An Evaluation of U.S. Military Non-Medical Counseling Programs

Military families face normal stresses that most families face, such as financial strain, stressful life events, and relationship problems. 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 deployments can also place an unprecedented 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. 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 services offered by the U.S. Department of Defense (DoD).

The DoD provides different counseling supports depending on the needs and preferences of service members and their families. Under the Assistant Secretary of Defense for Health Affairs, the DoD provides psychological counseling and psychiatric treatment for psychological problems that are likely to cause severe impairment or distress, including medically diagnosable mental health conditions such as major depressive disorder, posttraumatic stress disorder, traumatic brain injury, or drug and alcohol abuse. Most of these problems are biologically based conditions that involve longer-term treatment with medications 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 services, 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 problems such as stress management, marital or other relationship problems, employment issues, parenting, and grief and loss, along with the particular challenges associated with military life, including deployment adjustment issues associated with separation and reintegration. Non-medical counseling services within the DoD provide access to a trained professional who can help individuals address a range of problems and identify potential strategies that will help overcome them. These services include referrals to other resources that provide direct assistance for problems (e.g., spouse education and employment programs), training on managing problems (e.g., personal financial counseling), and counseling to help resolve family or personal problems that do not require medical or behavioral health treatment (e.g., marriage counseling, stress reduction). Non-medical counselors rely on different types of therapeutic or educational techniques aimed at preventing problems (or stress resulting from problems) 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 centrally managed in the Office of Deputy Assistant Secretary of Defense for Military Community and Family Policy (ODASD [MC&FP]). Both the MFLC and Military OneSource programs are offered to members of the active and reserve components, and their families, for up to 12 sessions per person per presenting problem at no cost. Both programs offer confidential, free assistance to service 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, psychology) who are licensed in a state, U.S. territory, or the District of Columbia as an independent practitioner. If the problem 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 expertise. The MFLC program provides in-person confidential non-medical, short-term, solution-focused counseling services. A hallmark of the MFLC program is privacy and confidentiality. Military OneSource consultation and non-medical counseling services 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 process and satisfaction measures 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 RAND to evaluate MFLC and Military OneSource to better understand their impact on military members and their families. Specifically, RAND was asked to expand the focus of research beyond process measures to also include assessing the extent to which these counseling services result in successful resolution of clients' problems, explore whether there are notable differences in resolution by problem 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 service members and their families.

Evaluation Design and Approach

This evaluation was designed as two separate but parallel studies. While both MFLC and Military OneSource provide non-medical counseling services to military-connected individuals and families, they operate separately and there are important differences in the ways in which services 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 methods used by counselors to help participants resolve their problems. 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 problem and perceived impact on their life prior to counseling and an assessment of their problems' severity and perceived impact shortly after initiating non-medical counseling (i.e., short-term outcomes). Questions addressed respondents' problems, problem 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 measures but allowed us to examine changes over time in outcomes of interest, including problem 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 measure problem 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 minimum of a full calendar year to ensure that findings were not driven by any potential seasonal variation in non-medical concerns or service 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 OneSource 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 session of 30 minutes or more in an individual or couples setting. Service 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 participants, and those expressing interest in the study were invited by RAND via email to participate in an online survey. Counselors did not have access to participant responses.

Response rates for both MFLC and Military OneSource were low but not atypical for studies of military service members and their families (Miller and Aharoni, 2015). Comparisons to population-level characteristics of program users revealed that study participants were representative of the population on demographic characteristics and problem type, which suggests 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 problem resolution, 2) resolution of stress and anxiety, 3) interference with work and daily life, 4) connection to services and referrals, 5) perceptions of non-medical counseling programs, and 6) perceptions of non-medical counselors. This article contains an overview of our analysis of survey data in each of these areas.¹ Although the MFLC and Military OneSource studies were conducted as separate 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 Problem Resolution

We examined the type of problems for which individuals were seeking non-medical counseling and assessed whether—over the short term—the severity of the problem tended to decrease following non-medical counseling. The most common problems participants reported were family or relationship problems, followed by stress, anxiety, or emotional problems, and problems with conflict resolution or anger management. In general, most people who used non-medical counseling reported being able to resolve their problem 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 important proportion of participants did not experience a reduction in problem severity as a result of non-medical counseling, especially in the short term. More specifically, our analysis indicated that

• participants reported a statistically significant overall reduction in problem severity following non-medical counseling
• over 65 percent of individuals experienced a reduction in problem severity after they initiated counseling
• reductions in problem severity were maintained long term with over 80 percent of individuals reporting the same or improved problem severity three months after receiving counseling
• women tended to report greater short-term problem resolution than men
• open-ended responses suggest that the broader community of service 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 service members and their families may experience periods of heightened stress and anxiety as a result of the military lifestyle. Stress and anxiety affect everyone 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 individuals reported feeling stressed or anxious as a result of their problem 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 services. Key findings include the following:

• After initiating counseling, over 70 percent of individuals experienced a reduction in the frequency of feeling stressed or anxious as a result of their problem.
• 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 problem, compared to how they felt prior to receiving services.
• Reported levels of stress in one's 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 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 services.

Interference with Work and Daily Life

The problems that service 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 significant decrease in the frequency with which the problem 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 problem 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 problems 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 interference 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 problem interference with work and daily life that were maintained over the long term by the majority of participants. Military OneSource participants reported more modest short-term declines in problem interference with work and daily life, but the vast majority of Military OneSource participants reported declines three months later.

Connection to Services 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 services for which they are eligible and referrals to medical or behavioral health services when needed. We examined the extent to which participants in non-medical counseling were connected to additional services, how satisfied participants were with those referrals, and whether the program followed up with them to make sure they had connected with services. Our results indicated that, of the non-medical counseling participants who had sought additional support from other individuals or providers for their problem, most were connected with support and services 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 services. Among participants who reported that each question was applicable to their problem (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 services outside the program, over 65 percent indicated that they had been connected to those services.
• About 45 percent of participants reported that they needed referrals to medical services, and a little over half of those participants agreed that their counselor had connected them with medical services.
• Of the 38 percent of MFLC and 46 percent of Military OneSource participants who reported needing referrals to physical health services, only around 37 percent agreed that they had been connected with physical health services 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 services, and 69 percent of those participants agreed that they had been connected with mental health services they would not have connected with on their own.
• Over 81 percent of non-medical counseling participants who reported that their counselor referred them to outside services were satisfied or very satisfied with program follow-up to make sure they connected with recommended services.

Perceptions of Non-Medical Counseling Programs

MFLC and Military OneSource are meant to increase access to high-quality services and to help individuals connect to needed services that will address their problems. In addition to assessing the effectiveness of these services on outcomes related to problem resolution and impact of the problem 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 measured by willingness to use services again or recommend them to others. Our findings suggest that a large majority of participants expressed favorable perceptions of non-medical counseling programs. 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 appointment.
• Over 90 percent of participants were satisfied or very satisfied with the level of confidentiality received.
• Over 90 percent of individuals reported being satisfied or very satisfied with the continuity of care they received.
• Over 90 percent of participants reported that they would be likely or highly likely to use non-medical counseling services 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 program 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 everyone can access services 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 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 problem 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 professionalism, 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 analysis shows that a large majority of participants expressed favorable perceptions of non-medical counselors. While there was 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 professionalism of the counseling staff.
• Over 95 percent of participants strongly agreed that their counselor listened to them carefully 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 knowledgeable about their presenting problem.
• Over 75 percent of participants were satisfied or highly satisfied with the number of materials 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 services they needed to address their non-medical problems and related concerns.

Conclusions and Implications

Findings from this study, though not causal, suggest largely positive outcomes for the participants of these programs who reported reductions in problem severity, stress and anxiety, and less problem 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 initiation of counseling services. 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. 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 (OSD).

Policy Implications

• The MFLC and Military OneSource programs should continue to be offered to service members and families. MFLC and Military OneSource are two key components of the suite of services and programs offered by the DoD. With consideration of the programmatic changes suggested below, service members and their families would benefit from the continued availability of the MFLC and Military OneSource programs.
• 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 services.
• Consider opportunities to expand the program, though expansion should be informed by additional information or research that was beyond the scope of this project. Given the strength of findings, the DoD may wish to consider opportunities for program expansion, particularly in locations where such services do not currently exist. For the MFLC program in particular, 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

• Provide opportunities for ongoing support, guidance, and training for counselors. 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 important 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.
• Strengthen non-medical counseling for child-related concerns. Participants who sought counseling for child-related concerns, on average, reported lower levels of problem resolution and lower satisfaction with the continuity of care. By nature, these problems 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 have. Programs may benefit from working to strengthen delivery of services potentially through warm handoffs to counselors who hold this more specialized level of training.
• Identify ways to systematically collect counselor-level feedback and incorporate findings into performance review. While we did not collect information on individual counselors for the purposes of this study, both the MFLC and Military OneSource programs may benefit from systematically collecting counselor-level feedback to establish 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.
• Strengthen continuity of care. Satisfaction with continuity of care varied across respondents. This was particularly true for the MFLC program, where counselors were more likely to rotate prior to the full resolution of an individual's problem. This rotation often resulted in a need to start over with a new counselor, which was viewed as inefficient and disrupting of progress.
• Strengthen screening and connections to other services. Survey results and open-ended comments from participants suggest that non-medical counseling could benefit from strengthening connections to other services. About a quarter of participants who sought additional help for their problem reported seeing a private counselor or specialist. Counselor training should focus on the process 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 services may be helpful. In addition, results suggest the need to strengthen the continuity of care during the referral process by establishing a more formalized, warm handoff and follow-up procedure.
• Conduct research to better understand how to strengthen service delivery. Despite improvements in severity, stress, and anxiety among many participants, about 20 percent reported that they did not experience problem resolution as a result of non-medical counseling. The outcome measures 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 problem and by looking at outcomes more specific to the presenting problem. 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 medical or behavioral health treatment within the military health system and to link participants with additional resources to help them resolve their problems. They are thus a key component of the broader support offered to military service members and their families. Findings from this study suggest that, overall, the programs are successfully providing short-term, confidential, 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 recommendations offered here can be used by OSD to further strengthen these programs.