The FOCUS Family Resilience Program AnInnovative Family Int.docx

The FOCUS Family Resilience Program: An
Innovative Family Intervention for Trauma and Loss
WILLIAM R. SALTZMAN*,†
This article describes the core principles and components of the
FOCUS Program, a brief
intervention for families contending with single or multiple
trauma or loss events. It has
been administered nationally to thousands of military family
members since 2008 and has
been implemented in a wide range of civilian community,
medical, clinical, and school set-
tings. Developed by a team from the UCLA and Harvard
Medical Schools, the FOCUS Pro-
gram provides a structured approach for joining with traditional
and nontraditional
families, crafting shared goals, and then working with parents,
children, and the entire
family to build communication, make meaning out of traumatic
experiences, and practice
specific skills that support family resilience. Through a
narrative sharing process, each
family member tells his or her story and constructs a timeline
that graphically captures the
experience and provides a platform for family discussions on
points of convergence and
divergence. This narrative sharing process is first done with the
parents and then the chil-
dren and then the family as a whole. The aim is to build
perspective-taking skills and
mutual understanding, to reduce distortions and misattributions,

and to bridge estrange-
ment between family members. Previous studies have confirmed
that families participating
in this brief program report reductions in distress and
symptomatic behaviors for both par-
ents and children and increases in child pro-social behaviors
and family resilient pro-
cesses.
Keywords: Family Resilience; Family Therapy; Trauma; Loss;
Narrative; Medical
Trauma
Fam Proc 55:647–659, 2016
INTRODUCTION
Converging developments in public policy and research are
influencing standards ofclinical and community-based practice
to include family-centered, strength-based pre-
ventive services. A growing literature confirms the
effectiveness of manualized family-cen-
tered preventive interventions for a wide spectrum of stressful,
traumatic, and loss
experiences (Rozensky, Celano, & Kaslow, 2013; Lucksted,
McFarlane, Downing, Dixon,
& Adams, 2012; Weisz & Kazdin, 2010; NRCIOM, 2009a). This
includes parental depres-
sion (Beardslee, Wright, Gladstone, & Forbes, 2007),
bereavement (Sandler et al., 2003),
substance use (Lochman & Steenhoven, 2002), parent and child
medical illness
(Rotheram-Borus, Lee, Lin & Lester, 2004), natural disasters
(Gewirtz, Forgatch, & Wiel-
ing, 2008), parental divorce (Wolchik et al., 2002), and military
deployment and associated

parental physical and psychological injury (Lester et al., 2016;
Cozza, 2015; Institute of
*UCLA Semel Institute for Neuroscience and Human Behavior,
Los Angeles, CA.
†Advanced Studies in Education & Counseling, California State
University, Long Beach, CA.
Correspondence concerning this article should be addressed to
William R. Saltzman, PhD, 2179 Kin-
neloa Canyon Rd., Pasadena, CA 91107. E-mail:
[email protected]
647
Family Process, Vol. 55, No. 4, 2016 © 2016 Family Process
Institute
doi: 10.1111/famp.12250
Medicine, 2014). Furthermore, there is growing interest in how
to implement and dissemi-
nate effective evidence-based strategies widely in order to have
a population-level impact
(Beardslee, Klosinski, Saltzman, Lester, 2013; Biglan, Flay,
Embry, & Sandler, 2012;
NRCIOM, 2009b).
This article describes the FOCUS Family Resilience Program, a
family-centered,
strength-based program that is designed to flexibly address the
needs of diverse pop-
ulations contending with a wide range of trauma or loss
experiences. This program
was initially developed by a team from the UCLA and Harvard
medical schools for

military families experiencing difficulties related to the stresses
of multiple wartime
deployments and parents returning with psychological or
physical injuries (Saltzman
et al., 2009). It has also been widely implemented in civilian
community mental
health, medical, and school settings. Findings from large-scale
longitudinal studies
indicate that this brief program is effective in reducing parental
posttraumatic stress,
anxiety, and depression along with child behavioral and
emotional difficulties, while
improving overall family functioning and child pro-social
behaviors, and that these
improvements sustain and even increase after cessation of the
intervention (Lester
et al., 2012; Lester et al. 2016; Saltzman, Lester, Milburn,
Woodward, & Stein,
2016).
Of great interest, secondary analyses employing structural
equation modeling show
that the improvements in parent and child adaptive functioning
are mediated by improve-
ments in specific aspects of family resilient functioning (Lester
et al., 2013; Saltzman
et al., 2016). Causal mapping of this relationship supports key
assumptions of family resi-
lience theory: that family resilient processes contribute to the
adaptation of family mem-
bers and that these interactive characteristics are amenable to
change (Patterson, 2002;
Walsh, 2016). Further, family-level interventions designed to
enhance resilient processes
may be useful tools for promoting sustainable positive
adaptation in the wake of trauma

and loss events (Saltzman et al., 2011; Walsh, 2007).
Program Development and Implementation
The FOCUS Family Resilience Program drew upon three
evidence-based family-
and trauma-focused interventions that had been evaluated
through randomized control
designs in various contexts (Beardslee, Wright, Gladstone &
Forbes, 2007; Layne
et al., 2008; Rotheram-Borus, Lee, Lin & Lester, 2004). The
resulting program was
piloted with active-duty military families and then standardized
for broader implemen-
tation (Saltzman et al., 2009). Through a national dissemination
sponsored by the
U.S. Navy Bureau of Medicine and Surgery and the U.S.
Department of Defense
Office of Community and Family Policy, hundreds of thousands
of service members
and their families have received FOCUS services over the past 7
years (Lester et al.,
2016; Beardslee, Klosinski & Saltzman 2013).
Concurrently, FOCUS has also been implemented across
multiple civilian settings
including county-wide departments of mental health, school
districts, numerous commu-
nity mental health clinics, and at selected service sites within
the SAMHSA National
Child Traumatic Stress Network (Saltzman, Bartoletti, Lester, &
Beardslee, 2014). The
range of families served include culturally and racially diverse,
single- and dual-parent
and foster adoptive families, immigrant families, and families
dealing with community

violence, serious and chronic illness, domestic violence and
child removal/reunification,
parental substance abuse and mental illness, and death of a
family member (Saltzman,
Pynoos, Lester, Layne, & Beardslee, 2013). Most recently,
program adaptation for serious
and chronic illness is being piloted at a comprehensive cancer
center, with a randomized
controlled study of program effectiveness.
www.FamilyProcess.org
648 / FAMILY PROCESS
Given the geographic dispersal and difficulty accessing mental
health services for
many military and high-need civilian families, a telehealth
version of the program
has also been developed so that families may engage in these
services at home
(Beardslee et al., 2013). Additional web- and smart phone-based
applications have
been developed to further support this distance delivery
approach to family resilience
enhancement (UCLA NFRC, 2013).
PROGRAM DESCRIPTION
The FOCUS Program is designed to offer “selected” preventive
services to families
exposed to significant levels of stress or loss who may be at risk
for psychological distur-
bance or impaired adaptation and “indicated” preventive
services to families who may

already present with significant psychological or behavioral
impairment. The program is
administered by masters- and doctoral-level, FOCUS-trained
clinicians (called Resiliency
Trainers (RT) in some settings). It is designed to reduce the
likelihood of problematic out-
comes for families and members who are “at risk” due to stress,
trauma, or loss and to sup-
port the recovery of symptomatic family members by mobilizing
supportive and resilience-
enhancing processes within the family. For significant
psychological disturbance, referrals
for more intensive forms of treatment are provided that may be
enlisted concurrently with
FOCUS participation.
The intervention program, combining and adapting methods
from strength-based fam-
ily systems approaches (Goldenberg & Goldenberg, 2013;
Lebow & Uliaszek, 2010), is
organized around five core elements and associated activities
that are based on principles
of family resilience (Walsh, 2006, 2016). These are described as
follows.
Eliciting Family Systemic Goals
The FOCUS clinician is skilled at eliciting and distilling the
family core concerns and
making sure the family members feel heard. During the initial
sessions, family members
are helped to move from a simple fault and blame understanding
of the presenting issues
to a systemic formulation which provides specific and concrete
examples of how all family
members have a part in the current cycle or problematic pattern.

More important in this
framing, each family member also has a part to play in the
family’s healing or return to
better functioning. A brief set of psychological health and
family assessments are admin-
istered that can be quickly scored and used to provide guided
feedback to the provider
and family. The assessment data and summarized family
interview information are used
to craft initial goals for the program that will customize the
ensuing intervention.
Providing Family Psycho-Education and Developmental
Guidance
Family resilience theory has emphasized the importance of
normalizing and contextual-
izing distress reactions common in situations of trauma and loss
(Walsh, 2003). This
approach brings a developmental lens to this effort to
understand expectable emotional
and behavioral reactions for children of specific ages. This
enables parents to normalize
and distinguish transient and expectable reactions from more
worrisome presentations
that may require professional attention. Family members may
also be aided by pragmati-
cally detailed information about the interpersonal and familial
impact of psychological or
medical conditions, and related treatment. This can help frame
medication or symptom-
based reactions such as irritability, disengagement, and
cognitive impairment as shared
challenges and reduce blame or guilt. In all cases, information
and guidance are woven
into conversation with family members, specific to their

presentation and needs, thereby
facilitating action.
Fam. Proc., Vol. 55, December, 2016
SALTZMAN / 649
Developing Shared Family Narratives Using Innovative
Timeline Technique
Trauma and loss experiences are inherently complex with many
separate moments in
which family members will have different types and degrees of
exposure to upsetting
events and come away with different interpretations and
possible misunderstandings of
others’ intentions and actions. This frequently leads to
breakdowns in family communica-
tion, shared meaning-making, cohesion, and support: essential
building blocks for a resili-
ent collective response (Walsh, 2006). The FOCUS Program
provides a structured
opportunity for each family member to tell and share his or her
story, facilitated by an
innovative timeline technique. Expanding the use of timelines in
individual developmen-
tal research (Masten & Narayan, 2012) and in family therapy
(McGoldrick, Gerson, &
Petry, 2008), this technique graphically captures each member’s
experience and provides
a platform for family discussions.
This narrative sharing process is first done with the parents and
then the children and

then the family as a whole; moving from individual “silo-ed”
stories to a shared under-
standing of what they have been through together. The simple
process of sharing and
bearing witness to each other’s narrative in a safe and
structured way initiates a process
whereby family members are able to gather essential context,
clarify distortions and
misattributions, bridge estrangements, and begin to rebuild or
strengthen communica-
tion, cohesion, and support. The program provides scaffolding
for these encounters and
helps move the family down the long road of making sense and
shared meaning of the
events.
Supporting Open and Effective Communication
A hallmark of a resilient family is direct, clear, consistent, and
honest communication
and the capacity to tolerate open expression of emotion (Walsh,
2003, 2006). These charac-
teristics are especially important for families experiencing
stress and change, given that
unclear, distorted, or vague communication can rob family
members of the essential tools
for successfully adapting to these challenges. Moreover, when
parents withhold or “put a
happy face” on communications about serious or difficult issues
children often fill in the
blanks with their worst imaginings (Greene, Anderson,
Hetherington, Forgatch, &
DeGarmo, 2003). It is important to work within the personal and
cultural framework of
each family and help them to find appropriate ways to invite
sharing of a wide range of

feelings and respect differences.
Enhancing Selected Family Resilience Skills
Specific parent skill sets and family-level coping strategies can
help families antici-
pate and mitigate the impact of stressful events and situational
triggers and improve
child adjustment (Saltzman et al., 2009; Spoth, Kavanagh, &
Dishion, 2002). Random-
ized controlled trials of resilience-enhancing child and family
interventions have iden-
tified specific skills as effective in improving individual and
family-level outcomes over
time (Beardslee et al., 2007; Layne et al., 2008). We model and
facilitate core transac-
tional skills in stress management and emotion regulation,
collaborative goal setting
and problem solving, and managing trauma and loss reminders,
fitting each family’s
unique strengths and areas of needed growth. For example, by
practicing in sessions
and at home, family members build skills to collectively manage
stress by identifying
and anticipating stressful situations, monitoring idiosyncratic
expressions of distress
among different family members, and providing support in a
timely and developmen-
tally appropriate manner. As needed, session time may focus on
helping parents work
together, productively negotiate decisions and disagreements,
and balance the family

organizational needs for flexibility and the maintenance of
consistent structure and
care routines (Walsh, 2016).
OVERVIEW OF SESSIONS
The intervention is generally delivered over eight sessions: the
first two with the par-
ents, the second two with the children, a fifth session with the
parents to prepare for the
family sessions, and then a series of three family sessions. The
program is flexible so that
the number of meetings may vary to fit the needs, capacities,
and availability of family
members. The program has been used with a wide range of
family constellations and the
clinician may flexibly determine which parent(s) or caregiver
should participate and
whether to include extended family members.
During the initial parent session, parents fill out the family
resilience assessment pack-
age that includes brief measures of parent depression, anxiety,
posttraumatic stress and
family resilient functioning, and a measure of child adaptive
functioning, and are helped
to describe their current concerns, challenges, and wishes for
their family. When possible,
the measures are administered on laptops and automatically
scored rendering user-
friendly summaries. The clinician incorporates the assessment
feedback and the parents’
input to frame initial goals for the family’s participation in the

program.
After goals are collaboratively developed with the parents, the
clinician maps out the
range of family needs and objectives with the understanding
that the FOCUS Program
can address some but not all of the issues. A sequenced plan is
discussed that draws upon
the resources and evidence-based practices offered within the
host organization and com-
munity. Parents may be advised to participate first in FOCUS or
to avail themselves of
other more urgently needed services (e.g., services for
substance use, depression manage-
ment, domestic violence, abuse or neglect, or even forms of
legal advocacy). Thus, FOCUS
offers a brief and flexible family module that is designed to
mobilize family strengths and
enhance key family capacities and may be used synergistically
with other evidence-based
programs such as Trauma-Focused Cognitive Behavior Therapy
(TFCBT) or Parent–Child
Interaction Therapy (PCIT). In fact, FOCUS is used in this way
as an initial engagement
and planning module for many community mental health
organizations and providers.
From the very beginning and throughout the program, psycho-
education on child devel-
opment issues and the family impact of trauma and loss
experiences is woven into discus-
sions. Based on the family goals, skill training and home
practice are also employed to
help the family make incremental progress in desired directions.
During the second parent session, the clinician usually begins

the process of eliciting
parent narratives and graphically rendering the narrative
timeline on a large piece of
paper, usually taped to a wall, that both parents can view. (A
simplified version of a parent
timeline based on a case example is shown in Figure 1.) Prior to
constructing their narra-
tives, parents are instructed on using the “feeling thermometer”
(on the vertical axis of
the timeline) as a means to describe their own levels of distress.
It provides a means to cal-
ibrate higher and lower points on the personal timeline with
more highly stressful or less
stressful experiences.
One parent or partner at a time is directed to share his or her
narrative while the other
bears witness. The listening partner is advised to not make
comments during the sharing
even if he or she has a very different recollection or
understanding of what “really” hap-
pened. It is assumed each will have very different views even of
the same events. The lis-
tening spouse is reassured that he or she will have a turn and
that this is an opportunity
to see things “through your partner’s eyes.”
In addition to drawing the timeline, the clinician also writes
down any key words or
phrases from the narrative that denote strong feelings or
attributions about self or others
SALTZMAN / 651

that may reflect distorted or potentially problematic perceptions
or beliefs (e.g., “I was so
stupid, I should have known . . .,” “It was my fault,” “You
never trusted me. . .,” “My life
ended then”). These will be revisited when both timelines have
been drawn and the clini-
cian summarizes the similarities and differences of each and
facilitates a discussion on
key points of divergence. These junctures frequently represent
points at which communi-
cation or support lessened or the spouses became distant or
estranged. During the subse-
quent discussion, distortions and misattributions can be
corrected and previously rigid
positions softened by better understanding the partner’s
experience.
The set of child sessions orient children to the program, collect
assessment data, elicit
current concerns and wishes, begin developmentally appropriate
psycho-education, and
elicit personal narratives. The initial meeting is often with all
children; then individual
sessions elicit their narratives. Depending on children’s ages,
they may do a similar time-
line as the parents or, for younger children, a “time map”
structured like a game-board
with spaces for the child to draw or describe important events
and experiences. Once
again, key phrases or words denoting important or problematic
assumptions, interpreta-
tions or beliefs are written down on the timeline. Children are
also helped to identify con-
cerns or questions they would like to bring up at the family

session.
Next, one or two parent preparation meetings are held to review
key portions of the chil-
dren’s timelines and questions so that the family sessions go
well and that the parents are
able to play an effective leadership role. Parents are helped to
respond to even volatile and
sensitive issues in an open and productive manner while sharing
appropriate portions of
their backstory. They practice skills to listen and respond
empathically to the children’s
narratives and questions.
Parental Timeline
Home Deploy 1 Home Deploy 2 Past
Month
Mother
Father
Death of
Buddy
Parent
Arguments
Children
Having
Problems
Painful
Goodbye

Delayed
Homecoming
Move
FIGURE 1. Timeline drawn to represent narratives of the
parents in the example.
The first family session is devoted to sharing family members’
narratives and
addressing their differences in experiences and interpretations.
This session usually
has the children sharing their timelines or time maps, with the
parents filling in rel-
evant context. The clinician guides conversations to address
past interpretations and
misunderstandings that are often related to current conflicts.
The intention is to
move from individual narratives to a shared narrative that
incorporates the unique
experiences of each family member and supplies contextual
information that helps
family members better understand and make sense of the events
they have been
through. Subsequent family sessions focus on applying selected
resilience skills to
specific family issues and problems, anticipating upcoming
individual and family
challenges, and developing shared family strategies for

maintaining good communica-
tion and support.
CASE EXAMPLE: THE PEARSONS
The following are excerpts from a composite case seen by
FOCUS clinicians.
Brandon (32) and Andrea (29) and their son Ethan (9) were seen
for FOCUS services. Brandon is
a career Marine and has been deployed twice with minimal time
in-between. Three years ago they
moved from North Carolina to California. Since returning from
his last deployment Brandon and
Andrea have experienced increased conflict and Ethan has had
behavior problems at school and
home. Prompted by her distress and concerns, Andrea sought
out family services.
During the initial parent sessions, the clinician engaged with the
parents and began
the collaborative process of learning about their concerns,
problems, and wishes, as well
as their strengths and past successes, and then translating these
into a set of shared goals
appropriate for this brief family program. Three parent sessions
were needed to elicit sep-
arate narratives from each and discussing the points of
convergence and divergence on
their overlapping timelines as well as experiences that evoked
strong reactions from either
spouse (Figure 2).
The first point of divergence was during their move West prior
to the first deployment.
Brandon was surprised at her stress elevation for the relocation

as he thought this was a
positive career move and opportunity for the entire family.
Andrea explained how she
tried to be positive and supportive of him but she found it very
difficult to leave behind her
friends and family, and experienced a sense of isolation in their
new home on base. In the
ensuing discussion, she was helped to describe her difficulties
with the transition and her
previously unexpressed anger because she did not feel she had
input into the decision to
move. After first arguing the point, Brandon was helped to
acknowledge her feelings and
recognize that “we were living in two different worlds on that
one.”
The next point of the timeline at which the clinician had noted
emotionally charged
comments from Brandon involved his leaving for his first
deployment. He experienced a
“painful goodbye” when his son Ethan refused to look at him or
speak with him. Brandon
shared that he thought Ethan was very angry at him for leaving
and breaking his promise
to go camping that summer. Even during Skype calls, he felt
that Ethan continued to be
resentful. This was new information for Andrea and she
expressed sympathy, insisting,
however, that she did not think Ethan felt that way.
The next important point on the timeline involved Brandon’s
witnessing of the death of
a friend who was a member of his unit. Brandon was guided to
not share graphic details of
the death but to focus on the impact of the event on him. He
spoke about his shock, fear,

and anger at the time and then the long-term sadness and
second-guessing that seemed to
haunt him, wondering if he could have done anything to prevent
the death. Andrea said
that she knew of his loss, but this was the first she fully
appreciated how he still thought
SALTZMAN / 653
about what happened and wondered if this contributed to his
current episodes of low mood
and tendency to isolate himself.
This discussion affected their processing of the next point of
timeline divergence, when
Brandon delayed his homecoming without informing the family.
Andrea and Ethan had
expected him on a specific date and arranged a homecoming
party. They were very disap-
pointed to learn at the last moment that he had decided, without
checking in, to voluntar-
ily extend his deployment. Andrea was furious at the time and
wondered if he did not
want to come home. In the ensuing discussion, Brandon tried to
explain how torn he was
at that juncture, both wanting to come home and yet not wanting
to leave his unit, as most
of them had extended their stay to complete their assignment. In
light of the death of their
buddy, this made more sense to Andrea than previously.
Brandon conceded that he should
have checked in with her on the decision.

Brandon and Andrea then discussed their experiences during the
second deployment,
when they both felt distant. Andrea noted that Brandon’s calls
home became short and
business-like and that both she and Ethan felt he came across as
if he did not miss them.
Brandon described how his worry about the family peaked
during this period, prompted in
large part by feeling helpless to do anything about ongoing
problems with Ethan and with
their finances. He said that his response was to “go on
emotional lockdown.” While not
resolving the issues, both experienced greater mutual
understanding.
In light of Brandon’s wartime experiences and repeated
references to his irritability,
mood changes, and sleep difficulties, the clinician explored the
couple’s understanding of
PTSD and whether they thought that this was part of the current
picture. Both said that
they had thought about it. Brandon had taken a screening after
his last deployment,
which had been negative. The clinician provided normalizing
information on common
FIGURE 2. Representation of Time Map and associated
drawings by the son in the example.

stresses and reactions with relocations, deployments, and war-
related trauma and loss,
contextualizing each member’s distress and the impact on
family relationships. The clini-
cian provided some materials on PTSD and they agreed to return
to the topic in later ses-
sions.
The final portion of the timeline review addressed experiences
during the past month.
Brandon and Andrea focused on recent blowups regarding their
different approaches to
responding to Brian’s challenging behavior at home and reports
of his difficulties at
school. As one of their shared goals was to better coordinate
their parenting, time was allo-
cated to developing a plan with specific joint actions, to be tried
as an “experiment” during
the next week. A second goal was to increase family closeness.
Toward that end, they
decided to plan for two sit-down family dinners with the TV off
during the upcoming week.
In conclusion, the clinician commented on specific family
strengths shown in their narra-
tives and praised their dedication to each other and their family.
Misunderstandings and omissions of personal information are
frequently at the heart
of conflicts and enduring family estrangements. In processing
these differences, parents
are able, at least briefly, to step away from their own
entrenched views and gain an appre-
ciation of the partner’s experience and the context for behaviors
that may have been
misunderstood and judged harshly. While differences of opinion
and negative judgments

may persist, this perspective-taking exercise usually softens
positions and enables greater
collaboration. At the end of the parental narrative sharing and
processing, it is often possi-
ble to refine or recast the goals for their relationship and the
family.
The first child session with Ethan focused on a playful activity
using a large color-coded
feeling thermometer (bottom quarter colored green, for fun or
relaxing experiences, next
quarter yellow, for experiences that were a little stressful or
uncomfortable, next quarter
orange, for more stressful experiences, and the top quarter red,
for very stressful or highly
distressing experiences) with prompts to describe recent
experiences within each color
zone. The clinician then wrote them on the poster next to the
appropriate part of the ther-
mometer. Referencing Ethan’s “orange and red,” moderately to
very stressful experiences,
she then guided a conversation on ways that he would like
things to be better or different.
This led to some personal goals from Ethan’s point of view. The
clinician also helped to
normalize and provide context to his “orange and red”
experiences that centered on sad-
ness over his father having to go away and his moodiness when
he returned. Some basic
information on the challenges presented to Marine families was
discussed and similar dif-
ficulties heard from other Marine children. Toward the end of
the session, she engaged
Ethan in play activities that began training in skills for emotion
awareness, communica-
tion, and regulation.

The second child session was devoted to constructing a
narrative time map with Ethan
(Figure 2). Ethan selected the events or experiences to put into
his time map while the
clinician asked questions to further draw out the details of his
thoughts and feelings sur-
rounding the events. During the conversation, Ethan was invited
to draw pictures of his
experiences. Key experiences from his point of view included
having a sad goodbye with
his Dad (orange on the feeling thermometer), feeling alone at
his new school during the
first deployment (orange), going to Disneyland on his birthday
when Dad returned
(green), playing basketball and making new friends during the
second deployment (green),
and hearing his parents argue loudly at night when he was in
bed (red). The clinician sum-
marized his experiences, noting the range of green, orange, and
red events and high-
lighted the strengths that Ethan had displayed in dealing with
some very difficult
situations. She noted that Ethan seemed to have questions about
whether his Dad would
be going away again, and about whether his parents’ arguing
was about him. She asked if
he would be willing to share his time map and drawings in the
upcoming family session
and ask his questions. He agreed, requesting the clinician’s help
in asking his questions.
SALTZMAN / 655

During the family prep session, the clinician shared key points
from Ethan’s narrative
and his specific questions. The parents were surprised to hear
the extent to which Ethan
was aware of their arguing and very worried that he would think
he was to blame. The
clinician shared that self-blame is not unusual in children this
age, and they discussed
how best to receive his narrative and respond to his specific
questions.
The first family session focused on Ethan sharing his time map
and drawings. Bran-
don and Andrea shared appropriate portions of their experiences
to help flesh out a
broader family perspective of the challenging events they had
all been through together.
They spoke about the difficult goodbye. Brandon shared his
relief that Ethan was not
mad at him and provided a heartfelt description of how difficult
it is for him to go away
and sometimes disappoint Ethan and his Mom. He then spoke
about the time he did not
come back when expected and how badly he felt about that. He
and Andrea talked about
things they would begin doing to make sure there were not
similar misunderstandings
again. With regard to their arguing, Brandon and Andrea
acknowledged their tensions
and wanted to hear and understand more about what it has been
like for Ethan and if he
had any more concerns or questions. They spoke honestly, in a
developmentally appro-
priate way, about their difficulties and what they were doing

now to work better
together. Finally, they led a discussion on family goals and how
they would all like
things to be different and better. They agreed that it would be
good to spend more fun
time together and collaboratively developed plans for things
they could do during the
coming weeks.
The next family sessions were devoted to further exercises that
provided practice in
selected family-level skills including how to have family
meetings at home, how to problem
solve as a team, how to notice and help each other when a
family member was feeling wor-
ried, stressed, or sad, how to plan consistent care routines (e.g.,
meals and bed time) and
opportunities to have fun together; and also, how to identify and
plan for specific trigger
situations or reminders that elicited stress reactions among
family members.
The final family session involved recounting the family’s
progress over the course of the
program, offering detailed praise for their accomplishments
while outlining the work that
remained, and insuring that explicit strategies were in place for
contending with antici-
pated challenges and setbacks. It also involved a review of their
“suitcase,” which is a col-
lection of all of their filled out worksheets, skill training
guidelines, and personalized sets
of coping strategies that they will take with them.
CONCLUSION

As this case illustrates, the FOCUS Program was designed as a
brief intervention to
enhance family resilience through a series of practical activities
that identify major stres-
sors and promote specific resilient processes. Our model builds
many key transactional
processes that were identified in Walsh’s (2003, 2006) family
resilience framework, orga-
nized in three domains of family functioning–communication
processes, organizational
patterns, and belief systems. As Walsh has elaborated, we find
in our work with families
that these core resilience processes are recursive and synergistic
across domains.
The FOCUS narrative sharing and subsequent skill practice and
assignments are
designed to build open and effective communication as an
antidote to familial misattribu-
tions and estrangement. In the case example, movement toward
greater clarity and open-
ness was initiated in the parent sessions when they were able to
pinpoint the sources of
long-term misunderstandings and share essential context and
backstory that permitted a
softening of polarized positions. In bearing witness to each
other’s narratives in a nonde-
fensive manner, they were able to extend their perspective-
taking skills and mutually
appreciate the fact that there is not only one “truth” in a
conflicted encounter. By allowing

themselves to openly share and discuss their hurt and anger over
past and current diffi-
culties, they expanded their tolerance for the expression of
differences and strong emo-
tions—a change that will hopefully enlarge the overall scope of
expression across the
family.
The openness and collaborative practice initiated in the parent
sessions and carried
through to the family sessions is also designed to foster key
characteristics of resilient
family organization. One hallmark of resilient families is that
they have sufficient flexibil-
ity to adapt to changing circumstances and demands while
maintaining family integrity
and core family structure. This balancing act is aided by having
clear and responsive fam-
ily communication, clear roles, boundaries and leadership, and a
flexible and collaborative
approach to dealing with challenges (Walsh, 2003). Almost all
of the skills and practice
exercises from which the FOCUS trainer clinician can select are
intended to build those
exact capacities: from collaborative goal setting, to family
problem solving, to leveraging
relationships to manage strong emotions, to collectively
identifying and responding to
trauma and loss reminders, to the practice of holding family
meetings. In the sequence of
sessions, parents are first stabilized as a team, then the child-
sibling dyad is supported
and given voice, then parents are coached on how to take
leadership of family meetings

and determine what to share and what not to share from their
narratives; all are in service
of maintaining clear leadership, boundaries and roles, and
consistency in care routines.
The program architecture and content, then, is specifically
designed to build resilient fam-
ily organization.
Finally, the FOCUS Program is designed to help family
members develop a coherent
sense of what they have been through, draw upon each other to
make meaning of these
experiences, access a foundation of shared beliefs, and maintain
a hopeful and confident
outlook. These characteristics, in the domain of resilient belief
systems, are pivotal to a
family’s adaptive response to stressful change and trauma. One
of the central purposes of
the sequenced narrative timeline activity, from parent, to child,
to family, is to increase a
sense of coherence and shared understanding of what they have
been through. The belief
that the traumatic experience is knowable and manageable is
supported by the graphic
rendering of individual narratives and the ability to visually
survey the ups and downs of
their experience, noting individual differences, strengths, and
successes at a glance. Fur-
ther, in the family sessions, as parents are helped to listen to
their children and then pro-
vide helpful context for understanding traumatic or adverse
experiences, they are gaining
practice in scaffolding children’s perceptions, assumptions, and
beliefs about themselves,
others, and the world and to collectively make meaning of their
experiences (Saltzman

et al., 2013).
Over the past decade, the FOCUS Family Resilience Program
has been used in a wide
variety of settings with diverse populations contending with
complex forms of trauma and
loss. A common experience has been that in most cases, even in
well-resourced treatment
settings, the family dimension of mental health work is
frequently underserved. One bar-
rier is the misconception that family work must be intensive, of
fairly long duration, and
require clinicians with extensive training. The successful
national dissemination of the
FOCUS Program with strong outcomes for a wide range of
family presentations suggests
that a brief, manualized family intervention program
administered by masters-level clini-
cians may meet this important service need. As demonstrated by
the large-scale use of
FOCUS by the Los Angeles County of Department of Mental
Health, the largest mental
health organization in the nation, perhaps FOCUS is best
applied as a practical and flexi-
ble family module, which may be used in conjunction with other
evidence-based treatment
programs and as an integrated part of a system of care designed
to systematically assess
and provide a spectrum of services that treats the whole person
within the context of fam-
ily and community.
SALTZMAN / 657

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