met over a video link with a counselor 8. N/A. I did not meet with a Military OneSource counselor in the past three months. PT4: Thinking about this concern, in addition to the Military OneSource counselors, did you seek support from other individuals or providers in the past three months? Select one. 1. Yes 0. No (skip to SR1) PT5: What other support ser vices helped you with this concern in the past three months? Select all that apply. a. Private counselor or specialist b. Military family support program c. Military and Family Life Counseling d. Religious, or faith- based community e. Extended family members or friends f. Other? (Specify) ___________________ g. Don’t know 122 An Evaluation of U.S. Military Non-Medical Counseling Programs SR2: For the following questions, please think about your interactions with the Military One- Source counselor for your initial non- medical concern. Please rate the extent to which you agree or disagree with the following statements. Select one response per row. 1. Strongly agree 2. Agree 3. Neither agree nor disagree 4. Disagree 5. Strongly disagree 9. Not applicable a. My counselor showed interest in my questions and concerns. 1 2 3 4 5 9 b. My counselor listened to me carefully. 1 2 3 4 5 9 c. My counselor spent enough time with me. 1 2 3 4 5 9 d. My counselor explained things in a way that was easy for me to understand. 1 2 3 4 5 9 e. My counselor answered all of my questions. 1 2 3 4 5 9 f. My counselor was knowledgeable in the area of my specific concern. 1 2 3 4 5 9 g. My counselor provided the ser vices I needed. 1 2 3 4 5 9 h. My counselor connected me to outside support and ser vices. 1 2 3 4 5 9 i. My counselor connected me to medical ser vices. 1 2 3 4 5 9 j. My counselor (or Military OneSource call center) followed up to make sure I was able to connect with the outside supports and ser vices they recommended. 1 2 3 4 5 9 SR3: Please rate the extent to which you agree or disagree with the following statements. Select one response per row. 1. Strongly agree 2. Agree 3. Neither agree nor disagree 4. Disagree 5. Strongly disagree 9. Not applicable a. My counselor addressed my cultural, language, or religious concerns. 1 2 3 4 5 9 b. My counselor understood military culture. c. It was easy to make appointments with my counselor to fit my schedule. 1 2 3 4 5 9 d. It was hard for me to get to my appointments with my counselor (e.g., due to lack of child care, transportation, office hours that didn’t work with my schedule). 1 2 3 4 5 9 Survey Instruments 123 PR6. Please rate the extent to which you agree or disagree with the following statements. Because of non- medical counseling provided by Military OneSource: 1. Strongly agree 2. Agree 3. Neither agree nor disagree 4. Disagree 5. Strongly disagree 9. Not applicable a. I connected with physical health care providers that I would not have on my own. 1 2 3 4 5 9 b. I connected with mental health care providers that I would not have on my own. 1 2 3 4 5 9 c. I connected with additional community ser vices that I would not have on my own. 1 2 3 4 5 9 d. I felt more prepared for deployment. 1 2 3 4 5 9 e. My family felt more prepared for deployment. 1 2 3 4 5 9 f. Reintegration after deployment was made easier. 1 2 3 4 5 9 g. My children felt better supported in school. 1 2 3 4 5 9 h. I wanted to stay in the military longer (or I wanted to remain a military family for a longer period of time). 1 2 3 4 5 9 PR7: Please describe your level of satisfaction with the following areas. Select one response per row. 1. Very satisfied 2. Satisfied 3. Neither satisfied nor dissatisfied 4. Dissatisfied 5. Very dissatisfied 9. Not applicable a. Continuity of care (For example, seeing the same counselor for each session or another counselor who knew about my concern and what we had discussed during previous counseling sessions) 1 2 3 4 5 9 b. Counselor (or Military OneSource call center) follow-up to make sure I connected with ser vices that they had recommended 1 2 3 4 5 9 c. Counselor or program follow-up with me if I missed an appointment 1 2 3 4 5 9 d. Confidentiality of personal and family information 1 2 3 4 5 9 e. The types of resources and materials they gave to me (the materials were relevant to my concerns) 1 2 3 4 5 9 f. The number of resources and materials they gave to me 1 2 3 4 5 9 g. Counselor knowledge about my non- medical concerns 1 2 3 4 5 9 h. Professionalism of counseling staff 1 2 3 4 5 9 i. Speed with which I was connected to counseling staff 1 2 3 4 5 9 124 An Evaluation of U.S. Military Non-Medical Counseling Programs PR8: How likely is it that you will use Military OneSource the next time you have a non- medical concern? 1. Very likely 2. Likely 3. Not sure 4. Unlikely 5. Very unlikely PR9 [Military OneSource only]: How likely is it that you would tell a friend to call Military OneSource for ser vices? 1. Highly likely 2. Likely 3. Not sure 4. Unlikely 5. Very unlikely PT1: Think about the three months since you completed the first survey. During that time, did you receive non- medical counseling from a Military OneSource non- medical counselor for any of the following concerns? Check all that apply per row. 1. Yes, I connected with a Military OneSource counselor about this issue/concern in the past three months, since I completed the first survey 2. No, but I have connected with a Military OneSource counselor about this in the past 3. I have never contacted a Military OneSource counselor about this issue a. Child issues (e.g., academic issues, behavioral concerns) 1 2 3 b. Family or relationship issues 1 2 3 c. Conflict resolution or anger management 1 2 3 d. Exceptional family member support 1 2 3 e. Stress, anxiety, or emotional prob lems 1 2 3 f. Deployment concerns or support 1 2 3 g. Reintegration concerns or support 1 2 3 h. Relocation/PCS concerns or support 1 2 3 i. Wounded warrior concerns or support 1 2 3 j. Loss or grief 1 2 3 k. Personal financial management 1 2 3 l. Employment assistance 1 2 3 m. Education assistance (for self or spouse) 1 2 3 n. Care for disabled or el derly adult 1 2 3 o. Other topic (specify__________) 1 2 3 Survey Instruments 125 PR10: What do you see as the major advantages or strengths of non- medical counseling offered by Military OneSource? Please do not include any personally identifiable information. [Open- ended] PR11: What do you see as the major concerns or challenges related to non- medical coun- seling offered by Military OneSource? Please do not include any personally identifiable information. [Open- ended] Instructions on screen: If you have not been satisfied with your experience with Military One- Source, we encourage you to reach out to them directly by calling: 1-800-342-9647. This will allow Military OneSource to become aware of the specific situation, and to allow for better help with any prob lem you may have experienced. Instructions on screen: Thank you for taking the time to fill out this impor tant survey. 127 APPENDIX C Tables of Significant Subgroup Differences All models reported in this appendix control for client- level characteristics using the following covariates: gender; a three- category age variable ( under 25 years; 25–40 years; 41 years and above); whether the respondent was a ser vice member (as opposed to spouse or other family member); ser vice affiliation (Air Force, Army, Marines, Navy, or Coast Guard); component affiliation (active; reserve); officer or enlisted (self or sponsoring family member); and, in the case of MFLC, whether the counselor was embedded in the sponsoring ser vice member’s unit or not. We also included an indicator of the category for the primary presenting prob lem. See the relevant chapter text for a description of each effect reported in this appendix. Subgroup Differences in Prob lem Severity (Chapter Three) Prior to Non- Medical Counseling As noted in Chapter Three, we observed significant subgroup differences in precounseling prob lem severity by gender among MFLC participants, by ser vice affiliation for Military One- Source participants, and by prob lem type for both MFLC and Military OneSource partici- pants. Tables C3.1 (MFLC) and C3.2 (Military OneSource) provide additional detail on these significant differences. Table C3.1 Precounseling Ratings of Prob lem Severity by Gender and Prob lem Type Among MFLC Participants Subgroup Low (%) Moderate (%) Severe (%) Very Severe (%) Gender Women 4.6 24.8 36.8 33.9 Men 5.8 28.9 36.7 28.5 Prob lem type Child issues 8.3 36.6 35.2 19.8 Deployment concerns 8.1 36.0 35.4 20.5 Education or employment 8.2 36.3 35.4 20.1 Family or relationship 3.5 21.2 37.2 38.1 Loss or grief 5.2 27.8 37.9 29.1 Stress, anxiety, or emotional prob lems 6.8 32.8 36.9 23.5 NOTE: N = 2,358. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non- response. 128 An Evaluation of U.S. Military Non-Medical Counseling Programs In Short- Term Resolution of Prob lem Severity In Chapter Three we also noted that there were significant subgroup differences in short- term change in severity among MFLC participants. Table C3.3 provides additional detail on these significant differences. Table C3.2 Precounseling Ratings of Prob lem Severity by Prob lem Type Among Military OneSource Participants Prob lem Type Low (%) Moderate (%) Severe (%) Very Severe (%) Ser vice affiliation Air Force 3.7 33.8 38.7 23.9 Army 2.6 27.0 39.5 30.9 Marines 2.4 25.2 39.4 33.0 Navy 2.7 27.5 39.5 30.3 Prob lem type Child issues 3.9 35.2 38.4 22.5 Deployment concerns 5.9 43.7 34.5 15.9 Education or employment 3.4 32.3 39.2 25.2 Family or relationship 2.4 25.8 39.6 32.1 Loss or grief 3.4 32.4 39.2 25.0 Stress, anxiety, or emotional prob lems 3.6 33.6 38.9 23.9 NOTE: N = 2,519. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non- response. Table C3.3 Short- Term Changes in Prob lem Severity by Gender and Prob lem Type Among MFLC Participants Subgroup Worsened (%) Stayed the Same (%) Improved a Little (%) Improved a Lot (%) Gender Women 1.5 17.8 42.3 38.5 Men 1.9 21.4 43.8 33.0 Prob lem type Child issues 2.5 26.8 44.4 26.3 Deployment concerns 1.7 20.2 43.5 34.7 Education or employment 2.0 23.0 44.2 30.8 Family or relationship 1.5 17.7 42.4 38.5 Loss or grief 1.5 18.6 42.9 36.9 Stress, anxiety, or emotional prob lems 1.6 19.2 43.1 36.1 NOTE: N = 2,358. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non- response. Tables of Significant Subgroup Differences 129 In Long- Term Resolution of Prob lem Severity We observed significant differences by rank in long- term change in severity among Military One- Source participants. Table C3.4 provides additional detail on these significant differences. Subgroup Differences in Retention Intentions We also noted subgroup differences by active- duty status among Military OneSource partici- pants and their willingness to stay in the military as result of non- medical counseling ( Table C3.5). Subgroup Differences in the Resolution of Stress and Anxiety (Chapter Four) Prior to Non- Medical Counseling In Chapter Four, we noted that some groups of individuals were significantly more likely to report frequent or very frequent stress and anxiety than others prior to non- medical counsel- ing. Tables C4.1 (MFLC) and C4.2 (Military OneSource) provide additional detail on these significant differences. In the Short- Term Resolution of Stress and Anxiety In Chapter Four we also noted that there were significant subgroup differences in the short- term prob lem resolution of stress and anxiety. Tables C4.3 (MFLC) and C4.4 (Military One- Source) provide additional detail on these significant differences. Table C3.4 Long- Term Changes in Prob lem Severity by Rank Among Military OneSource Participants Subgroup Worsened (%) Stayed the Same (%) Improved (%) Rank (self or sponsoring family member) Officer 2.0 15.1 82.9 Enlisted 3.4 22.7 73.9 NOTE: N = 608. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non- response. Table C3.5 Willingness to Stay in the Military by Active- Duty Status Among Military OneSource Participants Subgroup Agree/Strongly Agree (%) Neither Agree nor Disagree (%) Disagree/Strongly Disagree (%) Active duty 37.8 39.9 22.3 Reserve and guard 48.3 36.0 15.7 NOTE: N = 999. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non- response. 130 An Evaluation of U.S. Military Non-Medical Counseling Programs Table C4.1 Precounseling Frequency of Stress or Anxiety by Subgroups; MFLC Subgroup Never or Rarely (%) Occasionally (%) Frequently or Very Frequently (%) Gender Women 4.5 9.0 86.4 Men 8.9 15.3 75.8 Prob lem type Child issues 10.7 17.2 72 Deployment 7.3 13.1 79.6 Education or employment 8.6 14.8 76.5 Family or relationship 5.0 9.6 85.4 Loss or grief 7.2 12.9 79.9 Stress, anxiety, or emotional prob lems 7.7 13.7 78.6 NOTE: N = 2,370. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non- response. Table C4.2 Frequency of Stress and Anxiety by Subgroups; Military OneSource (Marginal Means) Subgroup Never or Rarely (%) Occasionally (%) Frequently or Very Frequently (%) Ser vice affiliation Air Force 5.4 13.9 80.7 Army 4.3 11.6 84.1 Marines 3.1 9 87.9 Navy 3.9 10.7 85.5 Age 18–24 3.3 9.2 87.5 25–40 4.1 11.2 84.7 41 and over 5.2 13.5 81.2 Gender Women 3.1 9.1 87.7 Men 5.8 14.9 79.3 NOTE: N = 2,513. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non- response. Tables of Significant Subgroup Differences 131 Table C4.3 Short- Term Prob lem Resolution of Stress and Anxiety by Subgroups; MFLC Subgroup Got Worse (%) Stayed the Same (%) Improved (%) Gender Women 0.9 16.5 82.7 Men 1.2 21.8 81.2 Ser vice affiliation Air Force 0.9 17.4 81.7 Army 1.0 17.8 81.2 Marines 1.4 24.6 74.1 Navy 0.8 15.3 83.9 Counselor embedded Yes 1.1 19.7 79.3 No 0.8 15.0 84.3 NOTE: N = 2,370. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non- response. Table C4.4 Short- Term Prob lem Resolution of Stress and Anxiety by Subgroups; Military OneSource Subgroup Got Worse (%) Stayed the Same (%) Improved (%) Gender Women 1.7 24.6 73.6 Men 2.4 31.0 66.6 NOTE: N = 2,513. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non- response. Table C4.5 Short- Term Changes in Level of Personal Stress; Military OneSource Subgroup Much More Than Before (%) More Than Before (%) About the Same (%) Less Than Before (%) Much Less Than Before (%) Prob lem type Child issues 1.3 4.2 32.7 50.1 11.7 Deployment 0.4 1.3 14.0 53.7 30.6 Education or employment 1.3 4.3 33.2 49.7 11.5 Family or relationship 1.2 3.8 30.9 51.3 12.8 Loss or grief 1.5 4.8 35.6 47.9 10.2 Stress, anxiety, or emotional prob lems 1.1 3.7 30.2 51.8 13.2 NOTE: N = 2,479. Changes in level of stress in personal life was mea sured by a single item assessed at Wave 1. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non- response. In the Short- Term Changes in the Level of Stress in One’s Personal Life 132 An Evaluation of U.S. Military Non-Medical Counseling Programs Subgroup Differences in Interference with Work and Life (Chapter Five) Prob lem Interference with Work Prior to Non- Medical Counseling We observed no significant differences in precounseling ratings of prob lem interference with work by subgroups among MFLC participants at Wave 1. Among Military OneSource partici- pants, we observed significant precounseling differences by ser vice affiliation, component, and prob lem type (see Table C5.1). In Short- Term Resolution of Prob lem Interference with Work Analy sis revealed several significant subgroup differences in short- term changes in prob lem interference with work. Tables C5.2 (MFLC) and C5.3 (Military OneSource) provide addi- tional detail on these significant differences. Prob lem Interference with Daily Routines Prior to Non- Medical Counseling Among MFLC participants, at Wave 1 we observed significant differences in precounseling ratings of interference with daily routines by gender and prob lem type (see Table C5.4). Mili- tary OneSource participants demonstrated significant differences by ser vice affiliation and age (see Table C5.5). Table C5.1 Precounseling Ratings of Prob lem Interference with Work by Ser vice, Active- Duty Status, and Prob lem Type Among Military OneSource Participants, Wave 1 Subgroup Never or Rarely (%) Occasionally (%) Frequently or Very Frequently (%) Ser vice affiliation Air Force 36.8 29.5 33.7 Army 29.2 29.0 41.7 Marines 22.7 27.2 50.1 Navy 27.2 28.6 44.2 Active duty Yes 31.3 29.2 39.5 No 26.2 28.2 45.6 Prob lem type Child issues 35.3 29.5 35.2 Deployment 39.3 29.3 31.4 Education or employment 19.3 25.4 55.3 Family or relationship 30.4 29.1 40.5 Loss or grief 32.5 29.4 38.1 Stress, anxiety, or emotional prob lems 28.2 28.8 43.1 NOTE: N = 2,513. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non- response. Tables of Significant Subgroup Differences 133 Table C5.2 Short- Term Changes in Prob lem Interference with Work by Gender and Ser vice Among MFLC Participants, Wave 1 Subgroup More Frequent (%) The Same Frequency (%) Less Frequent (%) Gender Women 2.4 29.7 67.9 Men 3.1 35.2 61.7 Ser vice affiliation Air Force 2.7 32.2 65.1 Army 2.5 30.9 66.6 Marines 3.6 38.0 58.4 Navy 1.6 22.7 75.7 NOTE: N = 2,378. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non- response. Table C5.3 Short- Term Changes in Prob lem Interference with Work by Gender and Ser vice Member Status Among Military OneSource Participants, Wave 1 Subgroup More Frequent (%) The Same Frequency (%) Less Frequent (%) Gender Women 3.1 38.8 58.1 Men 4.2 45.5 50.3 Ser vice member status Family member 4.1 45.1 50.8 Ser vice member 3.2 39.8 56.9 NOTE: N = 2,513. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non- response. Table C5.4 Precounseling Ratings of Interference with Daily Routines Among MFLC Participants, Wave 1 Subgroup Never or Rarely (%) Occasionally (%) Frequently or Very Frequently (%) Gender Women 16.5 25.1 58.4 Men 20.7 27.7 51.7 Prob lem type Child issues 25.5 29.7 44.9 Deployment 19.5 27.1 53.4 Education or employment 21.8 28.3 49.9 Family or relationship 16.6 25.2 58.1 Loss or grief 14.6 23.5 61.9 Stress, anxiety, or emotional prob lems 19.2 27 53.8 NOTE: N = 2,381. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non- response. 134 An Evaluation of U.S. Military Non-Medical Counseling Programs Short- Term Resolution Prob lem Interference with Daily Routines We observed no differences for Military OneSource and significant differences by gender in short- term changes among MFLC participants ( Table C5.6). Long- Term Resolution Prob lem Interference with Daily Routines We observed differences by ser vice member status in long- term changes among Military One- Source participants (see Table C5.7). There were no subgroup differences for MFLC. Table C5.5 Precounseling Ratings of Interference with Daily Routines Among Military OneSource Participants, Wave 1 Subgroup Never or Rarely (%) Occasionally (%) Frequently or Very Frequently (%) Ser vice affiliation Air Force 19.8 29.5 50.7 Army 15.6 26.5 57.9 Marines 15.2 26.1 58.7 Navy 15.0 26.0 59.1 Other 17.7 28.1 54.1 Age 18–24 16.1 26.9 56.9 25–40 15.7 26.7 57.5 41 and older 19.7 29.4 51 NOTE: N = 2,513. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non- response. Table C5.6 Short- Term Ratings of Interference with Daily Routines Among MFLC Participants Subgroup Less Frequency (%) Same Frequency (%) More Frequently (%) Gender Women 75.6 22.6 1.9 Men 70.4 27.2 2.4 NOTE: N = 2,381. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non- response. Table C5.7 Long- Term Ratings of Interference with Daily Routines Among Military OneSource Participants Subgroup Less Interference (%) Same (%) More Interference (%) Ser vice member status Family member 44.9 37.9 17.2 Ser vice member 33.0 41.4 25.7 NOTE: N = 594. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non- response. Tables of Significant Subgroup Differences 135 Difficulty Coping with Day- to- Day Demands Prior to Non- Medical Counseling Among MFLC participants, at Wave 1 we observed significant differences in difficulty coping with day- to- day demands by gender and prob lem type (see Table C5.8), and Military One- Source participants demonstrated significant differences by ser vice affiliation and gender (see Table C5.9). There was a significant difference in changes from precounseling to three- month follow-up among MFLC participants with diff er ent prob lem types (see Table C5.10). Table C5.8 Precounseling Ratings of Difficulty Coping with Day- to- Day Demands Among MFLC Participants, Wave 1 Subgroup Never or Rarely (%) Occasionally (%) Frequently or Very Frequently (%) Gender Women 23.3 22.6 54.2 Men 30.9 24.7 44.4 Prob lem type Child issues 38.7 25.1 36.3 Deployment 27.4 23.9 48.7 Education or employment 29.3 24.3 46.4 Family or relationship 24.1 23 52.8 Loss or grief 20.6 21.4 57.9 Stress, anxiety, or emotional prob lems 28.8 24.2 46.9 NOTE: N = 2,382. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non- response. Table C5.9 Precounseling Ratings of Difficulty Coping with Day- to- Day Demands Among Military OneSource Participants, Wave 1 Subgroup Never or Rarely (%) Occasionally (%) Frequently or Very Frequently (%) Gender Women 22.4 26.0 51.6 Men 26.3 27.4 46.2 Ser vice affiliation Air Force 28.9 28 43.1 Army 22.4 26 51.6 Marines 20.7 25.2 54.1 Navy 21.9 25.8 52.3 NOTE: N = 2,516. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non- response. 136 An Evaluation of U.S. Military Non-Medical Counseling Programs Subgroup Differences in Connection to Ser vices and Referrals (Chapter Six) For both MFLC and Military OneSource participants, significant subgroup differences emerged by ser vice member status for connections with outside support and ser vices (see Table C6.1 for MFLC and Table C6.2 for Military OneSource). Compared to family members, ser vice mem- bers were more likely to agree or strongly agree with the statement “My counselor connected me to outside support and ser vices” (73 percent compared to 80 percent for MFLC; 60 percent compared to 68 percent for Military OneSource, respectively). We also observed subgroup dif- ferences by whether the MFLC counselor was embedded in the unit (see Table C6.3) and by ser vice member status for Military OneSource participants (see Table C6.4) who responded to the statement that “My counselor [or Military OneSource call center] followed up with me to make sure I was able to connect with the outside supports and ser vices they recommended.” Table C5.10 Long- Term Changes in Ratings of Difficulty Coping with Day- to- Day Demands Among MFLC Participants Subgroup More Frequent (%) The Same Frequency (%) Less Frequent (%) Prob lem type Child issues 28.7 32.5 38.8 Deployment 11.0 21.8 67.2 Education or employment 5.3 12.9 81.7 Family or relationship 9.1 19.3 71.6 Loss or grief 3.9 10.0 86.1 Stress, anxiety, or emotional prob lems 9.5 19.9 70.6 NOTE: N = 433. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non- response. Table C6.1 Perception of Connection to Ser vices Among MFLC Participants Subgroup Strongly Agree (%) Agree (%) Neither Agree nor Disagree (%) Disagree or Strongly Disagree (%) Ser vice member status Family member 56.6 16.8 16.2 10.3 Ser vice member 65.6 14.6 12.6 7.3 NOTE: N = 1,531. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non- response. Tables of Significant Subgroup Differences 137 Subgroup Differences in Non- Medical Counseling Experience (Chapter Seven) Ease of Making Appointments That Fit with Participant Schedule When asked about the extent to which they felt they were able to make appointments with the counselor so that it fits their schedule, we observed a significant difference among MFLC par- ticipants whose counselors were embedded in their unit (see Table C7.1). Table C6.2 Perception of Connection to Ser vices Among Military OneSource Participants Subgroup Strongly Agree (%) Agree (%) Neither Agree nor Disagree (%) Disagree or Strongly Disagree (%) Ser vice member status Family member 39.8 20.6 21.0 18.6 Ser vice member 47.7 20.1 18.0 14.2 NOTE: N = 1,488. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non- response. Table C6.3 Satisfaction with Follow- Up Among MFLC Participants Subgroup Very Satisfied (%) Satisfied (%) Neither Satisfied nor Dissatisfied (%) Dissatisfied or Very Dissatisfied (%) Counselor embedded Yes 65.5 19.8 10.2 4.5 No 56.2 23.5 13.8 6.5 NOTE: N = 1,448. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non- response. Table C6.4 Satisfaction with Follow- Up Among Military OneSource Participants Subgroup Very Satisfied (%) Satisfied (%) Neither Satisfied nor Dissatisfied (%) Dissatisfied or Very Dissatisfied (%) Ser vice member status Family member 49.1 31.9 12.2 6.8 Ser vice member 56.8 28.5 9.6 5.1 NOTE: N = 1,587. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non- response. 138 An Evaluation of U.S. Military Non-Medical Counseling Programs Continuity of Care We observed that MFLC participants whose counselor was embedded in their unit were more likely to report being very satisfied with continuity of care, relative to those whose counselors were not embedded (see Table C7.2). Among Military OneSource participants, there was a significant difference in continuity of care in presenting prob lem (see Table C7.3). Table C7.1 Ease of Making Appointments Among MFLC Participants Subgroup Strongly Agree (%) Agree (%) Neither Agree nor Disagree (%) Disagree or Strongly Disagree (%) Counselor embedded Yes 83.8 13.3 1.6 1.3 No 76.9 18.6 2.4 2.1 NOTE: N = 2,328. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non- response. Table C7.2 Continuity of Care Satisfaction for MFLC Participants Subgroup Very Satisfied (%) Satisfied (%) Neither Satisfied nor Dissatisfied (%) Dissatisfied or Very Dissatisfied (%) Counselor embedded Yes 76.3 17.2 3.9 2.5 No 69.2 21.8 5.4 3.6 NOTE: N = 1,969. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non- response. Table C7.3 Continuity of Care Satisfaction for Military OneSource Participants Subgroup Very Satisfied (%) Satisfied (%) Neither Satisfied nor Dissatisfied (%) Dissatisfied or Very Dissatisfied (%) Presenting prob lem Child issues 44.7 39.2 10.4 5.8 Deployment concerns 79.9 16.4 2.5 1.2 Education or employment 65.1 27.3 5.1 2.6 Family or relationship 61.4 29.7 5.9 3.0 Loss or grief 64.3 27.8 5.3 2.7 Stress, anxiety, or emotional prob lems 62.5 29.0 5.6 2.9 NOTE: N = 2,184. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non- response. Tables of Significant Subgroup Differences 139 Recommendation of Program to Others We noted significant differences in the likelihood of recommending Military OneSource ser- vices by ser vice member status (see Table C7.4). Subgroup Differences in Perceptions of Non- Medical Counselors (Chapter Eight) Professionalism Respondents were asked if their counselors showed interest in their concerns or questions. Among MFLC participants, we observed a significant difference by subgroup when asked about their satisfaction with their counseling staff’s level of professionalism (see Table C8.1). We observed a significant difference among Military OneSource participants by ser vice member status and gender (see Table C8.2). Communication Respondents were asked the extent that they agreed that their counselor listened to them care- fully. Significant subgroup differences were observed among Military OneSource participants in officer status and gender (see Table C8.3) Table C7.4 Recommendation of Military OneSource Ser vices Subgroup Highly Likely (%) Likely (%) Neither Likely or Unlikely (%) Unlikely and Very Unlikely (%) Ser vice member status Family member 80.5 13.9 3.6 2.1 Ser vice member 86.0 10.2 2.5 1.4 NOTE: N = 2,426. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non- response. Table C8.1 Level of Satisfaction with Counselor Level of Professionalism Among MFLC Participants, Wave 1 Subgroup Very Satisfied (%) Satisfied (%) Neither Satisfied nor Dissatisfied (%) Dissatisfied or Very Dissatisfied (%) Counselor embedded No 77.9 17.7 2.5 1.9 Yes 83.8 13.3 1.7 1.3 NOTE: N = 2,202. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non- response. 140 An Evaluation of U.S. Military Non-Medical Counseling Programs Information Was Explained in a Way That Was Easy to Understand Respondents reported the extent to which they agreed that information was explained to them in a way that made it easy for them to understand. Among MFLC participants, we observed a significant difference whether or not the counselor was embedded in their unit (see Table C8.4). We observed a significant difference among Military OneSource participants by ser vice member status and gender (see Table C8.5). Left Counselor’s Office with Questions Answered Respondents reported their perceived level of counselor adequacy in addressing participant issues or concerns by session completion. We observed significant differences across Military OneSource ser vice member status subgroups and Military OneSource gender subgroups (see Table C8.6). Table C8.2 Counselor Showed Interest in Questions and Concerns Among Military OneSource Participants, Wave 1 Subgroup Strongly Agree (%) Agree (%) Neither Agree nor Disagree (%) Disagree or Strongly Disagree (%) Ser vice member status Family member 66.1 29.0 2.5 2.3 Ser vice member 71.7 24.5 2.0 1.8 Gender Women 72.2 24.1 1.9 1.8 Men 66.3 28.8 2.5 1.4 NOTE: N = 2,540. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non- response. Table C8.3 Level of Agreement That Counselor Listened Carefully; Military OneSource Subgroup Strongly Agree (%) Agree (%) Neither Agree nor Disagree (%) Disagree or Strongly Disagree (%) Rank (self or sponsoring family member) Enlisted 68.1 27.4 2.3 2.1 Officer 73.3 23.2 1.8 1.6 Gender Women 72.0 23.7 2.0 2.3 Men 65.5 28.8 2.6 3.1 NOTE: N = 2,538. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non- response. Tables of Significant Subgroup Differences 141 Table C8.4 Level of Agreement That Information Was Explained in a Way That Was Easy to Understand Among MFLC Participants, Wave 1 Subgroup Strongly Agree (%) Agree (%) Neither Agree nor Disagree (%) Disagree or Strongly Disagree (%) Embedded in unit Not embedded 79.8 16.8 2.2 1.2 Embedded 85.3 12.4 1.5 0.8 NOTE: N = 2,367. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non- response. Table C8.5 Level of Agreement That Information Was Explained in a Way That Was Easy to Understand Among Military OneSource Participants, Wave 1 Subgroup Strongly Agree (%) Agree (%) Neither Agree nor Disagree (%) Disagree or Strongly Disagree (%) Ser vice member status Family member 62.0 30.4 4.8 3.0 Ser vice member 68.6 25.6 3.6 2.2 Gender Women 68.9 25.3 3.6 2.1 Men 62.7 29.9 4.6 2.8 NOTE: N = 2,524. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non- response. Table C8.6 Level of Agreement That Counselor Answered Questions Among Military OneSource Participants Subgroup Strongly Agree (%) Agree (%) Neither Agree nor Disagree (%) Disagree or Strongly Disagree (%) Ser vice member status Family 57.1 28.3 9.7 4.8 Ser vice member 64.1 24.6 7.6 3.7 Gender Women 64.6 24.3 7.5 4.5 Men 57.6 28.1 9.6 4.8 NOTE: N = 2,497. All results are adjusted for covariates and represent averaged fitted probabilities across the imputed datasets to account for item non- response. 142 An Evaluation of U.S. Military Non-Medical Counseling Programs Cultural Competency Respondents reported their level of agreement with the statement that “My counselor addressed my cultural, language or religious concerns.” A significant difference in the responses to this question was observed by rank for Military OneSource participants (see Table C8.7). Table C8.7 Perceived Cultural, Language, and Religious Competence Among Military OneSource Participants Subgroup Strongly Agree (%) Agree (%) Neither Agree nor Disagree (%) Disagree or Strongly Disagree (%) Rank (self or sponsoring family member) Enlisted 43.7 30.7 19.2 6.4 Officer 51.2 28.5 15.5 4.8 NOTE: N = 1,450. 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Schafer, Joseph L., “Multiple Imputation: A Primer,” Statistical Methods Medical Research, Vol. 8, No. 1, 1999, pp. 3–15. Sherman, Michelle, and Ursula Bowling, “Challenges and Opportunities for Intervening with Couples in the Aftermath of the Global War on Terrorism,” Journal of Con temporary Psychotherapy, Vol. 41, No. 4, 2011, pp. 209–217. Snyder, Douglas K., Molly F. Gasbarrini, Brian D. Doss, and David M. Scheider, “Intervening with Military Couples Struggling with Issues of Sexual Infidelity,” Journal of Con temporary Psychotherapy, Vol. 41, No. 4, 2011, pp. 201–208. Sörensen, Silvia, Martin Pinquart, and Paul Duberstein, “How Effective Are Interventions with Caregivers? An Updated Meta- Analysis,” Gerontologist, Vol. 42, No. 3, 2002, pp. 356–372. Tanielian, Terri L., Benjamin R. Karney, Anita Chandra, and Sarah O. Meadows, The Deployment Life Study: A Methodological Overview and Baseline Sample Description, Santa Monica, Calif.: R AND Corporation, RR-209, 2014. As of August 1, 2017: https://www.rand.org/pubs/research_reports/RR209.html Taranowski, Chester J., and Kathleen M. Mahieu, “Trends in Employee Assistance Program Implementation, Structure, and Utilization, 2009 to 2010,” Journal of Workplace Behavioral Health, Vol. 28, No. 3, 2013, pp. 172–191. Trail, Thomas E., Sarah O. Meadows, Jeremy N. Miles, and Benjamin R. Karney, “Patterns of Vulnerabilities and Resources in U.S. Military Families,” Journal of Family Issues, June 30, 2015. U.S. Department of Defense, Department of Defense Directive 5124.02, Washington, D.C., June 23, 2008. — — — , Report of the 2nd Quadrennial Quality of Life Review, Washington, D.C., 2009. — — — , Department of Defense Instruction 6490.06, Washington, D.C., April 21, 2009. Venables, W. N., and B. D. Ripley, Modern Applied Statistics with S- PLUS, 4th ed., New York: Springer, 2002. Weinick, Robin M., Ellen Burke Beckjord, Carrie M. Farmer, Laurie T. Martin, Emily M. Gillen, Joie D. Acosta, Michael P. Fisher, Jeffrey Garnett, Gabriella C. Gonzalez, Todd C. Helmus, Lisa Jaycox, Kerry A. Reynolds, Nicholas Salcedo, and Deborah M. Scharf, Programs Addressing Psychological Health and Traumatic Brain Injury Among U.S. Military Ser vice Members and Their Families, Santa Monica, Calif.: R AND Corporation, TR-950, 2011. As of August 1, 2017: http://www.rand.org/pubs/technical_reports/TR950.html http://www.army.mil/readyandresilient/ http://www.rand.org/pubs/technical_reports/TR950.html https://www.rand.org/pubs/research_reports/RR209.html 148 An Evaluation of U.S. Military Non-Medical Counseling Programs Weiss, Eugenia L., Jose E. Coll, Jennifer Gerbauer, Kate Smiley, and Ed Carillo, “The Military Genogram: A Solution- Focused Approach for Resiliency Building in Ser vice Members and Their Families,” Family Journal, Vol. 18, No. 4, 2010, pp. 395–406. Werber, Laura, Margaret C. Harrell, Danielle M. Varda, Kimberly Curry Hall, Megan K. Beckett, and Stefanie A. Stern, Deployment Experiences of Guard and Reserve Families: Implications for Support and Retention, Santa Monica, Calif.: R AND Corporation, MG-645, 2008. As of August 1, 2017: http://www.rand.org/pubs/monographs/MG645/ Westwood, Marvin J., Holly McLean, Douglas Cave, William Borgen, and Paul Slakov, “Coming Home: A Group- Based Approach for Assisting Military Veterans in Transition,” Journal for Specialists in Group Work, Vol. 35, No. 1, 2010, pp. 44–68. Wolchik, Sharlene A., Irwin N. Sandler, Roger E. Millsap, Brett A. Plummer, Shannon M. Greene, Edward R. Anderson, Spring R. Dawson- McClure, Kathleen Hipke, and Rachel A. Haine, “Six- Year Follow- Up of Preventive Interventions for Children of Divorce: A Randomized Controlled Trial,” Journal of the American Medical Association, Vol. 288, No. 15, 2002, pp. 1874–1881. World Health Organ ization, Prevention of Mental Disorders: Effective Interventions and Policy Options: Summary Report, Geneva, 2004. As of August 1, 2017: http://www.who.int/mental_health/evidence/en/prevention_of_mental_disorders_sr http://www.rand.org/pubs/monographs/MG645/ http://www.who.int/mental_health/evidence/en/prevention_of_mental_disorders_sr www.rand.org RR-1861-OSD 9 7 8 0 8 3 3 0 9 8 8 4 9 ISBN-13 978-0-8330-9884-9 ISBN-10 0-8330-9884-5 54300 $43.00 This report evaluates two programs offered by the U.S. Department of Defense (DoD) that provide short-term, solution-focused counseling for common personal and family issues to members of the U.S. military and their families. These counseling services are collectively called non-medical counseling within the DoD and are offered through the Military and Family Life Counseling (MFLC) and Military OneSource programs. RAND’s National Defense Research Institute was asked to evaluate these programs to determine whether they are effective in improving outcomes and whether effectiveness varies by problem type and/or population. Two online surveys were provided to program participants—the first two to three weeks after their initial session and the second three months later. Surveys were designed to gain information on 1) problem severity and overall problem resolution, 2) resolution of stress and anxiety, 3) problem interference with work and daily life, 4) connection to other services and referrals, 5) experiences with MFLC and Military OneSourceprograms, and 6) perceptions of non-medical counselors. The majority of participants experienced a decrease in problem severity and a reduction in reported frequency of feeling stressed or anxious as a result of their problem following counseling. These improvements were sustained or continued to improve in the three months after the initiation of counseling. Non-medical counseling was not universally successful, however, and a small minority expressed dissatisfaction with the program or their counselor. Collectively these findings suggest a number of policy implications and programmatic improvements of interest to program leadership in the Office of the Secretary of Defense. N AT I O N A L S E C U R I T Y R E S E A R C H D I V I S I O N http://www.rand.org

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