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7 Postdeployment Reintegration INTRODUCTION Family- and Work-Related Problems of Deployment Although it has come to be well understood that deployments to combat or operations other than war can be highly stressful experiences, the challenges of the return home for service members and their families are frequently given less attention. Nonetheless, aspects of readjustment to the home environment have proved to be significant sources of concern to returning veterans. Many return- ing Vietnam veterans struggled with relationships with their bosses, coworkers, wives, family, and sexual partners (Egendorf, 1982~. Egendorf and colleagues' interview of veterans for their Legacies of Vietnam study found that about 50 percent of the veterans interviewed showed signs of disturbing, unresolved war experiences that affected their everyday lives (Egendorf et al., 1981~. The Na- tional Vietnam Veterans Readjustment Study found that 45 and 37 percent of men and women, respectively, serving in the Vietnam theater reported having at least one serious postwar readjustment problem and that roughly one in four Vietnam theater veterans continued to experience at least one such problem when they were surveyed in 1990 (Kulka et al., 1990~. Veterans who were ex- posed to war-zone stress displayed poorer levels of adjustment in family roles and marital relationships than civilians or veterans from the same era who were not deployed to Vietnam (Kulka et al., 1990~. After the Gulf War, veterans reported concern about family-related matters, money, and employment. In one group, although 12 percent suffered moderate or severe war-zone stress reactions, 19 percent experienced moderate or severe family adjustment problems (Figley, 1993b). Although no two deployments are alike, some of the experiences of recent deployments may be helpful when considering future needs and possible pre- ventive interventions. Separation from family has always been an important stressor during deployments, but the changing makeup of the deployed force has led to some new challenges. During the Gulf War, the percentages of deployed women and reserve-component service members were larger than they have ever 121

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122 STRATEGIESTOPROTECTTHEHEALTHOFDEPLOYED U.S. FORCES been. About 7.2 percent, or roughly 50,000 of the 670,000 service members de- ployed were women, 9.8 percent were members of the Reserves, and 6.2 percent were members of the National Guard (Gray et al., 1998~. More single parents and military career couples were also among the deployed than in the past (Figley, 1993b). For example, 16 percent of Vietnam veterans were married with children during their service in Vietnam (U.S. Department of Defense, 1991), whereas 60 percent of Gulf War service members were married with children during their service in the Gulf (Dove et al., 1994a,b). The first major deployment of women in a war was during the Gulf War, which also took a different type of toll on some families, in that significant numbers of men or extended family members were left in unaccustomed roles of caring for young children or infants. For financial reasons, many of these fami- lies chose to leave military bases to join relatives, but this placed them some distance from the support services available at the bases (Scurf~eld and Tice, 1992~. Upon the return of service members from deployment, families needed to readjust both to changed roles and often to changed locations. For the more than 20,000 single parents or almost 6,000 couples deployed to the Gulf (U.S. De- partment of Defense, 1991), finding appropriate long-term child care was an additional source of stress before, during, and, perhaps, after deployment. The health and well-being of the family members left behind is often a chief concern of deploying service members. Some have mentally or physically dis- abled dependents (elderly parents, special-needs children) whose medical care is a particular worry. The availability of adequate support services for these fami- lies during the deployment and into the reintegration period is crucial (Holloway, 1999~. The unprecedented call-up of National Guard and Reserve units for the Gulf War had a strong effect on service members and their families. Even after the fall of the Berlin Wall, many reserve personnel were under the impression that they were a reserve to the active component, to be called only in case of another world war. Following notification that they would be deployed, their unit mobi- lization plans included 30 to 90 days of training before deployment. Therefore, they had never planned to deploy in just a few days' time (Meyer, 1999~. Others had not anticipated that they would ever be called to a regional conflict and felt inadequately prepared, either emotionally or in terms of training, for participa- tion in warfare (Scurf~eld and Tice, 1992~. Extremely rapid deployment of troops (some within 36 hours) allowed little preparation for departure. Reserve component members thus frequently left behind disrupted families and careers. This rapid deployment also affected thousands of service members and their families who served in European theaters away from combat during the Gulf War (Ford et al., 1998~. After the deployment, many who were self-employed returned to find their businesses in trouble (Yerkes and Holloway, 1996~. A re- cent literature review considering stress and the Gulf War postulates reservists and reserve units to be at greater risk for stress reactions for the several reasons cited above (Marshall et al., 1999~.

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POSTDEPLOYMENT REINTEGRA TION Effects of Downsizing and Increased Operational Tempo 123 The National Guard and Reserves were not the only service members to return home to financial uncertainty. As the Gulf War deployment came to an end, the services were carrying out a substantial downsizing that meant many who might have liked to continue on active duty did not have that option (Johnson and Broder, 1 99 1; Lancaster, 1 992; Leavitt, 1 996; McCormick, 1 996; Landay, 1997~. In 1992, when the U.S. Congress contemplated cuts of up to $15 billion in the defense budget, Defense Secretary Richard Cheney announced that 300,000 active-duty personnel would be let go to allow savings of that magni- tude (Lancaster, 1992~. The Army active-duty force was reduced from 800,000 people at the height of the Gulf War to about 500,000 by the end of 1995. In April 1995, Defense Secretary William Perry notified the Army that it must pre- pare for further personnel cuts to 475,000 people, the smallest number of Army personnel since 1939 (McCormick, 1996~. The numbers of Selected Reserve personnel were at their largest (1.2 million) in 1989 (Leavitt, 1996~. However, by 1998, the total had fallen to roughly 890,000 (Kohner, 1999a). Decreases in support services frequently accompany decreases in numbers of personnel. Thus, at the same time people are downsized or encouraged to leave active duty, there are decreases in resources and support to make their transitions easier or mitigate their effects (Holloway, 1999~. Often the people who provide such support services are members of the reserve component, and they are deactivated just as they are needed for the reintegration process. At the same time that the sizes of the services have been decreasing, the op- erational tempo of the military has increased to an historic high. Between 1960 and 1991, the Army engaged in only 10 operational events, excluding training and alliance-related events. Since 1991, however, the Army has conducted 28 opera- tional events. The Marines had 15 contingency operations during the years 1982 to 1989; however, since the fall of the Berlin Wall the Marines have had 62 contin- gency operations (Baseman, 1999~. The Air Force is undergoing long-term de- ployments such as Operations Southern Watch and Northern Watch in Southwest Asia. The likely length of the deployment of U.S. forces as part of the North At- lantic Treaty Organization deployment to Kosovo is unknown as of this writing. The added deployments and contingency operations have come at a time when the number of Army divisions has been reduced from 18 to 10, the number of Navy ships has been cut from 546 in 1992 to 333 today, and the number of Air Force fighter wings has been slashed from 25 to 13. The quality of life of members of the military is slowly eroding because of the increased operational tempo and the continued reduction in personnel and resources (Baseman, 1999~. The health of veterans themselves is another particular challenge of home- coming. After the return of the military from deployment to Panama, families reported concern and confusion over symptoms exhibited by some of the re- turned service members. Symptoms included isolation, moodiness, detachment, and sleep disturbances (Scurf~eld and Tice, 1992~. The symptoms experienced by many Gulf War veterans also caused considerable concern to families, con

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124 STRATEGIESTOPROTECTTHEHEALTHOFDEPLOYED U.S. FORCES cern that was heightened following reports of"mystery illnesses" that began to appear in the media in the years following the return of service members from the Gulf War. Given the array of challenges described above, the period of return and re- integration after a deployment is a time when service members face particular hardships. The section that follows reviews the literature for available evidence about steps that might be effective in assisting service members upon their re- turn. A description of the programs that are currently in place in the military to help service members with reintegration follows. MILITARY REUNION AND REINTEGRATION LITERATURE REVIEW Information Gathering Psychological, sociological, and medical literature databases were surveyed for information on reintegration and reunion topics for the period from World War II to the present. Databases were accessed through the National Library of Medicine's MedLine, the American Psychological Association's PsycFirst, PsycINFO, and PsycLit, and from Sociological Abstracts, Inc.'s Sociological Abstracts database. Few studies on reintegration into the home environment for nonmilitary workers have been published in the searched literature. Similarly, few studies on the reintegration of military personnel of other countries were found. As a result, the literature review that follows primarily reflects findings from studies of U.S. military personnel and their families. Coping with family separations and reunions is a frequent reality of military life. Although much has been written on the process of separation of family and the service member in terms of emotional outcomes and coping strategies, there is relatively little systematic research on the specific theme of reunion- reintegration and emotional behavior (Mateczun and Holmes, 1996~. The fol- lowing summarizes the current understanding of features of reunion and reinte- gration based on information found in the literature. Family Factors The nature of a service member's homecoming is related to the terms on which she or he left the family. The type and frequency as well as the interper- sonal tone of communication during the period of separation also shapes expec- tations upon return. Leaving home at a time of unresolved conflict can result in hurtful discussions and angry feelings with family members while the service member is away. Leaving home on good terms enhances communication and, consequently, facilitates a pleasant homecoming (Yerkes and Holloway, 1996~.

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POSTDEPLOYMENT REINTEGRA TION 125 Families are encouraged to write letters, send electronic mail, telephone, and send audiotapes. Service members are encouraged to do the same, but it is sug- gested that they address the family members individually to personalize their communications (Black, 1993~. An easy transition back into the home environment also depends on how well a family has adapted to the long absence. Studies of prisoners of war (POWs) suggest that longer separations require more time for a family to reach equilibrium upon the POW's release and return (McCubbin et al., 1975; Nice et al., 1981~. Wives of POWs who have children or wives of POWs who work or who are more active and socially oriented through community activities, family support groups, and church functions cope better than those who do not perform such activities (Black, 1993; Figley, 1993b; Wood et al., 1995~. Work by Hunter (1984) indicated that those at great risk for poor adaptation to the separation were "immature, extremely dependent spouses, foreign-born spouses, and spouses who were isolated within a civilian community and expected veterans to make up for lost time by devoting more time to family matters" (Mateczun and Holmes, 1996, p.376~. Factors in the marital relationships of POWs were also relevant for success- ful readjustment. Spousal agreement on the husband's future career plans was crucial, and agreement on relationship roles was more important than who actu- ally performed the roles (Hunter, 1984; Mateczun and Holmes, 1996~. Reunion Period The literature indicates that during the reunion period, the service member goes through three phases: return, readjustment, and reintegration (Mateczun end Holmes, 1996~. Return Phase The return phase of reunion entails the anticipation of the reunion and the actual physical reunion of those who have been separated. This is a stressful period because changes in both the service member and his or her family have taken place during the separation, and there is apprehension about what these might be and how they will be responded to (Mateczun and Holmes, 1996~. Readjustment Phase The readjustment phase is the time during which service members and their families tend to modify their behavior to fit back into a lifestyle together. As mentioned above, each family member will have changed over the course of the separation. The readjustment period involves reaching an understanding that

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126 STRATEGIESTOPROTECTTHEHEALTHOFDEPLOYED U.S. FORCES these changes have occurred and allowing time to establish homeostasis (Figley, 1993a; Mateczun and Holmes, 1996~. During the readjustment phase, the re- turning service members typically experience initial culture shock and emotional overload that may cause the spouses to be emotionally separate. Some couples may have some sexual difficulties during this time. These may be due to factors such as unresolved feelings about the separation, known and unknown marital infidelities, or unresolved, unchannelled aggression (Peebles-Kleiger and Klei- ger, 1994~. In some families, however, the opposite may occur during the read- justment phase. There may be feelings of physical closeness, euphoria, and ex- citement with children and spouses. Couples may go through a honeymoon phase during which talking and reestablishment of intimacy take place until the first argument sets in. Reintegration Phase The reintegration phase is a time when the service member eases his or her way back into a routine, and returns to the day-to-day civilian or garrison life. To avoid upsetting the balance established during the service member's absence, the veteran must slowly work his or her way back into the family. The married couple works to reestablish intimacy as children and parents also try to reestablish famili- arity and connectedness (Peebles-Kleiger and Kleiger, 1994~. Families may need to be reminded to give each other some time to get reacquainted and learn the new roles and perspectives that may have been acquired during the separation. Families who expect changes in each other may be better able to cope with those changes and renegotiate their new relationship (Blount et al., 1992~. Ordinarily, changes in the handling of financial matters, household chores, and other responsibilities among family members have been made while the service member has been away, and attempts to maintain a lifestyle like the one before the separation may no longer be welcomed. The spouse who is left at home as the head of the household often matures, develops greater independence and self-confidence, and provides a different lifestyle for his or her family in the absence of the spouse (Boss et al., 1979; Nice et al., 1981; Ford et al., 1993; Wood et al., 1995~. A reliance on negotiation and compromise to work toward sharing the responsibilities can help during the reintegration phase. Although the return home from a deployment and reintegration into the home and work environment are challenging enough for the typical active-duty service member, they pose particular challenges for those who retire or who are discharged from the military upon their return. These persons must not only re- adjust to the family and home routine but must also begin an entirely new work life, with the attendant stresses of the job search and a new set of expectations in a very different work culture (Wolfe, 1 99 1; Figley, 1 993b).

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POSTDEPLOYMENT REINTEGRA TION 127 Return of the Wounded or Ill Veterans who are wounded or ill also face special challenges. Family and coworkers expect a quick return to normal and wonder why, once the physical wounds are healed, the returned service member is not the same as before the deployment. Complete healing may come slowly for some, if at all. Approxi- mately 479,000 (15.2 percent) of the estimated 3.14 million men who served in the Vietnam theater had posttraumatic stress disorder (PTSD) in 1990. An esti- mated 8.5 percent (610) of the 7,166 women who served in Vietnam had PTSD in 1990 (Kulka et al., 1990~. Role of Family in Readjustment Families have an important role in promoting readjustment behaviors in the returned service member. This role can be manifested in four related ways: (1) detecting traumatic stress, (2) confronting the trauma, (3) urging the recapitula- tion of the tragedy, (4) facilitating resolution of the trauma-inducing conflicts (Figley, 1995~. Changed patterns of behavior can be detected because family members are aware of each others' habits and dispositions and can easily detect a behavior change or traumatic stress once the family member has returned from the deploy- ment (Figley, 1995~. Once the behaviors are recognized, family members are in a position to confront the traumatized person about them either by approaching him or her directly or in a more subtle and indirect manner (Figley, 1995~. Families can promote readjustment behavior by encouraging the traumatized veteran to summa- rize what had happened before the return through answering five basic questions: (1) What happened to me that was so traumatic? (2) Why did it happen to me? (3) Why did I and others in the same situation act as we did? (4) Why have I acted as I have since then? (5) If something like this happens again, will I be able to cope more effectively? (Figley, 1988, 1995~. Addressing these questions may be more difficult when the behavior change is a response to more subtle challenges than a particular traumatic event. For example, the veteran could be disappointed that the family he or she returned to differs from the one that he or she remembered and envisioned while on deployment. Finally, families can help in facilitating resolution of the internal conflicts. For example, they can help with the healing by providing more positive or opti- mistic ways to view the stressful events and their consequences (reframing) (Figley, 1995~. With supportive listening, they can help the traumatized person with clarifying insights and help with more appropriate assignment of blame and credit (Figley, 1995~.

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128 STRATEGIES TO PROTECT THE HEALTH OF DEPLOYED U.S. FORCES Family Roles in Readjustment in Non-Military Settings Like families of military personnel, family members of corporate executives also must frequently reorganize the family system when a spouse is away on business. Although the absences are often not as prolonged as in military sepa- rations, a spouse is sometimes gone long enough to require a reorganization of family roles. Boss and colleagues used a coping inventory to study 66 corporate wives. A factor analysis indicated that wives coped with the stress of routine absence of a husband or father by fitting into the corporate lifestyle, developing maturity and interpersonal relationships, and establishing independence (Boss et al., 1979~. Although several studies of coping behaviors for separations in the civilian community have been conducted, research is lacking concerning family coping upon reintegration (Boss et al., 1979; Mateczun and Holmes, 1996~. Prevention of War-Related Stress for Family Members No studies have confirmed the effectiveness of specific programs for pre- venting war-related stress for families of service members (Figley, 1993b). How- ever, Figley describes several factors associated with lower levels of family mem- bers' stress due to separation and reintegration: (1) preparation of the service member and his or her family for all aspects of deployment with briefings and educational materials; (2) frequent contacts with other families in similar situa- tions to provide support groups for families and service members; (3) provision of educational programs for the community so that it can support and encourage the families of service members; (4) provision of accurate and timely information about the health, safety, and return schedule of the service member; and (5) provi- sion of a contact point for returning service members to ensure provision by the military of adequate health and human services especially for those who do not live near military installations, for example, members of the reserves and their families (Hill, 1949; McCubbin et al., 1974; McCubbin et al., 1976; Hunter, 1982; Kaslow and Ridenour, 1984;Hobfolletal., l991;Wolfe, 1991~. PROGRAMS TO ASSIST FAMILIES AND SERVICE MEMBERS WITH REINTEGRATION The armed services have developed various programs to assist service members and their families through their return and to ease the transition into the home environment. Because no studies have confirmed the effectiveness of specific programs to help families and service members, the military programs were developed on the basis of experience and anecdotal evidence. Few of the programs offered by the services are mandatory. Instead, it is generally up to service members to seek out the programs for themselves and their families.

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POSTDEPLOYMENT REINTEGRA TION 129 Navy Support Services Some of the earliest programs to assist service members with homecoming were developed by the Navy. The Navy's return and reunion programs are based on three assumptions: (1) separations due to deployments are normal, even though they are stressful events in Navy family life; (2) Navy families are not dysfunctional; they are basically healthy families; and (3) increasing a family's cohesion, adaptability, and communication supports the overall goal of the pro- grams offered by the Navy (Tinney, 1998~. Because they are a part of the Navy, Marines also have access to the Navy programs. During deployment, several means are used to maintain communication between families and deployed personnel. For example, the Navy established services whereby families can make videotapes of themselves and send them to the service member. Aboard ships service members have opportunities to do the same. This service is rapidly being supplanted, however, by the increased use of electronic mail and sailor phones aboard ships (Stokoe, 1999~. This change has been evident at the world's largest naval base in Norfolk, Virginia, which contains 300,000 sailors, Marines, civilian employees, and fam- ily members. During the recent deployment Operation Desert Fox, the use of electronic mail was far greater than that during any other deployment and was a family's primary means of staying in contact with service members (Vogel, 1998~. Some service members feel that electronic mail gives them a great boost in morale and allows them to help resolve problems at home faster because of the faster communication with family members (Della Cava 1998~. The Navy Family Ombudsman program is another way to keep families abreast of relevant news and information during the deployment and the return. The program was developed in 1970 and was standardized in 1994 to provide each command with an official representative to provide information and refer- rals to families, serve as a point of contact between the commands and families during deployment, and provide newsletters that contain family information (B. Ray, 1998~. The Navy established the first family service center in Norfolk, Virginia, and now has 68 centers throughout the world to provide assistance and counsel- ing for families of service members (Tinney, 1998~. In the early 1970s, Navy chaplains began providing informal support and help for sailors as they prepared for the return home. In 1980, an official return and reunion homecoming pro- gram was developed at the Norfolk Family Service Center (Stokoe, 1999~. As part of this program, a team of two to six individuals, usually education and pro- gram specialists, meet with the sailors at sea and with family support groups at home before the service member's return. They find out what some of the ap- prehensions and common concerns are and then relay the information between groups to provide service members and families with better coping strategies (U.S. Army Combined Arms Command, 1991; Tinney, 1998~. The time is spent facilitating group discussions and giving interactive presentations both in person and through closed-circuit television (Tinney, 1998~. Programs for couples, sin

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130 STRATEGIESTOPROTECTTHEHEALTHOFDEPLOYED U.S. FORCES ale sailors, sailors reuniting with children, and others are also available (Tinney, 1998~. Frequently, command leadership requires attendance for briefings cov- ering financial concerns and reintegration with family (Stokoe, 1999~. Upon their return, Navy service members go through a redeployment proc- ess that includes checklists about their medical and dental status and any family problems that might exist (for example, family health problems). Since the service member is eager to return home, he or she may not necessarily bring up problems that might delay the return (Conner, 1999~. Lifelines is a new initiative introduced by the Secretary of the Navy. It uses the Internet (www.lifelines4qol.org), teleconferencing, satellite broadcasting, and cable television to respond to quality-of-life needs of active-duty members, reservists, U.S. Department of Defense (DoD) civilian employees, and their families. This system of care allows families and service members to access community information and services at their own pace in their homes or local libraries without traveling long distances (Stokoe, 1999~. Army Support Services The other armed services have developed similar family center programs. The Army has provided increased support for service members and their fami- lies since the Gulf War. New guidelines, training curricula, briefings, work- books, and videotapes have been developed to better educate soldiers and their families. These tools are a part of an Army-wide program called Operation READY (Resources Educating About Deployment and You) that was developed for both active duty and reserve component personnel including the National Guard (Barnard, 1999~. Operation READY provides guidelines to facilitate helping soldiers and families with issues concerning reunion into the home envi- ronment. Using Operation READY, family centers assist families with financial matters and other needs while the service member is deployed. Family support groups formed at individual units, primarily at company levels, can receive help from the Family Assistance Center staff (U.S. Army Combined Arms Com- mand, 1991; Barnard, 1999~. Family Assistance Centers provide a contact that families can turn to for questions and concerns, provide referrals to agencies appropriate for their needs, and distribute monthly newsletters that provide accu- rate information about the troops during a deployment (U.S. Army Combined Arms Command, 1991~. Air Force Support Services The Air Force family support centers provide a variety of programs for service members from all branches of the military. There are programs for relo- cation assistance, transition assistance, career focus, information and referral, personal financial management, volunteer services, resource networks for em

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POSTDEPLOYMENT REINTEGRA TION 131 ployment, family services, and family readiness (Coyle, 1999~. An array of services provide support related to separation and reunion. Stress management classes are offered to couples and families during and after deployment to help in coping with the stresses of separation and reunion. At Boiling Air Force Base, the First Sergeant's Adopt an Airman program offers service members of all ranks an opportunity to talk about their deployments with a first sergeant and discuss fears and anxieties about returning home. The first sergeant acts as a liaison for higher-ranking officials and enlisted members (Coyle, 1999~. The Hearts Apart program provides support groups to help families express their feelings and concerns during a deployment and prepare them for their reactions when their loved ones come home. The readiness program also provides video teleconferencing, video electronic mail, and international calling cards for fre- quent communication while the service members are away. Programs to Help Support National Guard and Reserves The three services have developed many programs to assist active-duty serv- ice members and their families in coping with the emotional and mental chal- lenges of reintegration and reunion after a deployment. Although all components have addressed these issues to some degree since the Gulf War, the provision of support services in the National Guard and Reserve has been more inconsistent (Ogilvy-Lee, 1999~. Individuals who join National Guard and Reserve units are civilians with regular jobs outside of military life. They frequently do not live close to military bases. When they are called to military duty they are given the assurance that their jobs will be waiting for them when they return. By law, their jobs are protected for 5 years, but even with this legal protection, some reserve members have reported subtle discrimination that is difficult to prove (Barnard, 1999~. Members of the reserves who own their own businesses may return from service to find that their businesses have failed (Ogilvy-Lee, 1999~. The Army Reserve uses the Operation READY training program to prepare soldiers and their families for deployment and reintegration. The Army Re- serve's Family Readiness Offices are located at its Regional Support Commands and 7th ARCOM (Army Reserve Command) in Germany. These Family Readi- ness Offices manage the mobilization assistance program (deployment assis- tance) for family members. They also manage the unit Family Support Group Programs that are essential in the Army reserve and receive strong program and command emphasis. Since units are geographically dispersed, the unit support groups are important in reaching out to help family members directly. Deployed soldiers maintain contact with family members by telephone and through infor- mational mailings (e.g., newsletters). Operation READY reunion materials are used by family support group volunteers to help family members prepare for the soldiers' return. Soldiers are now provided reunion briefings at the demobiliza- tion station used for all Army Reserve soldiers returning to the United States after a deployment. Chaplains and Family Readiness Offices coordinate reunion

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132 STRATEGIESTOPROTECTTHEHEALTHOFDEPLOYED U.S. FORCES workshops for both soldiers and family members about 6 weeks after redeploy- ment (which is often the time of the end of the "honeymoon phase"), as re- quested by the units when problems begin to appear in families (Barnard, 1999~. During the Gulf War in 1990 and 1991, the deployment of many more Air Force reservists than in previous deployments raised concerns about providing support for their reintegration to the home environment. Although no official programs were in place for the Air Force Reserves immediately following the Gulf War, programs to provide help in separation and reintegration issues began in 1993 in response to a survey that showed a need for family support-type pro- grams (Bassett, 1998~. Rather than relying on volunteers, the Air Force Reserve Family Readiness Program employs professionals to provide help in separation and reintegration issues for Air Force reservists and their families. Counseling and educational workshops as well as relevant resource materials are available on installations. In contrast to the other service reserves and National Guard, Air Force Reserve personnel are located on active-duty installations and air reserve bases, thus enabling ready access to programs and support (Bassett, 1998~. The Navy and Marine Reserve forces are provided with the same family service centers, support groups, and programs provided to Navy active-duty forces if they have been deployed continuously for 2 weeks or more. As with the Army Reserves, however, there are problems of access for those reservists and their families who live far from a base. However, activities such as the Reserve Mobili- zation Exercises (drills and exercises that help reservists prepare for deployment) and the newly begun Lifelines have the potential to provide greater access to pro- grams that help reservists and their families during deployment and reintegration. The National Guard has a dual federal and state role and mission and is made up of the Army National Guard and the Air National Guard. During a period of 1 year from late August 1990 through August 1991, the National Guard set up 471 family assistance centers and served 257,731 military family members from all services throughout the 54 U.S. states and territories (Ogilvy-Lee, 1999~. Each state and territory has a full-time State Family Program Coordinator, who oversees the unit family support programs. Support at the unit level for the Guard members and their families is provided to a significant degree by specially trained volun- teers, who are assisted by a unit military member trained in family assistance. Training workshops, booklets, and referral within the state and the local commu- nity are used extensively to assist and support Guard members and their families. Guard units also have Operation READY program materials available to them. As noted by other directors of readiness programs within the reserve component, not enough family program funding and full-time employees are available to provide the support needed for the National Guard (Ogilvy-Lee, 1999~. VA Support Programs The U.S. Department of Veterans Affairs (VA) also has programs to assist in the return and reintegration of service members into the home environment

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POSTDEPLOYMENT REINTEGRA TION 133 after deployments. The U.S. Congress authorized the establishment of Vet Cen- ters in 1979 to provide readjustment counseling, particularly for needs sur- rounding war-related psychological trauma including PTSD (Flora, 1999~. Vet Centers are administered by the VA's Readjustment Counseling Service (RCS), and are community-based, nonmedical facilities intended to provide maximum ease of access for local veteran populations and to emphasize postdeployment rehabilitation in an informal setting. Currently, 206 Vet Centers in the United States and its territories provide services to veterans (both active-duty and reserve) of deployments to World War II, the Korean War, Vietnam, the Gulf War, Lebanon, Grenada, Panama, and Somalia (U.S. Department of Veterans Affairs, 1998a,b; Flora, 1999~. The services include assessment for PTSD, counseling and psychotherapy, family counseling, educational and supportive counseling to help veterans with current civilian life, employment and educational counseling, and multiple referral services (Flora, 1999~. Community outreach and local networking are important components of the services provided by the Vet Centers as are collaborations with local VA medical facilities. The Vet Centers serve as the community access point for VA health care for many veterans (Flora, 1999~. Vet Centers are typically staffed by a four-person team with a team leader, two counselors, and an office manager. Vet Center teams include psychologists, social workers, nurses, and other professional counselors and paraprofessionals. Roughly 80 percent of all Vet Center counselors and team leaders are veterans and about 60 percent have served in combat theaters (Flora, 1999~. Vet Centers serve approximately 130,000 veterans each year and interact with more than 700,000 veterans and family members. The Vet Centers also make over 100,000 referrals to VA medical facilities each year. More than 96,000 Gulf War veterans have been seen at Vet Centers since April 1991. There are some indications that Vet Centers are helpful to veterans. Ac- cording to a Vet Center Readjustment Counseling Service client satisfaction survey, more than 90 percent of veterans seen at Vet Centers said that they would recommend the Vet Center to other veterans. Also, the Gulf War veter- ans' prospective PTSD study, undertaken by RCS in collaboration with the VA's National Center for PTSD, found that the rate of PTSD decreased in a treatment-seeking veteran group (Litz et al., 1995~. In addition, the final report of the Presidential Advisory Committee on Gulf War Veterans' Illnesses (1996b), praised the outreach services that the Vet C~enters were nrovidin~ to contact and inform Gulf War veterans. After the Gulf War, the U.S. Congress established an additional readjust- ment counseling resource specifically for Gulf War veterans. The Persian Gulf Family Support Program operated from October 1992 to September 1994 to provide services such as those carried out at Vet Centers as well as Gulf War illness-related outreach from 36 VA medical centers. The outreach included briefings for National Guard and Reserve units, local veterans service organiza- tion chapters, and grassroots family support groups. At day-long Persian Gulf Health Days, educational seminars on illnesses, traumatic stress, and VA bene ~. ~

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134 STRATEGIESTOPROTECTTHEHEALTHOFDEPLOYED U.S. FORCES fits were held for veterans and the general public. Veterans were able to enroll in the VA Registry at those seminars (Presidential Advisory Committee on Gulf War Veterans' Illnesses, 1 996b). Although evaluation of that program is beyond the scope of this report, the study team suggests that elements of the program found to be effective be im- plemented during rather than after future large deployments and given the flexi- bility to continue as long as the needs remain apparent. Special strengths of the Persian Gulf Family Support Program were its availability for both National Guard and Reserve components, its family-focused interventions, and its out- reach. Screening tools were used to help identify problems of individuals and families and assess program effectiveness to some extent (Altheimer, 1999; Murphy, 1999; Rathbone-McCuan, 1999~. Lessons learned from the program should be applied to similar programs in the future. However, since the final report of the program was presented to the U.S. Congress in 1994, no evalua- tions of the Persian Gulf Family Support Program have been conducted (Murphy, 1999; Rodell, 1999~. The plan recently released by an interagency working group in response to Presidential Review Directive 5 includes mention of the reintegration of service members after deployments. Among the goals articulated in the Deployment Health chapter is to "Preserve the health and well-being of those who have served and their families" (National Science and Technology Council, 1998, p. 12~. Several related objectives with associated strategies are presented to address this goal: Strategy 3.1.1: Develop interagency solutions to provide access to the appropriate levels of financial support, health services, and readjustment counseling for mili- tary service members' transition to future military service or civilian life. Strategy 3.1.2. Establish a combined DoD [U.S. Department of Defense], VA, DHHS [U.S. Department of Health and Human Services] plan to respond promptly and in a coordinated manner to both the anticipated and unanticipated health needs and concerns of veterans returning from major deployments. Strategy 3.2.4. Prepare DoD and VA plans for providing individual and family counseling and mental health services for military members and members of their families, especially in preparation for and upon the return home of the deployed military member. (National Science and Technology Council, 1998, p. 13) Although these strategies listed in the Presidential Review Directive 5 are indeed sound and reasonable, to the study team's knowledge no steps have yet been taken to carry them out. FINDINGS AND RECOMMENDATIONS Finding 7-1: The changing demographics of the deployed forces, increased operational tempo, and increased reliance upon the reserve component all bring

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POSTDEPLOYMENT REINTEGRA TION 135 heightened needs for support services for service members and their families both during and after deployments. Recommendation 7-1: Planning and operational documents for military deployments should be required to include plans for supporting the return and reintegration of active-duty and reserve service members involved in the deployment. These plans should specify anticipated problems and preventive and support strategies to deal with anticipated and unanticipated problems; the resources required to carry out the strategies; and proposals for how the required resources will be funded and made available. The funding consequences of the resulting requirements should be reflected in the regular funding cycle and in requests for supplemental funding asso- ciated with deployments. Finding 7-2: Since the Gulf War, the services, including the reserve compo- nents, appear to have made progress in responding to the support needs of serv- ice members and their families during reintegration. The resources and person- nel to provide support to the reserve components appear to be less robust and perhaps lacking, however, given the increasing operational tempo and reliance upon these reserve forces. Recommendation 7-2: As part of the planning described in Recommendation 7-1, particular attention is needed to address and provide resources for the readjustment needs of reserve-component service members and families. Finding 7-3: Evaluation of both the support programs and the premise for their use appears to be limited. Recommendation 7-3: Evaluate the efficacy of the readjustment programs in place on the basis of clearly stated objectives. Currently, such evaluations exist but are op- tional. Carry out research into the needs of service members and their fami- lies during deployments and upon reintegration into the home environment. Use the findings to reevaluate programs and policies. Finding 7-4: It is crucial that service members returning from deployment have seamless access to health care and support services and that they know what services are available and how to access them. This is particularly important for those who will no longer be part of the active-duty forces.

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136 STRATEGIESTOPROTECTTHEHEALTHOFDEPLOYED U.S. FORCES Recommendation 7-4: As outlined by the National Science and Technology Council, the U.S. Department of Defense and U.S. Department of Veterans Affairs should coordinate plans to have reintegration support and health care services available to service members upon their return and be pre- pared to continue it while needs for such services remain widespread.