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Returning Home from Iraq and Afghanistan: Preliminary Assessment of Readjustment Needs of Veterans, Service Members, and their Families APPENDIX B TOWN HALL MEETINGS The committee understood that to carry out its task it would be important to hear from people who had firsthand knowledge of readjustment needs—active-duty personnel, veterans, family members, health-care providers, and community leaders. Thus, in addition to its six meetings and literature reviews, the committee hosted a series of informal meetings in communities near military installations that have deployed large numbers of troops to Iraq and Afghanistan. The committee chose a wide array of communities across the United States and held meetings in Killeen and Austin, Texas (near Fort Hood and Camp Mabry, respectively); Jacksonville and Fayetteville, North Carolina (near Camp Lejeune and Fort Bragg, respectively); and San Diego, California (near Camp Pendleton). Committee members also met with the Marine and Family Services Division at Camp Pendleton to gain a better understanding of the needs of marines and marine family members and to learn of the services offered. In addition, groups of committee members and staff traveled to Ohio, Michigan, Indiana, and Watertown, New York, to meet with National Guard members and community representatives. The committee members thank all those who took time to coordinate the meetings and to meet with them and help them to understand the many unmet needs faced by active-duty service members, veterans, and their families and communities. The individual anecdotes shared in the open meetings have been invaluable in providing the committee with a qualitative understanding of the challenges faced not only by active-duty military, reservists, and veterans of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) in getting access to services but by their family members and by providers trying to meet the readjustment needs of the military and veteran communities. A summary of each meeting and the major themes that emerged are provided below. Killeen, Texas (Fort Hood): Army Fort Hood, near Killeen, Texas, home to over 50,000 active-duty service members, is one of the Army’s largest installations. Over 85% of its units have been deployed to Iraq or Afghanistan at least once, and most have served two tours (see http://pao.hood.army.mil/fact.sheets.aspx, accessed on November 18, 2009). The committee held a town hall meeting at the Hilton Garden Inn in Killeen, Texas, on April 27, 2009. Numerous mental health providers attended the meeting and stated that they were overwhelmed by the number of service members and veterans requesting mental health care, citing caseloads of up to 900 patients. Some noted that the system was being “overtaxed to the breaking point”; others noted that the “system was overwhelmed.” Several veterans expressed frustration with long
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Returning Home from Iraq and Afghanistan: Preliminary Assessment of Readjustment Needs of Veterans, Service Members, and their Families delays (12 months in one case) in scheduling appointments and with long wait times between appointments. The providers who spoke stated that they do not have sufficient time for long-term treatment or to ensure necessary followup visits for their patients. The mental health providers also stated difficulties in recruiting and retaining qualified mental health professionals because of overwhelming caseloads (one speaker referred to a high rate of “burnout”) and noncompetitive compensation; those difficulties were exacerbated by the need to attract skilled providers to remote rural locations. One of the nurses who attended the meeting noted that there was only one neuropsychologist for the combined Temple, Austin, and Waco area. Several attendees expressed frustration with the lack of couples and family counseling services, especially relationship and anger-management counseling. Although both veterans and care providers expressed frustration with barriers to accessing mental health care, they seemed pleased with the quality of the care. For example, one veteran stated that the Department of Veterans Affairs’ 7-week posttraumatic stress disorder (PTSD) treatment program was “wonderful” and provided the skills to “to deal with my everyday PTSD.” Other issues centered on the burden of traveling long distances to receive needed care, which was described as a disincentive to many who could not take time from work or be away from children or who found the ride too painful (for those with injuries) to make long trips. For example, one woman veteran of OIF who suffered multiple illnesses and injuries described how for a year she had had to drive 2 hours from Ft. Hood to Brooke Army Medical Center in San Antonio twice a week for treatment that was not available in Killeen. During that time, her children, both young teenagers, had to become caretakers for their mother. Their father, her ex-husband, is serving his third tour of duty in Iraq. The committee heard from reservists (in Killeen and elsewhere) who had trouble in getting medical care when accidents occurred while they were in transit to or from reporting to duty. In one case, a reservist was caught between the Department of Defense (DOD) TRICARE health-care system and private health insurance, noting that neither would pay for his care and each stated that it was the responsibility of the other because he was injured on his trip home from service. He stated that he was paying for his medical care “out-of-pocket” and had already lost his car because he could not continue to make payments on it. He and other reservists noted that they felt that the reserve and National Guard members were treated like second-class citizens compared with active-duty service members with regard to obtaining care. Austin, Texas (Camp Mabry): Texas National Guard On April 28, 2009, the committee met with community leaders and representatives of groups that provided services to the reserve component at Camp Mabry, in Austin, Texas, the headquarters of the Texas National Guard (both Army and Air National Guard). The attendees stated that the community, reservists, and employers face substantial employment-related issues. For example, a representative from the Employer Support of the Guard and Reserve reported that employers are initially supportive of reservists during their first deployment, but their willingness to bear the cost of keeping jobs open for activated reservists declines sharply during subsequent deployments, especially in the current economic recession. He noted that many businesses cannot sustain the rehiring of people over multiple deployments, because their positions have been filled by permanent employees.
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Returning Home from Iraq and Afghanistan: Preliminary Assessment of Readjustment Needs of Veterans, Service Members, and their Families A psychologist from the police department expressed concern about hiring or rehiring returning reservists who may suffer from undiagnosed illnesses, such as mild traumatic brain injury (TBI) or PTSD, which could affect their judgment if they were civilian law-enforcement officers. She was concerned about providing certification for weapons possession for many of those who applied to become police officers. Several other issues were raised by community representatives, such as the large number of returning OEF and OIF veterans who had TBI or had screened positive for PTSD returning to the community and the costs associated with those illnesses (both social and economic). Numerous attendees described the many programs that had been developed at the state and local level to address the needs of the retuning OEF and OIF veterans and their family members. They noted that there are many resources and services but that better coordination is needed to maintain effectiveness and cost effectiveness. Others noted that service members and family members are not aware of all the programs available, that family and peer support is weak, and that the issue of stigma prevents many from seeking mental health counseling and treatment. Finally, the results of a statewide survey regarding unmet needs of OEF and OIF veterans and family members were reported. Several themes emerged: military families need stronger support (such as financial assistance, housing, food, clothing, and child care), health services are insufficient and should be expanded (both mental and general medical), returning veterans need more employment training and education than are available, and many people do not know how to connect with the resources available to them, both government and nongovernment organizations, both local and national. Toledo, Ohio: Michigan, Indiana, and Ohio National Guard To gain a better understanding of the unique challenges faced by those serving in the National Guard, a subgroup of the committee met with members of the Michigan, Indiana, and Ohio National Guard and health-care providers for these populations. The meeting was held at the Hampton Inn in Toledo, Ohio, on May 11, 2009. The reserve and National Guard have many of the same readjustment needs as active-duty service members and veterans, but their support systems might be less effective. In Michigan, for example, the National Guard and reserve members are activated from communities across the state rather than from a local unit, so Guard members and reservists are not deploying or returning home with their peers; this results in isolation and limited or remote services. The committee was told that many of the programs and services that are available are poorly advertised and that many people who have readjustment needs may not be aware of the services. In addition, especially in rural areas, the geographic distance between patients and providers creates an additional barrier to access. Fayetteville, North Carolina (Fort Bragg): Army With almost 50,000 service members stationed at the base, Fort Bragg, near Fayetteville, North Carolina, is one of the largest Army installations and has the largest airborne facility (see http://www.time.com/time/magazine/article/0,9171,1860898,00.html, accessed on November 18, 2009). Fort Bragg deploys more troops to OEF and OIF than any other post (see http://www.mybaseguide.com/army/fort-bragg/units.aspx, accessed on November 19, 2009). The meeting was held on June 2, 2009, at American Legion Post 202. The active-duty service members and veterans discussed primarily mental health issues and noted that stigma is
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Returning Home from Iraq and Afghanistan: Preliminary Assessment of Readjustment Needs of Veterans, Service Members, and their Families attached to seeking treatment for mental health and that many consider it a “stripe-killer.” The committee was told that for veterans who did seek treatment for mental health the wait times were too long for appointments and between appointments (echoing what the committee had heard at Fort Hood). Many of the family members at the meeting (particularly mothers) stated that they were overwhelmed by their responsibilities, and this often led to “taking it out on the kids.” The younger mothers also seemed largely unaware of support services available to them. Two veterans discussed the difficulty of obtaining medical care. They cited long wait times for appointments, and several described appointments that were scheduled without their input at unreasonable locations and on unworkable dates. Jacksonville, North Carolina (Camp Lejeune): Marine Corps Marine Corps Base Camp Lejeune, near Jacksonville, North Carolina, is the largest Marine Corps amphibious-training facility. Over 47,000 marines and sailors are stationed at the base (see http://www.globalsecurity.org/military/facility/camp-lejeune.htm, accessed on November 18, 2009). The committee attempted to hold a town hall meeting on June 2, 2009, at American Legion Post 265, but even with efforts to advertise the event in the Camp Lejeune Globe, on Facebook, through e-mail listservs maintained by veterans’ service organizations, and through the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury, no active-duty personnel or veterans attended the meeting. San Diego, California (Camp Pendleton): Marine Corps Camp Pendleton is a large Marine Corps base near San Diego, California. It has over 42,000 active-duty personnel, and nearly 23,500 reservists also train there (see http://www.pendleton.usmc.mil/information/basefacts/population.asp, accessed on November 18, 2009). The meeting was held at the Q Restaurant and Sports Bar in Oceanside, California, on August 10, 2009. Many of the marines who attended brought their wives, and some brought their children. It was a dinner meeting at which the committee members and attendees could talk informally. Many of the marines, who had yet to be deployed, told us that the military is doing a good job of supporting them. Some who had deployed and their wives stated that they needed additional educational opportunities, training, and assistance in finding jobs. Others were having trouble in adjusting to life outside the military and were worried about the adverse career effects of seeking care for mental health issues. Many preferred to seek mental health counseling from the military chaplain, believing that to be a safer alternative. Earlier on that day, several members of the committee met with staff at the office of Marine and Family Services (MFS) Division at Camp Pendleton to gain a better understanding of the service providers’ perspective on readjustment needs at the base. The MFS staff members discussed the changing focus of services and programs offered at Camp Pendleton; in particular, they noted the challenge of keeping up with the growing need to support new parents and to provide counseling to prepare families, especially children, for separation during deployment. They also noted that in recent years the number of domestic-violence cases had increased (an issue that was mentioned by community leaders outside Fort Drum). A staff member discussed the benefits of having the substance-abuse counseling and mental health services in the same location at Camp Pendleton, which allows providers to treat
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Returning Home from Iraq and Afghanistan: Preliminary Assessment of Readjustment Needs of Veterans, Service Members, and their Families substance abuse concurrently with comorbid mental health conditions (30% of Camp Pendleton residents who come in for substance-abuse screening have an existing diagnosis of PTSD, depression, or anxiety). The MFS counselors raised the concern that although counseling records are confidential, any referral for additional mental health care in a military treatment facility must be recorded on the marine’s permanent record, and this deters many service members from seeking recommended followup treatments. In addition, attrition rates are high in treatment programs, and many patients drop out before completing the recommended regimen. Furthermore, it was noted that most marines do not seek counseling or treatment for substance-abuse disorders, because that would have to be reported to the chain of command and could result in dishonorable discharge. A staff member told the committee that when a marine finally comes for substance-abuse treatment, it is usually after a career-ending event, such as an arrest for driving under the influence. The MFS office lacks the resources to assign case managers to everyone in treatment programs, and counselors reported that Military One Source1 referrals take too long to process for most service members and their families to get timely treatment. The MFS office has proposed bringing in social-work students from the University of Southern California as a possible way to alleviate the staff shortage, but they noted that there is insufficient space to house additional providers. Watertown, New York (Fort Drum): Army Fort Drum, which is near Watertown in upstate New York, has about 17,000 active-duty personnel assigned to the base. It is home to the 10th Mountain Division, which has seen more deployments than any other division in the Army. A subgroup of the committee met with community leaders on September 25, 2009, to gain a better perspective on community effects. In general, the community representatives stated that close coordination with the military leadership at Fort Drum had been useful in meeting the needs of the military community. The civilian health system is fully integrated with the military and the civilian populations (there is no military hospital on the base). They noted that recruitment of health professionals is difficult because of the rural location and the payer mix (civilian and military). In addition, the law requires that financial incentives for health-care providers be available for recruitment but not for retention. Apparently, regional partnerships help to leverage resources and helped the local community college in doubling its nursing program. In discussion with the community leaders, the subjects below were raised as important for the community: An increase in domestic violence. The people who met with the committee noted that the deployments are having an effect on rates of domestic violence. The police hear that “It’s out of character” or that he or she “wasn’t like this before” from victims. It was noted that there has been a 25% increase in domestic disputes. It was reported that “we spend 90% of our time on 10% of the population, the ‘frequent fliers.’” The need for about 20 more officers was noted, as was a need for more case workers to deal with divorce and custody issues in family court. 1 Military One Source is a free service provided by the Department of Defense (DOD) for active-duty, Guard, and Reserve service members and their families. One can access Military One Source by phone or online. The service is completely private and confidential, with a few exceptions (http://militaryonesource.com/MOS/About.aspx).
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Returning Home from Iraq and Afghanistan: Preliminary Assessment of Readjustment Needs of Veterans, Service Members, and their Families Additional mental health–care providers are needed, including child psychiatrists. There is always a need for mental health services, especially for family members. Caseloads are high, and weekly hours are long for school-based social workers. Jobs and education are needed for veterans. More job training is needed to break the cycle of reliance on social services. Many veterans and family members are healthy and eager to work but have no skills. Deployments lower the population. Revenues decline as communities collect smaller amounts in sales taxes. Longer deployments have resulted in “single” mothers’ not staying nearby; they leave and go home to their parents. The extensions of deployments are hard on the communities. There are unmet needs and services to families and children, especially on return of troops. For example, reimbursement models are not set up to provide family counseling. The family members typically access care in the community and pay out of pocket because of the TRICARE benefit design. In addition, about 25% of the population of schoolchildren turns over every year. That results in confusion for the children in the schools. There is a need for trained counselors and specialists for schoolchildren. When military families are transferred, they have to restart care with a new set of service providers. There are unmet needs and services for families and children, especially on return of troops. For example, reimbursement models are not set up to provide family counseling. The family members typically access care in the community and pay out of pocket because of the TRICARE benefit design. In addition, about 25% of the population of schoolchildren turns over every year. That results in confusion for the children in the schools. There is a need for trained counselor and specialists for schoolchildren. When military families are transferred, they have to restart care with a new set of service providers.