APPENDIX E

INDIVIDUAL ETHNOGRAPHIC ASSESSMENTS OF SIX COMMUNITIES

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Westat conducted a series of ethnographic assessments for the Committee. The communities visited include: Jacksonville, North Carolina; El Paso, Texas; Watertown, New York; Lakewood and Lacey, Washington; Georgetown, South Carolina; and Little Falls, Minnesota. This appendix contains each of those individual assessments and Chapter 7 provides a summary and conclusion regarding the impact of military deployments on communities.



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APPENDIX E INDIVIDUAL ETHNOGRAPHIC ASSESSMENTS OF SIX COMMUNITIES Westat conducted a series of ethnographic assessments for the Committee. The communities visited include: Jacksonville, North Carolina; El Paso, Texas; Watertown, New York; Lakewood and Lacey, Washington; Georgetown, South Carolina; and Little Falls, Minnesota. This appendix contains each of those individual assessments and Chapter 7 provides a summary and conclusion regarding the impact of military deployments on communities. E-1

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Understanding the Community Effects of Multiple Military Deployments Case Study Reports E-2

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Jacksonville, North Carolina Case Study Report E-3

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Impacts of Multiple Deployments: Jacksonville, North Carolina OVERVIEW This report presents the study team’s findings from a weeklong site visit (April 18–25) to Jacksonville, North Carolina, a midsized city on the coast that is adjacent to Marine Corps base Camp Lejeune. A key finding from this location was that multiple deployments appear to have had little effect on the overall local economy. Many interviewees attributed this to Project CARE, a Data Sources Chamber of Commerce–initiated effort to mitigate  Chamber of Commerce negative community effects from deployments by  Churches providing support to service members’ families,  City Government communicating with businesses, and promoting a  Fire and Police Chiefs positive community spirit toward the military. Community members spoke of their concerns that  Health Department additional mental health care services are needed both  Jacksonville Jamboree on base and in the community, where some service  Kindergarten Readiness members prefer to seek help. They also spoke of the Program need for more federal resources to address  Onslow County Partnership infrastructure problems in the community related to the for Children growing military population.  Recreation and Parks Department  School Board and Transition GEOGRAPHIC ORIENTATION Counselors  Social Services Department Community: Jacksonville, North Carolina  United Way Jacksonville, North Carolina, lies on the eastern shore of the state in Onslow County and adjacent to the southern Outer Banks and is contiguous with both Marine Corps Base Camp Lejeune and Marine Corps Air Station New River. According to the 2010 Census, Jacksonville’s population of 70,1451 represents an increase of about 5% over the 2000 population. Demographically, 9.7% of the population of the city is age 5 or younger, compared with 6.6% for North Carolina and 6.5% for the United States. Only 5.4% of Jacksonville residents are age 65 years or older, compared with 12.9% for North Carolina and 13.0% for the United States. Jacksonville also has a proportionately larger male population than the rest of the state or country, at 58.8% of the population. The young age distribution and high proportion of males are likely due to the presence of the Marine Corps in the community.1 Race and ethnicity trends in Jacksonville are similar to those in the state of North Carolina, with 67.7% reporting their race as white, 20% reporting their race as black, and 13% reporting Hispanic or Latino origin. Home ownership rates in Jacksonville are disproportionately 1 All population statistics are from the 2010 Census and the American Community Survey (http://quickfacts.census.gov/qfd/states/37/3734200.html). As will be noted throughout this report, Jacksonville officials and other community members do not believe these figures accurately represent the local population. E-4

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low (38.8%) when compared with the rates for North Carolina (68.1%) and the United States (66.6%). The median household income in Jacksonville during the years 2006–2010 was $42,469, compared with $45,570 for North Carolina and $51,914 for the United States. Military Installation: Camp Lejeune Camp Lejeune is home to the largest concentration of Marines and U.S. Navy personnel in the world and currently encompasses 156,000 acres. The base was established in 1941 to meet the need for an East Coast amphibious training facility and has grown over the years to train men and women to fight wars in the Pacific Islands, Korea, Vietnam, Kuwait, Afghanistan, and Iraq. Several satellite facilities offer infantry training and serve as the home of the amphibious assault Marines and vehicles, the Marine Corps Engineer School, and the Coast Guard’s Port Security Training Detachment. The Marine Corps Air Station New River, a helicopter base, is also located in Jacksonville. According to its website, Camp Lejeune is the “Home of Expeditionary Forces in Readiness,” and troops from the base have played a crucial role in both Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF). The author of an August 2010 article from the Jacksonville Daily News explains how “the contribution of the corps—with a heavy emphasis on the efforts of Camp Lejeune-based troops—played a vital role in rounding a corner in the war and securing a victory pennant.”2 As one city official recounted: I have a vivid memory . . . after everything took place and 9/11 became apparent, there were some announcements made as to how we were going to be impacted . . . we were going to be the first ones in. Since 2003 when the first U.S. troops entered Iraq, Jacksonville has been faced with a steady stream of deployments. Members of the Social Services Department explained how the deployment patterns have changed over time: [Deployments are] more frequent than they used to be. . . . [They] used to be a little longer, would go a year or 18 months, but then they’d be back for at least a year or 2 years . . . now they are gone anywhere between 6 and 9 months, they are here a couple of months, and then they are gone again for the same amount of time. [Social services representative] Many of the troops deployed to Iraq and Afghanistan from Camp Lejeune are infantrymen, and the base has suffered a high proportion of troop deaths compared with other military installations. Relationship Between Community and Military Installation The relationship between the base and the community is best described as dichotomous. Although there are extremely close ties between the base and both the city and the county, in other regards the military and civilian worlds are separate. The close ties are noticeable 2 See http://www.jdnews.com/articles/success-82029-iraq-vital.html. E-5

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everywhere: Military families may live on base but shop, work, and send their children to school in the county school system; military members may live on base or in civilian housing and purchase goods and services in the city or county; civilian contractors and other business people provide goods and services to the base; and civilian staff work on the base. Military and civilian personnel, such as police officers and firefighters, respond to emergencies together and occasionally train together on or off the base. Military personnel may serve as volunteer coaches for school or community sports teams. The areas of separation, though not as immediately apparent, are equally widespread. Military or military-affiliated status confers a set of rights and privileges that is not shared by those without military status. A social service professional pointed out, for example, that women who are in relationships with service members but are not legally married cannot seek services on base. Conversely, a military member who obtains a restraining order against an abusive spouse through military channels will find that the restraining order cannot be enforced off base because it is not recognized in a civilian jurisdiction. The base is the main economic driver in the area, with effects felt both in the city and throughout Onslow County. One Jacksonville Chamber of Commerce member said that the “entire market is the base.” According to the Camp Lejeune 2012 Base Guide, the base and surrounding community are home to an active duty, dependent, retiree, and civilian employee population of more than 180,000 people and the base contributes more than $3 billion each year to the local economy in payroll, contracts, construction, and other services. The economic and social effects are mixed: Positive effects of the military presence include  Source of income and employment (e.g., as the leading employer in Onslow County, the Marine Corps Community Services employs more than 2,200 civilians at Camp Lejeune),  Strong consumer base, and  Source of civic pride and cultural continuity. Negative effects of the military presence include  Traffic congestion and strains on infrastructure,  Overreliance on one source of income, which decreases the level of available employment opportunities,  Prevalence of high-risk behaviors associated with hosting a large population of young men and women (e.g., drinking and driving), and  Need to provide social services beyond those available on base to those who do not have access. Historically, Jacksonville saw a substantial drop in its population during the first Gulf War as dependents left to return to their families for support during deployments. E-6

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In the first Gulf War . . . a lot of people broke their leases because they thought that war was going to be an incredibly long period of time . . . they picked up and went back home to be with their loved ones. [City official] In that time period, Jacksonville pretty much emptied out. Not only did the service members leave, but a lot of their dependents left as well. [Community college representative] In an effort to prevent this flight from reoccurring, the Onslow County Chamber of Commerce put an innovative program called Project CARE in place. This effort, which was activated several times starting in 2003, combines the efforts of various local government, military, Chamber of Commerce, and community organizations to provide support to families of deployed services members, assist businesses in dealing with the deployments, and increase community spirit toward the military. Project CARE was cited by many interviewees as a successful strategy to mitigate the potential negative effects of multiple deployments: I think the community as a whole . . . made it important to let the dependents know during the second Gulf War that they could stay here, that people in the community cared about them and were going to take care of them. It made a very big difference. Jacksonville certainly didn’t clear out. [City official] This intervention has helped to create social and economic stability in Jacksonville throughout the OIF/OEF engagements. EFFECTS OF DEPLOYMENT ON THE COMMUNITY Economic Impacts Multiple deployments appear to have had no discernible effects on the broad, community- level economy. Interviewees regularly described the local economy as robust and benefiting from the nearby presence of Camp Lejeune. There were suggestions that deployments may cause microlevel economic shifts (e.g., increased storage unit rentals before deployments, increased large-item purchases by young soldiers upon return from deployment), but interviewees did not indicate multiple deployments to be behind these small-scale rhythms. Overall Commerce As suggested above, the overall economy in the area has seen continued growth, strong military incomes, a good business climate, and relatively low unemployment rates. As of March 2012, unemployment rates were lower in Jacksonville and Onslow County (8.7% and 8.4%, respectively) than in North Carolina (9.7%) and the United States as a whole (9.1%) (http://data.bls.gov). Pay and housing allowances to military families have spurred a construction boom in homes, apartments, retail stores (including major consumer goods such as furniture and cars), restaurants, hotels, child care facilities, and ancillary services such as barbershops and storage facilities. Jacksonville officials noted that there is a large amount of construction work being done on base, and the restaurants in town are always full. E-7

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Every restaurant in town has a long line . . . hotels are packed . . . over the past several years there has been a lot of construction and work on base, and that has put a lot of construction workers . . . into our community. . . . [Emergency services representative] Some of these businesses experience cyclical ups and downs related to deployments. For example, barbershops see less business during deployments, but storage facilities flourish. In addition, the Basic Allowance for Housing (BAH), hazard pay, and savings while overseas tend to make the military-affiliated population stronger consumers than civilians are. Spikes in spending for consumer goods can probably be linked to deployment cycles, with young single service members reportedly making large purchases (e.g., cars, motorcycles) upon return from the combat theater. Importantly, the change in deployment cycles (shorter duration, but more frequent) was perceived by some respondents to have helped reduce the impact on the local economy: They’re only gone for 6 to 9 months now; it doesn’t hit the economy within the county as hard as it used to when they deployed for a year at a time. . . . [Social services representative] For the most part, the data suggest that the community has been insulated from the national economic recession. Some interviewees did note one probable effect of the recession, namely, that many family members of deployed Marines have moved to Jacksonville to help the nondeployed spouse because they themselves are unemployed and thus able to relocate. We’ve been seeing a lot of family members relocate here . . . to help them take care of the kids . . . and once they’ve been here for 3 or 4 months, they start getting into the job market . . . it’s not a short-term thing, it’s a long-term thing. [Chamber of Commerce member] Although the supports are undoubtedly welcomed by the nondeployed spouse, unemployed relatives can put an extra strain on family finances. And if these family members do find work, they often end up being underemployed, as discussed below. The community also has been spared an economic blow in that the Department of Defense has not chosen to pursue any large-scale Base Closure and Realignment (BRAC) actions at the base. The only BRAC action taken at the base to date is the closing of the brig in an effort to consolidate correctional facilities in the mid-Atlantic Region.3 Although several respondents mentioned that the Marine Corps plans a gradual drawdown of service members, to date this has not significantly affected the area and business leaders say it will likely take place over the nextseveral years. Although the economy of the area remains fairly robust, economic conditions for individuals can vary: 3 See http://www.jdnews.com/news/brac-14971-lejeune-gombar.html. E-8

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Single Marines receive hazard pay, housing allowances, and other benefits; are typically economically stable; and can afford to make major purchases such as cars and furniture upon their return from deployments. Civilians may experience more dire economic situations, social services may be stretched because of the alleged Census undercount that affects federal funding for local programs (see below), high-paying jobs are scarce, housing is expensive, and consumer goods like cars may be high-priced because local businesses set their prices relative to the military salaries: When I purchased my car, I went to Wilmington because I can’t buy in Jacksonville . . . the prices in Jacksonville are significantly higher . . . they know they are going to get those young military guys who have all this pocket change. [Community member] Military families’ economic situations may depend on their number of dependents, employability of the “at-home” spouse, and their skills in managing money. Unofficial military dependents (e.g., girlfriends and children) can experience more economic stresses depending on available jobs and how much the military member is willing and/or able to support them. Family spending cycles may be related to deployments. For example, the number of pregnancies increases dramatically when Marines return from overseas, potentially resulting in increased spending for health care and, ultimately, food, clothing, and other items needed for the new family member. Labor Supply and Employment Military activities have had a significant effect on high turnover of the labor supply in Jacksonville and Onslow County, but this must be seen as a result not necessarily of deployments, but of regularly scheduled Permanent Change of Station (PCS) rotations. One member of the Chamber of Commerce representing a large national retailer told us that each year about 4% to 5% of his staff members ask for “hardship transfers” to other national locations because of a family member’s PCS transfer. Representatives of child care facilities, the hospitality industry, automotive sales, and city government all reported that military-affiliated employees have a lot of turnover and it is difficult to replace good staff members who leave: You get some really good ones, and you know they are going to leave one day and you just hate it . . . our office manager . . . we are just dreading the day when she leaves and how we are going to replace her. [Chamber of Commerce member] There’s about 700 volunteers for fire and rescue in the county. I’d say about 85 to 100 of those are direct military connected, and that is a constant revolving door in that area. They’ll be here for a while and then they’ll leave for deployments. [County EMS representative] E-9

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It has been a struggle these last couple of years trying to keep staff, and we’ve tried to be as consistent as possible because with the kids dealing with transition at home, we want them to at least be able to come to the Rec site and see familiar faces. [Recreation and Parks Department representative] It’s almost like if I could ask two nonlegal interview questions, it would be are you pregnant, or are you a spouse of an active duty military, because I know what is going to happen. [Health Department representative] The Onslow Police and Fire Departments are particularly prone to seeing turnover because many of their staff members are affiliated with the military. Among paid staff, they said, Police Department members are about 50% retired military; paid Fire Department staff members are about 20% retired military. They see turnover of about 15% per year. A representative of the County Health Department said turnover is a major problem in the Health Department as well, where many positions require specialized, long-term training and have licensure and certification requirements. For example, a nurse specializing in treating sexually transmitted diseases may require up to 2 years of training in order to function independently in the position; if staff members are prone to leave every 3 years, it is difficult for the county to justify the cost of such trainings. Deployments also directly affect the labor supply. During the Health Department and Police/Fire Department interviews, interviewees mentioned that local employers must be flexible in terms of spouses’ issues during deployment, such as finding child care and spending time with active duty spouses before and after deployments. One interveiwee told us that following one return from deployment, 19 of 20 waitresses at one restaurant became pregnant. For employers, it is illegal to ask a potential employee if they are married to a Marine or if they are pregnant, so businesses are forced to be flexible to accommodate military families to meet their staffing needs: A girl that works for us, her husband was just injured, that’s a major thing. For childcare, they are the only one at home [and we] just have to work with them on their schedules. [Chamber of Commerce member] [As an employer, we’re sensitive . . . you’ve got a mom who is weeping, or it was just really hard to come in the day after she put her husband on the bus. . . . [Mental health representative] In addition, and as suggested previously, deployments and PCS transfers together contribute to a scenario where underemployment is common. Unlike communities with universities or large-company headquarters that draw long-term residents who are highly educated, Jacksonville is focused on providing goods and services to the highly transient base population and to civilians in and around the city. Many local residents are underemployed in low-pay, semiskilled retail or service jobs. Underemployment disproportionately affects military dependents and individuals moving to Jacksonville to support their families; these people are more likely to have higher skills than the local job market can accommodate: E-10

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A lot of them are coming from larger cities where there’s a lot of hi-tech or tech or manufacturing firms. So when they get here, we don’t have the same firms and we definitely don’t have the same pay scales that they have. [Chamber of Commerce representative] I think the issue for us is underemployment. . . . We are so heavily reliant upon retail sales. . . . We have seen a decline in the ability to be self-sufficient in that even though you may be . . . employed, you still require economic assistance to maintain family stability. [Social services representative] Thus, even though the overall unemployment situation in Jacksonville and Onslow County looks good, findings from the site visit suggest that multiple deployments have potentially exacerbated an already dynamic labor market by contributing to high staff turnover rates, increasing the need for employers to make periodic accommodations for military spouses, and leading to a high underemployment rate among extended members of military families. Housing Market Continued overbuilding of the housing stock was a topic of concern to almost everyone interviewed. As one city official explained, the “housing market is soft because it’s been overbuilt.” The BAH is high enough for many Marines to purchase homes or rent recently constructed apartments. This has created a strong housing market that has had several effects.  Growth in areas outside the city has put severe pressure on infrastructure and EMS services: The city taxpayers bear the burden . . . [we] need resources for infrastructure and road improvements . . . funding for that would be really helpful. [EMS representative] . . . infrastructure . . . we are way behind the 8-ball on that. . . . [Chamber of Commerce representative]  Home and apartment prices are driven by the BAH, putting adequate housing well out of reach for many nonmilitary individuals and families: The housing that is being built is really being built to those housing allowances. [Chamber of Commerce member] I can’t afford to live in Onslow County, I’d love to. I work here . . . but I can’t [afford it]. . . . [Community member] As a result, individuals and families that do not receive the BAH may spend a high proportion of their income on housing, leaving them in danger of having insufficient E-11

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A variety of respondents reported that bonding was difficult for the youngest children, who might not recognize a parent returning from deployment even if they had seen them on the computer screen during video chats. Similarly, most interviewees perceive that older children and adolescents, as one leader put it, “are acting out . . . with anger, misbehaving,” but gave few ways in which this manifests itself. Conversely, two school employees told us that the National Guard kids are not the ones acting out. One said, “Most kids of dads who are deployed don’t want to add to the stress. They don’t get in trouble. I haven’t seen any adverse effects.” One person emphasized the importance of keeping children active in sports, Scouts, and other organized activities. Another described the Boys and Girls Club, which opened locally in the last few years, as busy and an important addition to the community. A few interviewees explained that addressing children’s mental health predeployment could prevent some problems. One said that “a counselor that drops by the house to see how it’s going” during and after deployment could help children to process their feelings. That would be helpful. . . . I think probably weekly or every other week, a little extra. Maybe a little counseling that looks like a visit to a kid, versus somebody that’s telling me what to do. Just chit chat with a couple of folks that might give them ideas, maybe do a little extra education stuff with them when they’re in that 5-6-7-8 years old. Because at that point, I don’t even think they know how to process their feelings. [City government employee] Opinions on the benefits of Skype communication between family members were mixed. Several interviewees said it was a good way for a very young child to connect with and recognize a parent when they return from deployment. However, one National Guard member said that his roommate during deployment often started his day badly with his wife’s complaints about what was going on at home. A county employee told us that the state of “might deploy” is stressful for the entire family. When deployment orders come in, additional training time—as much as a year—is required predeployment, and postdeployment events at bases around the country before returning home also take time away from the family. The stress takes its toll on the family. One member of the health community told us, “I feel the tension sometimes” between a returning soldier and spouse and said that couples struggle with how to manage the house when one parent has made decisions in the other’s absence. Although several interviewees reported that deployments cause an increase in divorce, a few explained that the dissolution of those marriages is caused by weak relationship foundations rather than by deployment. They told us that if a couple gets married too quickly, weeks before being deployed, or, as one person described, via videocast, the relationship is more likely to fail. Behavioral Health Issues Many community members reported substance abuse and suicidal thoughts as problems among National Guard members, but it is difficult to link them specifically to deployments. As noted in the description of formal supports, alcohol use is common in the community generally. Two interviewees who work closely with activated National Guard members indicated that E-120

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drinking increases with deployments and is worse after multiple deployments. Similarly, drug abuse is a problem in the community. Team members were told that local civilians use marijuana, crystal methamphetamine, and heroin, but service members are tested monthly, so, as one counselor reported, they stick to “pills and alcohol.” Suicide is a local concern, but has always been a concern. A few interviewees recalled a suicide at Camp Ripley a few years ago during annual training, as well as calls about suicidal ideation both at Ripley and in the community. National Guard suicides are evident in the press, but may not link directly to the community. When asked by the study team whether the suicides could be linked to mulitple deployments, interviewees said it was difficult to connect these instances to deployments. Also, as discussed earlier, unaddressed mental health issues will put an extra burden on civilian health care providers in the future. As noted, the small emergency facility in Little Falls can quickly reach capacity if the ER is holding a patient with acute mental health needs who requires a locked room and law enforcement presence. Physical Health Issues Back pain was the most commonly mentioned physical health issue stemming from multiple deployments, though most interviewees did not discuss physical health issues. The prevalent concern was about what one interviewee termed the “young immortals”—National Guard members who want to remain deployable and therefore fail to report injuries (that may make them eligible later) for a VA disability claim. One counselor who works with veterans voiced concern for the future of OIF/OEF soldiers: That 25-year-old limping around with the knee, now it’s no problem. . . . By the time he’s 35, he can’t get out of his own vehicle. We have to get these folks aware. I hear “Well, there’s a lot of guys that are worse off than me, I don’t want to jeopardize . . . my ringing in the ears isn’t that serious.” That’s all well and good when you’re younger, but when you get to that retirement age, where is your health insurance going to be and you’re not VA eligible anymore because you didn’t file a claim for disability? Conversely, two interviewees who had deployed previously mentioned their own service-related back injuries as their reason for leaving military service. As with mental health issues, unaddressed physical health issues may put an extra burden on civilian health care providers or go untreated. As one source knowledgeable about the National Guard pointed out, service-related disabilities are not covered by employer health care. With only a 5-year statute of limitations to file VA claims, Nation Guard members may be left without VA-covered care for a lingering injury. Health Issues and Law Enforcement The perception from law enforcement is that there has been no appreciable increase in DUI or suicides among the National Guard as a result of deployments, although statistics among E-121

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the general population might indicate an increase. Community members were mixed in their perceptions of the impact of multiple deployments on law enforcement, particularly the issue of domestic violence. A law enforcement informant told us, “I haven’t seen it,” but representatives of a human service organization believe that domestic violence increases with deployments. Community Competence Several services are available to support service members and their families at Camp Ripley (during training and the deployment cycle), through the VA, and in the civilian community in Little Falls and Morrison County. There were no obvious gaps in formal health care supports for activated service members or veterans with a service-connected disability, though several of the supports that were said to be most valued are less than 5 years old. Moreover, team members were told about barriers to seeking services, including young National Guard members who do not report injuries in order to “remain deployable,” a stigma related to National Guard members’ seeking mental health assistance, resentful service members and spouses who want nothing to do with the military, and civilian unfamiliarity with the specific services available. Interviewees reported gaps in services for military families. Behavioral and Mental Health Services Interviewees almost uniformly identified local mental and behavioral health as the biggest deployment-related challenge for all age groups in their community. Financial management skills were also mentioned as a stressor for service members who deploy. Mental health issues are beginning to be addressed with an approach that was described in an interview as evolving, primarily through nonprofit Northern Pines, which provides a range of mental health education, counseling, and psychiatry across six counties. Northern Pines is the mental health contractor supporting children in Little Falls community schools, as well as individuals training at Camp Ripley. According to interviews and documents available online, a Northern Pines employee who is an OIF/OEF Army veteran identified the need and garnered support from the executive director to provide services for veterans and families.13 Family eligibility has evolved to offer sliding-scale services, and “families” is now defined as spouses, children, and parents of deployed soldiers or veterans. Several respondents reported that the program has worked closely with the National Guard in the last few years to provide outreach and support at reintegration events, as well as responding to emergency mental health calls at Camp Ripley. The veterans program is run by a part-time coordinator and full-time VISTA national service program volunteer committed from Fall 2011 through 2013, and one interviewee reported that they are bringing another veteran counselor on board in August 2012. One mental health professional, however, said these services are still underused by eligible community members. Several interviewees explained that a Mobile Crisis Outreach (MCO) and stabilization team serves the six counties through Northern Pines.14 In addition to responding to acute mental health needs in hospital emergency rooms, homes, and law enforcement facilities, the MCO team 13 See also http://www.npmh.org/Veterans%20Service/NPVSMP%20Brochure2.pdf. 14 See also http://www.npmh.org/mobile-crisis-outreach.html. E-122

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has been called to Camp Ripley “on occasion . . . anyone in need is never turned away from here.” The value of MCO to Ripley, which includes a counselor with military experience, came up in several interviews and one person said, “We wouldn’t survive without them.” Another interviewee described several instances when the team was called to Camp Ripley and successfully identified issues of addiction and suicidal ideation.15 Several interviewees mentioned the contributions of Lutheran Social Service (LSS), a Minnesota not-for-profit organization, in providing services for veterans. LSS C.O.R.E. (Case Management, Outreach, Referral and Education) is a statewide program for military, veterans, and family members. A few interviewees emphasized the value of the program’s financial counseling. LSS C.O.R.E. also provides telephone mental health counseling and referrals. One person the study team spoke with, however, said that some community leaders described challenges in providing referrals to local resources, which are discussed in the following pages. Physical Health Services St. Gabriel’s Hospital is located in Little Falls. It provides full-service care, and underwent significant renovation in 2007, expanding patient care facilities. The hospital is the first place many local area residents arrive after being injured or if they experience a mental health crisis bceause it has the only emergency room (ER) in the area. They see occasional traffic in the ER from Camp Ripley related to the county’s MCO efforts. A hospital worker explained that with an eight-bed ER, the community’s resources are insufficient to address the most acute psychiatric needs. She went on to explain the value of the crisis team and mediating the security hazards posed by treating people in crisis in the ER: It can take hours and hours to find a place to place someone that needs placement. They end up at the far corners of the state. . . . There is a safety problem both for them and for staff, in your small critical access hospitals, which is all Morrison County has, and surrounding us. We don’t have behavioral health units. We don’t have psychiatrists. . . . When you’ve got somebody in a locked room and you’re supposed to be watching them all the time with a sheriff outside guarding them. That wouldn’t happen if we didn’t have the crisis team there. We still have eight other rooms that are full, plus people in the waiting room. [Hospital employee] Military and VA Supports The National Guard and VA reportedly provide the first line of support to activated National Guard members and their families through the FAC and other services at Camp Ripley, FRGs, the VA clinic in Brainerd, and the expanded VA campus in St. Cloud. The mayor in Little Falls commented, “I would say they handle it among themselves.” Formal events during predeployment, at demobilization, and at 30/60/90-day reintegration events were described by various respondents as important supports. At these large events, National Guard members are reportedly provided with information about benefits, asked 15 See also Brunswick, M. (2012, January 29). Anti-suicide program for military runs low. StarTribune. Available at http://www.startribune.com/local/130949523.html. E-123

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individually about service-connected injuries, enrolled in the VA Health Care System (with “80 to 90 percent enrollment in Minnesota” according to one military leader), and provided with contact information to access a range of services. Local providers, including the Morrison County VSO and Northern Pines veterans program, told us that they participate in these events. For example, the VSO speaks with returning soldiers individually to identify any service- connected injury or disability, including mental health issues that may be presenting, and help them complete VA paperwork. There was general agreement that many of the mental health issues the counselors see postdeployment with veterans and families present at or after a 1-year “honeymoon period.” One National Guard member informally mentioned a new 1-year reintegration event, but this does not appear to be a statewide program. Both military-affiliated and civilian interiewees unanimously identified the FAC at Camp Ripley as a primary support for addressing stressors around the deployment cycle. Several of them described how counselors listen to stories of individual challenges, follow up on concerned phone calls from neighbors, and connect service members and their families to needed services. For example, the FAC provides assistance to National Guard families with financial issues by contacting community volunteers to shovel snow and by giving them grocery cards from the community or firewood from Camp Ripley. Several interviewees told us that the FAC proactively offered consistent individual outreach to those who might be struggling, and counselors told us that they are on call 24 hours a day. One source close to the Camp Ripley FAC told us: Some of [the veterans served] you had to seek out. Maybe their neighbors would call and say, “I know he’s been out of work and his unemployment stopped from deployment. They have no groceries and I’m getting worried about them.” I would call them up and say something like, “I’m calling everybody that was deployed. . . . How are things going?” They always say, “It’s going great.” “Oh really? Are you working yet?” “No.” “Well how are you feeding your family and paying your bills?” “Well that’s an issue.” Then they start talking about it and pretty soon we’re paying their rent and their electric. You can’t wait for them to come in, because most of them won’t. They’ve still got that military pride. [Community member] Interviewees identified FRGs as a support, but the effects are mediated because members of deployed units come from broad geographic areas. One FRG leader said the geographic distance “is hard. You send emails to these people, but very seldom will they travel 100 miles to attend a 2- or 3-hour FRG meeting. . . . We did make phone calls from time to time too, but most of the time you do not put a name and a face together.” In part because soldiers attach and reattach to multiple units, FRGs were said to be less active or even “dormant” when the unit was not deployed. In addition, two women service members said their husbands were unlikely to participate in FRG activities. Several National Guard members and spouses described the challenges and said the primary contacts used for support are the FACs. Military OneSource was mentioned in passing in a few interviews as a resource during deployment, but its utility was limited for National Guard members and families before and after activation. In addition, two interviewees asked how you would counsel a child over the phone. E-124

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Several persons the team spoke with said that the St. Cloud VA Health Center has expanded services to meet the growing demand, including adding a women’s health clinic and increasing the number of mental health care providers to “almost 30.” Both veterans and service providers in Little Falls said the St. Cloud VA was doing a good job. As one service provider in the community said, “I can’t say enough positive things about St. Cloud VA, one of the best because it’s got the small-town flavor. At the Minneapolis one, you never see the same person twice. Locally, I think we’re doing well.” Although improved, services for veterans are still reportedly stretched. In addition, team members were told that, although veterans are legally entitled to time off of work for health care, they may be laid off if they regularly miss work for appointments. TRICARE was mentioned as the only health insurance some National Guard members could obtain for their families. However, one provider said that “there have been huge issues around TRICARE and behavioral health reimbursement” and the paperwork is “a nightmare.” But another provider was more positive, saying, “On the medical side, it doesn’t take as long as it once did.” Other County Services Several interviewees referred us to the Morrison County VSO, who helps those who were deployed to the OEF/OIF theaters to navigate the bureaucracy of the VA and access physical and mental health benefits after deployment. Although the VSO is state mandated, several interviewees told us that the supports provided by the Morrison County VSO are exceptional. These include presentations and brief one-on-one sessions during reintegration events, as well as assisting returning soldiers in filling out VA paperwork, reviewing VA decision letters, and helping with appeals as needed. The office provides counseling, assistance in obtaining benefits for any service-connected disability, and transportation in the Veterans Van once a week to the St. Cloud VA Health Center. At a time when other counties were downsizing their VSOs, the Morrison County Commission reportedly approved expanded staffing to include a veterans service case aide and provided more private office space in the county office building to increase confidentiality for veterans seeking help and offer more support than counties with larger veteran populations. As a result, in addition to serving OEF/OIF veterans and other veterans in Morrison County, two interviewees told the team that the office is now contacted by veterans from other counties for assistance. Beyond the Yellow Ribbon of Morrison County Beyond the Yellow Ribbon (BTYR) is a Minnesota program to link military members and their families to informal programs and supports in the community. 16 The Morrison County effort, which several interviewees said is in process, has 12 subcommittees to address how to connect individuals with services across domains in what one committee member called “single touch.” Many interviewees described it as an important way for community members to show support and said it will be strong when in place. Yet there were questions from a few community members regarding the value of BTYR to National Guard members and their families; currently there are significant overlaps with FAC, which is the major point of referral; and one resident 16 See http://www.beyondtheyellowribbon.org/yellow-ribbon-community-campaign. E-125

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who was very familiar with the resources at Camp Ripley described the services provided by theBTYR as “vague.” The Military Family Care Initiative, created by then-Minnesota First Lady Mary Pawlenty and mentioned by a few community members, has been incorporated into BTYR. 17One National Guard member said she had used the program to locate services. She contacted a Lions Club group in St. Cloud while she was deployed; they sent a group of volunteers to spend a day chopping wood for her family. Gaining BTYR status involves identifying and connecting leaders in key areas, including city/civic/military, public safety/judicial, and businesses/employers.18 Although team members were told that the action plans have not been completed by the various committees, several interviewees reported increasingly systematic efforts to ensure that businesses are military friendly—for example, offering a discount to individuals with military identification and joining Employer Support of the National Guard and Reserve (ESGR). ESGR businesses receive tools to locate returning service members and a tax credit for participating. One small business owner in town showed us a statement of support that she had signed a few hours before. Social Capital Virtually all community members the team spoke with identified Little Falls as a small town with a “neighborly” culture, and informal supports appeared to be strong. Small Town Relationships Team members heard from a variety of sources that extended families live in the region, everyone knows everyone, families help families, and neighbors help neighbors in need. The community also appeared to be receptive to newcomers.19 Several residents who had relocated from elsewhere in Minnesota to work at Camp Ripley described informal supports they had received that the team viewed as comparable to the supports described by those whose families had been there for generations. Interviewees commonly offered the examples of shoveling snow or taking care of children without pay. One interviewee described a variety of informal supports provided to her husband and children while she was deployed: [What] he did have was a friend at Ripley who provided childcare at Ripley. . . . My girlfriend’s family took my girls for free on weekends. . . . That was huge. [My husband] would get to drop them off on Friday, pick up on Sunday, mow the grass, do whatever . . . I have a church that’s very nice. While I was gone, someone picked up my child and brought her to school for a year, back and forth to daycare. So I think it’s individual help. [City government employee] One downside of the reliance on informal supports, according to several interviewees, was that National Guard members and their families do not always ask for help when they need 17 See https://www.militaryfamilies.state.mn.us/about.php. 18 See http://www.beyondtheyellowribbon.org/images/stories/PDF/YRRP_Min_Requirements_and_Best_Practices -City.pdf. 19 During the site visit, team members did not encounter anyone who was not origina lly from Minnesota. E-126

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it. Virtually all interviewees told us that people want to help, but a few stated that “they don’t know how,” and another explained that needs must be identified by the individual or someone close. Local families were described as “proud,” and people may refuse help or be angry if help is provided without a request. However, interviews with residents indicated that even if someone does not ask for or refuses help, formal services, such as those from Northern Pines and the FAC are sometimes engaged by a call from a neighbor. One service provider recommended asking specific questions—for example: “Do you need anything? ‘No.’ Do you need your gutter cleaned? ‘Well, yes.’” Extensions of Formal Supports Several of the individuals who provide formal deployment cycle support were identified by interviewees as the go-to people to address the impact of multiple OIF/OEF deployments on Little Falls. This round-the-clock availability was also described in several interviews as a community stressor leading to “burn out” among the staff of the key programs. One community member described the continuing late-night calls she receives to drive a drunk National Guard member home after return from deployment. She went on to say: Even though I’ve quit my job, I’m still doing it, kind of. I’m still out there and helping. . . . Families still call me, because I’ve been doing it for so long, to ask questions about retirement, “What if I get deployed again? How do I go about getting into the VA?” So I answer questions like that. If you go to the fair and things somebody is always stopping you and asking what can I do about that. Hopefully I can help them. If I can’t, I can’t, and I send them to the Family Assistance Center then . . . I’m probably always going to do that. [Community member] Another resident told us about how serving local veterans presents a personal challenge: I had an episode a couple of months ago. I went to the grocery store after work and one of these guys—not OIF/OEF ers—bumped into him in a parking lot, he’s chewing on my ass all the way into the grocery store, bitching about the VA . . . what kind of compensation is that . . . I told him to call me in the morning, I can’t do a damned thing about it at the grocery store. I give him the slip. He must have had a mission, because there I am going through checkout and he’s waiting to chew on me all the way out to the car. After a while that gets more than a little old. [County government employee] Faith Community The faith community does not appear to play a central role in addressing the impacts of multiple deployments in Little Falls. Churches were mentioned in only a few interviews, and military support was not evident on church websites. A church employee described a clergy forum at the St. Cloud VA to address issues they might see in their membership related to deployments, as well as available VA services. One community member described a church that assembled decks of playing cards for deploying soldiers; another mentioned sending care packages. Otherwise, the help provided from the faith community was described as “individual” by several community members. E-127

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SUMMARY As one interviewee told us: “People make the difference.” Though formal structures are slowly coming into place, Little Falls is a small town that still relies heavily on its people to support its community members. What’s Working In Little Falls, residents are the souce of many of its strengths in assisting active duty and activated National Guard members and families during deployment and reintegration. Such supports are often personal and occur on a case-by-case basis. Interviewees also praised strong leadership in the community for improving and expanding organized supports to assist military members and veterans and their familites, including those who have experienced multiple deployments. They spoke positively about the following efforts:  The Veterans Service Office in Morrison County: This office helps veterans and National Guard members navigate the bureaucracy of the VA after deployment. Both the Morrison County office space and staff were expanded to meet growing needs.  Northern Pines: With the increased the need for mental health services for veterans, service members, and their families, the leadership at Northern Pines has been extremely responsive, supporting half of the costs for the expansion under the organization’s overhead. One of the services provided by Northern Pines is the Mobile Crisis Outreach (MCO) program, a partnership among six counties that is meeting a need on base and in the community for soldiers that go into crisis or are suicidal or have suicidal thoughts. The program also provides needed security in hospital emergency rooms, providing staff to separate the patient from others seeking care at the ER.  Beyond the Yellow Ribbon: Though still in development in Little Falls, many community leaders believe this program holds promise for offering a one-stop shop to connect service members with community resources. Because it is a joint effort between the community and the National Guard, it has the potential to organize community capacity, thereby reducing burden on key liaisons and preventing burnout. Other community leaders were less enthusiastic, however, and were waiting to see how the BTYR program distinguishes itself from other, extant community efforts.  Good working relationship between Little Falls and Camp Ripley: Solid communications between the base and the town were believed to have helped mitigate the effects of multiple deployments on Little Falls. Community Needs Community members raised several concerns related to deployments, with some concerns focused on current needs but others addessing potential longer-term needs: E-128

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 Several community members raised concerns about the long-term mental well-being of service members and the future services they will need. National Guard members the study team spoke with believe the 30/60/90-day postdeployment screenings are valuable, but both those members and mental health professionals pointed out that mental health issues may arise later than 90 days—sometimes 12 to 18 months after they return from deployment.  Two interviewees close to the National Guard were concerned that people are falling through the cracks. One described the challenge that exists when National Guard members want to remain deployable and do not seek needed services. If they do not report military-related injuries or health problems on a timely basis, they will not be eligible for VA disability claims later when their problems worsen and may affect their employability.  Some mental health professionals interviewed by the study team indicated that postdeployment mental health screenings available to National Guard members are not as effective as they could be. One interviewee observed that these screenings are not as consistent as those available to Army soldiers. They said that mental health screening questions during the 30/60/90-day reintegration events were asked by VSOs, who might be great at referring service members to appropriate clinicians, but who generally are not trained in mental health issues and interventions. Unless service members self-report, they said, the responsibility is on the chain of command (especially the first sergeant) to identify symptoms of depression or posttraumatic stress and encourage service members to seek help.  Most community members the team spoke with think there are insufficient mental and behavioral health supports for children in military families. Community members frequently had trouble articulating what the needs are, except to say “children act up.” But some members we spoke with observed anger among teenagers. Others were concerned about behavioral responses among elementary school-aged children, for example, ages 6 to 8.  Community members also observed a general lack of formal supports for military families. Team members were told that the FRG model is not always a reliable support for families of the deployed because members of the National Guard units are geographically dispersed. Military spouses we spoke with were as likely to turn to the FAC as to their FRG leader. Moreover, there were no support groups in Little Falls. Northern Pines observed that when they attempted to set up groups on post, the main interest was from the spouses. However, the timing and location of the groups was not conducive to attendance by families or spouses.  With the impending drawdown in troops, local community members pointed to the long-term need for economic opportunities for returning service members. Without jobs, these community members felt that behavioral and mental health problems would escalate. E-129

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 Some interviewees pointed to the need for supports for the supporters. Although the dedicated individuals that make up the fabric of Little Falls are unquestionably a strength, the emotional nature of the work takes a toll. One mental health professional said, “Everyone who works with the veterans burns out.” Supporters themselves have sought counseling to deal with the stress of working with service members and veterans.  Though many community members were satisfied with Camp Ripley’s efforts to engage the community, a few raised questions about how effectively Camp Ripley communicated details about events, such as job fairs and welcome home activities for returning troops. Others said that, even though Camp Ripley publicized base events in the local newspaper, it was not always clear whether these events were for the public or military families only. Suggestions from the Community The community offered the following suggestions for possible improvements or next steps that may help address the needs associated with multiple deployments:  The military should add a mental health screening beyond 90 days because mental health issues may surface later on.  Providers of mental health supports should increase the number of mental health professionals with military experience. Interviewees said it is the shared experience that increases credibility and makes service members more willing to confide in a mental health professional: One OIF/OEF veteran who provides mental health services said, “We’ll send a professional out there. They’ll talk for 2 hours and will get almost nothing. I go out there for 10 minutes, they ask me where I served, I tell them. Boom, we have all the information we need.”  Children with parents who are deployed should receive counseling. Rather than formal counseling, the visit could be an informal check-in. One participant suggested play therapy for toddlers, and another participant suggested a “chat” to help children process their feelings.  There should be more education for the business community on mental health issues among service members. This type of outreach, such as a seminar or a forum, would help educate employers on what symptoms or issues to look for in service members they employed and how they could assist service members in reintegration efforts.  More entrepreneurship supports should be provided in order to improve jobs in the region. As National Guard members reintegrate into the community, they may aspire to open their own businesses. Businees leaders said entrepreneurship supports would help the National Guard members to understand how to start and manage a small business. E-130