This chapter examines the effects of deployments to Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) on communities. The committee studied the effects in two ways: First, it conducted an extensive review of the literature. Second, it commissioned ethnographic studies to illustrate the effects of the deployments on six communities either located near major military installations (Jacksonville, North Carolina; El Paso, Texas; Watertown, New York; Lakewood and Lacey, Washington) or having relatively large, recently deployed National Guard populations (Georgetown and Andrews, South Carolina; Little Falls, Minnesota).
REVIEW OF THE LITERATURE
The body of literature documenting the effects of OEF and OIF deployment on communities is scant. The committee found no community-wide assessments of the effects of OEF and OIF deployment. In an effort to find related research, the committee expanded its literature search to cover the community effects of any military deployment. The committee broadly defined the term community effect to refer to any impact on local public or private providers of goods and services.
Community-Wide Economic Effects of Deployments
The committee found no studies that examined the community-wide economic effects of OEF and OIF deployments. It did identify one study, published in 1994, that quantified, over a seven-county region, the economic effects of troops deploying from Fort Stewart and Hunter Airfield in Georgia (Kriesel and Gilbreath, 1994). At the time of the study, Fort Stewart held 25,000 Army troops and had had recent deployments—to the First Gulf War, and to Florida in response to Hurricane Andrew. Fort Stewart is a major employer in the surrounding rural communities. For the economic analysis, the investigators focused on the consequences of a 1,000-troop deployment for 1 year. That unit was selected so that study results could be extrapolated to future deployments of varying lengths and sizes. The investigators found that such a deployment is associated with decreased expenditures in sectors of the local economy including food, housing, retail, transportation, health care, and entertainment. In all, the authors estimated that the 1,000-troop deployment for 1 year reduced direct local spending by $10.56
Kriesel and Gilbreath (1994) applied those estimates to a software model for input-output analysis that contained county-level economic data. With the model, they were able to forecast the economic consequences of the deployment within the seven-county study area. The model showed that 240 economic sectors were affected by troop deployments from Fort Stewart; however, only 101 of the sectors were present in the seven-county study region, meaning that many of the economic effects associated with deployments from Fort Stewart were felt outside the immediate region. The results of the model are summarized in Table 7.1.
“Direct impact” as shown in Table 7.1 includes, for example, decreased sales at restaurants as a result of fewer patrons. “Indirect impact” includes the decreased purchases that restaurants in turn would make from wholesalers, as well as the ensuing chain of decreased economic activity (for example, wholesalers purchasing less produce from farmers, who in response might decrease their production the following year). “Induced impact” considers the broader economic fallout from the deployments—for example, reduced overall consumer spending caused by lower wages as a consequence of less revenue at local businesses. “Direct impact plus indirect impact plus induced impact” equals the total economic impact in the region for each of the categories in Table 7.1.
The column labeled “Total Gross Output” in Table 7.1 quantifies the impact that deploying 1,000 troops for 1 year has on the output of goods and services in the region. In 1991 dollars, such a deployment from Fort Stewart would reduce the total gross output in the seven counties by $13.87 million. Wages and salaries paid to employees of local vendors would be reduced by $4.15 million over the year, and total income (wages plus interest, profits, rental income) would be reduced by $7.05 million. Value added (employee compensation plus indirect business taxes and property income) would be reduced by $7.77 million, and a total of 266 jobs would be lost.
Although this type of analysis is geographically specific, it does shed light on how a deployment might affect local economies with heavy reliance on military installations. The Kriesel and Gilbreath study suggests that there are significant economic losses to communities that deploy a relatively high concentration of service members.
TABLE 7.1 Local Economic Impacts from Deploying 1,000 Troops for 1 Year, Fort Stewart and Hunter Army Airfield (in 1991 USD)
|Total Gross Output ($ in millions)||Wages and Salaries ($ in millions)||Total Income ($ in millions)||Value Added ($ in millions)||Jobs|
|Indirect + Induced Impact||‒13.8669||‒4.1519||‒7.0548||‒7.7697||‒266|
SOURCE: Kriesel and Gilbreath, 1994 (with permission).
The majority of reservists and National Guard soldiers hold private-sector jobs in the community (CBO, 2005). They are often activated for deployment with little warning, which can be disruptive and costly to employers. The effects of activation vary greatly among businesses that employ reservists, depending on the size of the business and the nature of the position vacated by the deploying employee. The most adverse effects of deployment are borne by small businesses that lose essential employees, businesses that rely on employees with highly specialized skills, and self-employed businesses owned by reservists (CBO, 2005; Hope et al., 2009).
Small businesses (fewer than 100 employees) employed about 18% of reservists in 2004 (CBO, 2005). Approximately 8,000–30,000 of 860,000 reservists in the Selected Reserves1 were estimated to hold key positions in small businesses in 2004. About 55,000 reservists (9% of total reservists in 2004) were self-employed or employed by a family business. Self-employed reservists were more likely to be in construction, legal, health care, and building-maintenance fields than were reservists who were not self-employed.
Types of Deployment Effects
The committee reviewed the limited literature documenting the effects of National Guard and reserve activation on civilian employers. According to the Congressional Budget Office (CBO), only 6% of businesses employ reservists. However, in communities with a higher concentration of National Guard and reservists, the effect of deployments can be more profound. That is particularly true among businesses that employ reservists in key positions or those with specialized skills (CBO, 2005).
Allison-Aipa et al. (2005) interviewed 28 private-sector employers of reservists to measure problems following the activation of the reservists. The employers were a convenience sample identified by a unit of the Maryland National Guard. The 28 employers, 39% of which were in law enforcement, reported that reserve activation had a negative impact on work scheduling (61%), product delivery (50%), coworker workload (68%), morale (29%), and the hiring and training of replacements (57%). Many reported that reserve call-ups came with too little notice (72%), at an inconvenient time (50%), and with an unclear length of assignment (61%). Most employers (71%) reassigned the responsibilities of the activated employee to his or her coworkers. Forty-two percent of employers stated that 2 weeks was the maximum that a reservist could be away before the workplace was negatively affected.
A CBO survey found that about 15,000 small businesses reported experiencing financial loss or difficulty operating their businesses in 2001–2004 (CBO, 2005). Reservists notified their civilian employers, on average, 13 days ahead of activation. Sixty percent of reservists gave their employers notice of 1 week or less. Unclear length of deployment further complicated employers’ responses to the reservists’ activation. In many cases it was not known how long a reservist would be away, making it difficult for employers to decide how to respond to the temporary vacancy.
1The Selected Reserve is a subset of reservists who are required to be available for mobilization within 24 hours. They are drawn from all services: the Air National Guard, Air Force Reserve, Army National Guard, Army Reserve, Coast Guard Reserve, Marine Corps Reserve, and Navy Reserve.
Call-ups of reservists have direct financial impact on their employers largely because the reservists’ jobs and some benefits are guaranteed to them by law when they return. The Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA; PL 103-353) requires employers to reemploy reservist employees after their service is completed; the act also prohibits employment discrimination based on past, present, or future military service. Returning reservists are entitled to continued pension benefits as if they had not been activated, and they have the right to retain their health coverage. When they return from activation, reservists are also entitled to career advancement and seniority benefits as if they had been continuously employed. USERRA does not require employers to pay salaries for reservists during mobilization, but some employers elect to supplement military pay.
The Institute for Defense Analysis attempted to quantify the cost to employers resulting from reserve activation (Doyle et al., 2004). On the basis of published civilian age-group and firm-size data, Doyle et al. estimated that 50–58% of employed reservists participate in an employer-provided retirement plan and that employers’ costs for reservists’ retirement plans average $372 per month. In addition, using published civilian age-group and firm-size data, Doyle et al. estimated that about 65% of reservists participate in employer-provided healthinsurance plans and that the monthly employer cost averages $215 for a single individual and $550 for a family.
Small businesses are disproportionately affected by the loss of reservists who are ordered to active duty, because an employee at a small firm accounts for a greater share of output than that of an employee at a large firm. Doyle et al. (2004) interviewed a small number of recipients of Small Business Administration Military Reservist Economic Injury Disaster Loans, which are given to companies that are unable to meet their operating expenses after an essential employee has been called to active duty. The findings indicate that the most common effect of activation is lost business and that losses are experienced even after reservists return from active duty. Furthermore, replacing a reservist, even if it is feasible, does not necessarily offset lost business; in some cases the long-term effect of activation might result in permanent harm to the business (Doyle et al., 2004).
The CBO study found financial effects similar to those cited above (CBO, 2005). Health care coverage for activated reservists who elect to keep their employer’s health coverage costs about $260 per month for individual coverage and about $600 per month for family coverage, regardless of how long the activation lasts. If the employer offers a matched contribution to the reservist’s retirement plan and the reservist continues to contribute while activated, the employer is required to continue to match the contribution for the duration of the activation. The CBO estimates that paying this benefit costs employers about $175 a month, or $2,100 for a 1-year activation, for each participating reservist. Some employers voluntarily pay benefits that exceed those required by USERRA. For example, CBO reports that 16% of recently activated reservists continued to receive either partial or full salaries for the duration of their activation.
Effect on the Workforce
A study conducted by the RAND Corporation found that the overall effect of reservist activation on the workforce was minimal (Loughran et al., 2006). The study found that, at most, activated reservists or deployed active-duty service members constituted 0.2% of the workforce
nationwide in 2001–2004. The study notes, however, that active-duty service members and reservists are geographically concentrated, and thus the effect of their deployment is likely far greater in some communities than in others.
For active-duty deployments, the authors found that for every 10 service members deployed, about one civilian is hired and enters the workforce. It is unclear why this occurs, although the authors speculate that it might be due to the entering of the workforce by spouses of deployed service members while their husbands or wives are away (Loughran et al., 2006). For every reservist activated, the authors found a corresponding short-term decline in the workforce; after 4 months, however, employment levels return to preactivation levels, which is likely due to employers simply taking time to hire replacement workers. The authors acknowledge that although in the aggregate, activations and deployment are not likely to have any long-term effect on the US economy, certain communities and businesses with relatively large concentrations of reservist employees might feel the brunt of deployment more significantly. Police departments, for example, are often staffed by reservists and might have difficulty restaffing in the short term following activations. This is especially true in smaller communities where the pool of eligible trained officers looking for work is likely minimal.
Hickman (2006) examined the effect of reserve activation expressly on police forces. The analysis, covering a 12-month period, found that about 2% of the police workforce nationwide was activated in 2003. However, the rate of activation varied greatly depending on the size of the force and community. For example, in the 362 law-enforcement agencies supporting larger communities (250,000 or more), 1.6% of the workforce was activated. The 4,178 law-enforcement agencies serving small-to-medium-sized communities (10,000–49,000) lost 3.7% of the workforce to activation. However, the 9,941 agencies serving small communities (10,000 or less) lost 11.4% of the workforce. Costs associated with those losses are mostly attributable to the increased overtime needed to compensate for the lost workforce. Using the Department of Justice’s Law Enforcement Management and Administrative Statistics (LEMAS) survey data, the author calculated that the total cost per activated officer was $650–$2,000 per week. Hickman estimated the total cost per law-enforcement agency was $2,050–$6,020 per week.
The Small Business Administration looked at revenue loss in small businesses related to reserve activation (Hope et al., 2009). The authors found that among small firms (100 or fewer employees), for every reservist activated there was a 0.30% decrease in sales. In large firms, a 0.02% decrease in sales was associated with every employee activated. This 15-fold difference in sales impact demonstrates the heavier toll experienced by small businesses. The authors also found that for every 10% increase in activations of 30 days or more, small firms face a 3.7% decrease in sales.
Programs to Assist Employers
The committee is aware of programs and federal laws designed to lessen the financial burden that employers of reservists or self-employed reservists face when reservists are activated and deployed. The Veterans Entrepreneurship and Small Business Development Act of 1999 (PL 106-50) allows small businesses that lose essential employees or owners to active duty to defer payment of preexisting direct loans from the Small Business Administration. The law also requires the Small Business Administration to lower the borrower’s interest rate. This law helps many activated reservists who are self-employed, considering that they are generally essential employees or owners.
The Servicemembers Civil Relief Act of 2003 (H.R. 100) can also help relieve the effects of activation on self-employed reservists by allowing them to reduce certain business-debt interest costs and, under certain circumstances, to terminate business leases before a call-up. Finally, the Military Reservist Economic Injury Disaster Loan (MREIDL) program under the Small Business Administration provides funds to help an eligible small business meet the ordinary and necessary operating expenses that it is unable to meet because an essential employee was called up for active duty (US Small Business Administration, 2011).
Employment of the Returning Veteran in the Community
When veterans return to their communities, they need to readjust to the civilian workforce. Recently separated reservists have the opportunity to return to their previous positions because employers are required by law to hold the reservists’ jobs open. But recently separated veterans who enlisted in the military at a young age might be entering the civilian workforce for the first time. As discussed in Chapter 8, among those in the labor force, veterans who served after 2001 have higher rates of unemployment than do their civilian counterparts. One reason might be that approximately 20–25% of returning veterans have psychiatric symptoms or diagnoses (Hoge et al., 2006; Jacobson et al., 2008; Seal et al., 2007; Tanielian and Jaycox, 2008).
Burnett-Zeigler et al. looked at employment status among 585 National Guard service members recently separated (45–60 days), returning from OIF and OEF (Burnett-Zeigler et al., 2011). Less than half (41%) of the participants were employed at the time of the survey. Those who reported recent combat exposure were more likely to be employed (46%) compared with those who did not report recent combat (36%). Physical- and mental-health status, posttraumatic stress disorder (PTSD), depression, alcohol use, and anxiety did not affect the participants’ employment status. Among the employed, 79% were employed full time. Service members below age 30 were less likely to be employed than those 31 or older (29% and 57%, respectively). In the adjusted analyses, those with better mental-health status and poorer physical-health status were more likely to be employed full time vs part time. The authors note that more time might be required for the negative effects of mental-health status, alcohol use, recent combat exposure, and PTSD to affect employment rates. Additionally, Burnett-Zeigler et al. suspect that having a psychiatric illness or combat trauma might affect the maintaining of employment more than it affects the obtaining of employment. The authors also note that selection bias should be considered, as only 60% of those approached chose to participate in the study.
Erbes et al. (2011) studied 262 National Guard and reserve service members who returned from OIF after a 16-month deployment. The authors conducted structured diagnostic interviews with these individuals on their reentry into civilian life and sent out a questionnaire 1 year later. In total, 5% had PTSD, 6% had subthreshold PTSD, 11% had major depressive disorders, and 11% were experiencing alcohol abuse or dependence. The study found that the rates of employment of the study participants at both time points did not differ from the rates of employment in veterans without a psychiatric diagnosis, but those with psychiatric diagnoses reported functioning, at both time points, at a lower level of work performance.
Smith et al. (2005) looked at PTSD-symptom severity and its effect on employment outcomes. Researchers used the Clinician-Administered PTSD Scale (CAPS) to measure PTSD-symptom
severity in the 325 Vietnam-era veterans participating in the study. All participants had either severe or very severe symptoms. For every 10-point rise in the CAPS score, indicating a meaningful increase in PTSD symptoms, the likelihood of no employment increased 5.9 percentage points (p < 0.01). Correspondingly, the probability of part-time work decreased 2.1 percentage points (p < 0.01), and the probability of full-time work decreased 3.8 percentage points (p < 0.01). CAPS scores did not have any significant association with earnings for fulltime workers or all workers (full-time and part-time combined).
Taken together, studies of employment show that veterans who have psychiatric illness are at a disadvantage in obtaining or maintaining employment. When they are employed, it might only be part time rather than full time, or they might be functioning at lower levels. PTSD appears to be the strongest risk factor for occupational impairment.
Community Interventions to Assist Employment
There are many Department of Veterans Affairs (VA) and other public- and privatesector programs and interventions designed to help veterans enter the workforce. The question is: What types of vocational services are most effective for veterans with psychiatric illness? Resnick and Rosenheck looked at the relationship between PTSD and employment among 5,862 veterans in Veterans Health Administration Compensated Work Therapy, a vocational rehabilitation program (Resnick and Rosenheck, 2008). This program, dating back to the 1930s, aids veterans with disabilities in obtaining competitive employment in the community, working in jobs they choose, and receiving compensation. The VA employs them, finds work for them at other federal agencies, or enters into contracts with private providers that employ them. Resnick et al. found that veterans who had received a diagnosis of PTSD were 19% less likely to be employed on completion of the program (odds ratio [OR] = 0.81, 95% confidence interval [CI] = 0.69–0.96, p = 0.02) compared with veterans who had not received a diagnosis of PTSD. Mood disorders and substance-use disorders were unrelated to employment. Compared with unemployed veterans, employed veterans were more likely to be younger, to receive less public financial support, and to have fewer medical conditions. Veterans with severe mental illness were less likely to be employed. Those who had served in a theater of operations had higher rates of employment, a finding that the authors assert was anomalous. In terms of program efficacy, 30% of veterans who had received a diagnosis of PTSD were employed on completion of the program vs 36% of veterans who had not received a diagnosis of PTSD—rates that the authors considered to be low.
Rosenheck and Mares (2007) examined the individual placement and support (IPS) approach to job training for veterans who had a diagnosis of mental illness. IPS is an evidencebased practice that stresses rapid job placement, choice of jobs, emphasis on obtaining competitive jobs, ongoing support without a time limit, and integration of vocational support and clinical care (Bond et al., 2001). The Rosenheck and Mares (2007) study compared employment outcomes between two cohorts: the Phase 1 cohort of 308 veterans participated in the VA program before the IPS was established in 2001, and the Phase 2 cohort of 321 veterans received IPS. Both cohorts were followed and interviewed quarterly for 2 years. Because the cohorts were not assigned randomly, the analyses were adjusted for characteristics that were significantly different between the two groups. Veterans were eligible if they were homeless, were not receiving VA health services, sought competitive employment (a non-VA job in the community), had received a diagnosis for a psychiatric or substance-use disorder, and had been unemployed
for the previous 30 days or longer. The Phase 2 group had 15% more days per month of competitive employment (8.4 days compared with 7.3 days; p < 0.001) and 32% fewer days of noncompetitive employment (a job through the compensated work therapy program, for example). Overall, days of combined employment (competitive and noncompetitive) were not significantly different between the groups; however, the difference in the number of competitive work days was significant at eight of the nine study sites.
Davis et al. (2012) were the first to perform a randomized controlled clinical trial of IPS in veterans who had received a diagnosis of PTSD. Veterans were randomly assigned to receive IPS (n = 42) vs standard vocational services (n = 43) sponsored by the VA. Over the course of 12 months, 76% of IPS recipients gained competitive work vs 28% of controls—that is, the IPS group was 2.7 times more likely to gain competitive employment. Further, the IPS recipients worked substantially more weeks and earned higher income. Taken as a whole, the evidence supports IPS as a preferred type of vocational rehabilitation service. Communities serving veterans can utilize this model to deliver vocational assistance for veterans who do not qualify for VA services.
Homelessness and Community Impacts
Among veterans, those who are homeless have the greatest needs for community-based services—not only for shelter but also for identification and amelioration of the risk factors for homelessness, including psychiatric and substance-use disorders. Consequently, the community-based services needed by the homeless are wide ranging. They include housing, employment, health care, social services, education, and outreach, among others.
Epidemiology of Homelessness Among Veterans
By January 2009, only 916 veterans of OEF and OIF had formally sought VA homeless services (Perl, 2010). However, the VA has classified an additional 2,986 OEF and OIF veterans at risk for homelessness. Those numbers are relatively low at present, but the risk of homelessness can continue for many years after separation, and the current numbers might well not be indicative of lifetime incidence. For example, 76% of homeless Vietnam combat veterans reported that they had not been homeless for at least the first 10 years after separation (Perl, 2010).
The committee is not aware of any studies examining the population-based prevalence of homelessness among those deployed to OEF and OIF. There is one study of the prevalence of homelessness in a national sample of 1.1 million recipients of VA mental-health services: it found that of 124,471 OEF and OIF veterans, 4,478, or 3.8%, were homeless in 2009 (Edens et al., 2011). That figure is likely to be an underestimate because it only examined recipients of VA mental-health services. The only other estimate, made by the VA and the Department of Housing and Urban Development (HUD), pertains to all homeless veterans—irrespective of deployment. The most recent estimate by the VA and HUD is that 75,609 veterans were homeless in January 2009. Of those, 57% were in shelters or transitional housing, and 43% were either on the street or in a place not intended for human habitation, such as in an abandoned building (US Department of Housing and Urban Development and VA, 2011).
From 2008 to 2009, 1 of every 168 veterans, or 136,334 veterans, spent at least one night in an emergency shelter or in transitional housing. Veterans are about three times more likely
than are nonveterans to be homeless. Veterans make up less than 8% of the general population, but they comprise about 12% of the overall homeless population and, more specifically, 16% of the homeless adult population (US Department of Housing and Urban Development and VA, 2011).
Minorities are overrepresented among homeless veterans. African Americans constitute 34% of homeless veterans but are only 10.5% of the overall veteran population. Similarly, Latinos are 8.3% of homeless veterans but comprise only 3.6% of the overall veteran population. Native Americans make up 3.4% of the homeless veteran population but are only 0.7% of the overall veteran population. Homeless veterans are generally older, with only 7% of homeless veterans being younger than 30 years of age, compared with 26% of homeless nonveterans (US Department of Housing and Urban Development and VA, 2011). Males who are 45–54 years of age and women who are 18–29 years of age are at higher risk of homelessness compared with those of other ages (Fargo et al., 2012).
Similar demographic data are contained in a report from the Congressional Research Service (Perl, 2010). Homeless veteran men are generally older and better educated as compared with nonveteran homeless men. Homeless veteran women are also more educated than their nonveteran homeless counterparts, and homeless veteran men have more physical-health problems than those of nonveteran homeless men. Examined separately, female veterans, of all ages, are two to four times more likely to be homeless than their nonveteran counterparts (Perl, 2010).
Risk Factors for Homelessness in Veterans
Veterans and nonveterans share many of the same risk factors associated with homelessness (Balshem et al., 2011). These include childhood risk factors (absent or negligent parenting), living in foster care, and prolonged episodes away from home (as a runaway). The homeless, regardless of veteran status, tend to have similar rates of substance abuse, but it is unclear whether homeless veterans compared with the nonveteran homeless have comparable rates of mental illness and different overall health status. Certain veteran-specific exposures, including combat injury, intense combat exposure, and military sexual trauma, are associated with future mental illness and unstable income and employment, all of which are risk factors for homelessness in veteran and nonveteran populations.
Prolonged or intense combat exposure can negatively affect long-term employment, mental health, and other social outcomes, all of which can increase the risk of homelessness (Jacobson et al., 2008). Substance-use problems and weak social networks often emerge during active-duty service or during readjustment to civilian life. Alcohol abuse, a known risk factor for homelessness, is generally higher among male and female veterans as compared with the general population. Additionally, National Guard and reserve soldiers are at increased risk of new problem drinking in the postdeployment period after combat exposure. Among persons who are homeless, alcohol abuse is more prevalent among veterans than among nonveterans, but veterans and nonveterans had similar rates of other substance abuse.
Homeless individuals are more likely to engage in survival criminal behaviors, such as theft and prostitution, which can lead to incarceration (Balshem et al., 2011). Likewise, legal restrictions and other readjustment difficulties following incarceration increase the risk for homelessness. Adjusted for age, about 1,253 of every 100,000 veterans, or 1.3%, are
incarcerated, which is about 10% lower than the rate in the nonveteran population. Among incarcerated veterans in state prisons, 57% committed violent crimes, compared with 47% of incarcerated nonveterans who committed violent crimes. Legal and regulatory restrictions previously limited homeless veterans with criminal records and untreated drug abuse from accessing some public services. Recent policy changes by the VA and HUD under the Obama administration have relaxed these restrictions and established subsidized housing vouchers in an effort intended to end veteran homelessness by 2015 (VA National Center on Homelessness Among Veterans; Vogel, 2011).
War-zone stress among Vietnam-era veterans led to difficulties in readjusting to civilian life, to social isolation, and homelessness among white male veterans, according to the landmark National Vietnam Veterans Readjustment Study (NVVRS) (Kulka et al., 1990). In a followup study involving 1,460 male veterans from the NVVRS, Rosenheck and Fontana (1994) found that postmilitary social isolation, psychiatric disorder, and substance abuse were the strongest risk factors for homelessness. Several premilitary factors also increased risk, including childhood physical or sexual abuse, other childhood traumas, and placement in foster care during childhood.
The committee identified two studies on homelessness among OEF and OIF veterans. Tsai et al. (2012) characterized the homeless OEF and OIF veteran population, comparing it with the homeless veteran population overall. Investigators identified 994 OEF and OIF veterans among the 44,577 homeless veterans referred to the Housing and Urban Development–Veterans Affairs Supportive Housing (HUD–VASH) program between 2008 and 2011. OEF and OIF veterans were underrepresented in the homeless population in comparison with the overall veteran population (3% vs 12%). Naturally, however, OEF and OIF veterans are younger than veterans having served prior to OEF and OIF, and more time might be needed before the full extent of homelessness among OEF and OIF veterans is realized. The authors also found that OEF and OIF homeless veterans were much more likely to have received a diagnosis of PTSD compared with homeless veterans from prior conflicts (67% vs 8–13%). Among OEF and OIF veterans, 38% had a substance-use disorder. The authors point out that most homelessness services focus on substance-abuse problems, which is appropriate given the number of homeless with substance-abuse issues. However, they point out that among OEF and OIF homeless veterans, it might be more appropriate to focus on treating PTSD, given the very large number of homeless OEF and OIF veterans with the condition.
Edens et al. (2011) studied a national sample of veterans (1.1 million) who used mental-health services at the VA in FY 2009. The authors performed a nested case control study of OEF and OIF veterans, who constituted 11% of the national sample. Consistent with the findings involving Vietnam veterans, almost all psychiatric and substance-use disorders increased the risk of homelessness (Table 7.2). The major exception was PTSD, which neither increased the risk of, nor protected against, homelessness. The authors point out that this finding might be explained by increased outreach by the VA to aid OIF and OEF veterans to access services. The following factors protected against homelessness in this sample: receiving a service-connected disability rating, having income greater than $25,000, and living in a rural location. For reasons unclear, having an anxiety disorder was also mildly protective (OR = 0.9, p < 0.001).
|Diagnosis||Odds Ratio for Homelessness|
|Posttraumatic stress disorder||1.0|
ap < 0.01.
bp < 0.001.
cp < 0.0001.
SOURCE: Edens et al., 2011 (with permission).
Female veterans, as noted above, are at two- to fourfold increased risk for homelessness (Perl, 2010). Washington et al. (2010) looked at risk factors among female homeless veterans in Los Angeles, California. They matched 33 homeless women veterans with 165 housed women veterans on age, geographic region, and period of service. Significant risk factors for homelessness included unemployment (adjusted odds ratio [AOR] = 13.1; 95% CI = 2.7, 63.0); being disabled (AOR = 12.5; 95% CI = 3.5, 45.0); having a positive PTSD screen (AOR = 4.9; 95% CI = 1.9, 12.7); having been sexually assaulted during military service (AOR = 4.4; 95% CI = 1.4, 14.0); having a positive anxiety disorder screen (AOR = 4.1; 95% CI = 1.3, 13.2); and having overall fair or poor health (AOR = 3.2; 95% CI 1.3, 7.9). Having at least a college degree and being married were protective, lowering the odds of homelessness 5 and 10 times, respectively.
Community Services Needed by Homeless Veterans
The Congressional Research Service identified three needs that will have to be met to minimize homelessness among OEF and OIF veterans (Perl, 2010):
1. Permanent and supportive housing for homeless and low-income veterans,
2. Adequate transition assistance for recently returned veterans to help identify and mitigate issues that put them at increased risk of homelessness, and
3. Specific services for women veterans, such as treatment for physical and sexual trauma and child care for dependent children (North and Smith, 1993; Wenzel et al., 2000).
A more comprehensive range of services was identified by nearly 20,000 consumers and providers of homeless services who were surveyed by the VA (Kuhn and Nakashima, 2010). The consumer sample consisted of three groups of homeless veterans: those who are homeless, those in transitional housing, and those in permanent housing. The top 10 list of needs varies among the three types of homeless veterans and the providers, but there are many overlapping service needs, such as long-term permanent housing, welfare payments, child care, dental care, job training, and legal assistance (Table 7.3).
|Veterans Literally Homeless||Veterans in Transitional Housing||Veterans in Permanent Housing||Providers|
|1.||Long-term permanent housing||Welfare payments||Dental care||Child care|
|2.||Welfare payments||Child care||Legal assistance for childsupport issues||Legal assistance for child-support issues|
|3.||Dental care||Legal assistance for child-support issues||Welfare payments||Legal assistance for outstanding warrants and/or fines|
|4.||Guardianship (financial)||Family reconciliation assistance||Child care||Family reconciliation assistance|
|5.||Legal assistance for child-support issues||Guardianship (financial)||Legal assistance for outstanding warrants and/or fines||Legal assistance to help restore driver's license|
|6.||Job training||SSI/SSD process||Family reconciliation assistance||Credit counseling|
|7.||Legal assistance for outstanding warrants/fines||Long-term permanent housing||Credit counseling||Long-term permanent housing|
|8.||SSI/SSD Process||Legal assistance for outstanding warrants and/or fines||Reentry services for incarcerated veterans||Dental care|
|9.||Family reconciliation assistance||Discharge upgrade||Legal assistance to help restore driver's license||Help managing money|
|10.||Job finding||Women's health care||Job training||Guardianship (financial)|
SOURCE: Kuhn and Nakashima, 2010 (adapted from Table 7 on p. 13 and Table 8 on p. 17).
The VA survey was conducted by Project CHALENG (Community Homelessness Assessment, Local Education and Networking Groups). Launched in 1994, this VA program is designed to enhance the continuum of care for homeless veterans provided by the local VA and its surrounding community service agencies. The concept behind Project CHALENG is that no single agency is capable of providing the full spectrum of services required to reduce homelessness. Project CHALENG enhances coordinated services by bringing the VA together with community agencies and other federal, state, and local governments that provide services to the homeless to raise awareness of homeless veterans’ needs and to plan to meet those needs (VA, 2012a).
Community-Based Homelessness Programs
Communities that strive to provide services to homeless veterans need to be aware of (1) the federal housing and related social service programs sponsored by the VA and other federal agencies and (2) the research on the effectiveness of these programs. To implement their programs, the VA and other federal agencies often enter into contracts with local providers of community-based services.
The VA, HUD, and Department of Labor (DOL) have a number of programs for mitigating homelessness among veterans (Table 7.4; GAO, 2010). One of the most high-profile programs is the VA initiative to end homelessness by 2015. Under this initiative, community organizations can apply for grants for purposes including the following: to assist homeless veterans in obtaining housing and other federal benefits and to offer them temporary financial assistance toward rent, utility payments, security deposits, and moving costs. The initiative, begun in the summer of 2012, is expected to dispense $100 million to VA programs and community-based service providers nationwide (VA, 2012b). The initiative to end homelessness is affiliated with the joint federal program HUD–VASH, which provides homeless veterans with housing vouchers and VA case-management services. Voucher recipients pay no more than 30% of their income on rent. For FY 2012, Congress appropriated $75 million to the HUD–VASH program, with which HUD–VASH plans to house an additional 11,000 veterans. By the end of FY 2012, HUD–VASH will have issued 49,000 housing vouchers to chronically homeless veterans—80% of the administration’s target of 60,000 by 2015 to end chronic homelessness among veterans (National Coalition for Homeless Veterans, 2011).
TABLE 7.4 Targeted Homelessness Programs for Veterans
|Federal Agency||Program||Description||Funding, FY 2009 ($ in thousands)|
|VA||Initiative to End Homelessness by 2015||Make grants to community organizations to provide services to very-low-income veteran families living in, or transitioning to, permanent housing||$100,000|
|HUD–VA||HUD- and VA-Supported Housing (HUD–VASH)||Provide subsidized housing and services for homeless veterans||(HUD) $75,000 (VA) $54,218|
|VA||Healthcare for Homeless Veterans||Perform outreach to identify homeless veterans for VA services and assist them in accessing appropriate healthcare and benefits||$80,219|
|Compensated Work Therapy Transitional Residence Program||Provide vocational opportunities in residential setting for veterans recovering from chronic mental illness, chemical dependency, and homelessness||$22,206|
|Homeless Providers Grants and per Diem Program||Promote the development and provision of supportive housing and supportive services to help homeless veterans achieve residential stability, increase skill levels, and obtain greater self-determination||$130,000|
|Domiciliary Care for Homeless Veterans||Provide services to economically disadvantaged veterans||$98,789|
|Loan Guarantee for Transitional Housing for Homeless Veterans||Increase the amount of housing available, and provide services||$45|
SOURCE: GAO, 2010.
Research on the Efficacy of the Housing and Urban Development–Veterans Affairs Supportive Housing (HUD–VASH) Program
Researchers have studied the cost-effectiveness of HUD–VASH housing programs for veterans (Rosenheck et al., 2003). During a 3-year prospective study, the authors compared the cost-effectiveness of three different housing programs for veterans. Study participants included a total of 460 veterans: 107 veterans in San Francisco, California; 165 veterans in New Orleans, Louisiana; 91 veterans in San Diego, California; and 97 veterans in Cleveland, Ohio. Eligible veterans had to have been homeless at enrollment for 1 month or longer and had to have received a major psychiatric diagnosis (schizophrenia, bipolar disorder, major affective disorder, or posttraumatic stress disorder) or a substance-abuse disorder diagnosis. Participants were randomly assigned to one of three programs: (1) HUD–VASH, which included case management plus Section 8 housing vouchers2 (n = 182), (2) case management without special access to Section 8 vouchers (n = 90), or (3) standard VA homeless services (n = 188). Researchers followed up with participants every 3 months for 3 years in order to ascertain housing outcomes and the cost-effectiveness of supported housing.
Overall, the HUD–VASH participants had 36.2% fewer homeless days than those experienced by the standard treatment group and 35.8% fewer homeless days than those experienced by the case-management group. The case-management group was not significantly different from the standard treatment group. Veterans in the HUD–VASH program reported greater satisfaction with housing and reported fewer problems than were reported by the other groups. HUD–VASH participants also reported larger social networks and better relationships with family and friends. Researchers calculated cost-effectiveness acceptability curves which illustrate that the benefits outweigh the costs, depending on the societal value of a day of housing. If a day of housing is valued at $50, the researchers calculated a 56% probability that the benefits outweigh the costs. The probability goes up to 80% if a day of housing is worth $75.
2Section 8 housing vouchers are so named by virtue of the authorizing legislation: Section 8 of the Housing Act of 1937 (42 U.S.C. § 1437f). The law allows voucher recipients to choose any housing that meets the requirements of the program and is not limited to units located in subsidized housing projects. The administration of the housing vouchers is accomplished locally by public housing agencies. These agencies receive federal funds from the U.S. Department of Housing and Urban Development. See http://portal.hud.gov/hudportal/HUD?src=/topics/housing_choice_voucher_program_section_8 (accessed July 20, 2012).
O’Connell et al. (2010) conducted a 5-year longitudinal study that examined the housing and care provided to HUD–VASH participants. The study was a real-world analysis as opposed to the clinical trial of Rosenheck et al. (2003). HUD and local housing authorities, between 1992 and 2006, handed out more than 4,000 Section 8 vouchers to HUD–VASH participants. The VA, in turn, provided case management for the delivery of health and social services. O’Connell et al. studied 2,925 (71%) of the 4,125 veteran participants in the HUD–VASH program between August 1992 and July 2006. Most were recruited through the Health Care for Homeless Veterans (HCHV) program. About one-third of participants were homeless 1–6 months before they enrolled in the program, and nearly 20% had been homeless for 2 or more years. The investigators found that entry into the program was slow, taking an average of 161 days (Standard deviation [SD] = 213 days) after initial intake. Eighty-two percent of the sample was housed through HUD–VASH, and housing lasted 2.6 years, but not the 5 years advertised by the program. Only a small fraction of participants received rehabilitation (6%) or employment (17%) services. The investigators concluded that housing programs did not adhere to the stated aims of the program, either because of implementation failure or because the needs and preferences of veterans differed from those suggested by the program.
Residential Treatment Programs
McGuire et al. (2010) studied homeless veterans who participated in residential treatment programs of three different types. The authors sought to determine which type of program was responsible for housing and several other outcomes 1 year after the time-limited program ended. Three forms of residential care services, funded by the VA, were available:
1. Health Care for Homeless Veterans, which utilizes locally contracted halfway-house and substance-abuse treatment programs to provide residentially based treatment;
2. Grant and Per Diem (G&PD) program, which provides services and housing per diem payments to community-based grant recipients that also work with local VA medical centers to provide physical- and mental-health services; and
3. Domiciliary Care for Homeless Veterans (DCHV) program, which provides physical- and mental-health treatment, substance-abuse treatment, and sobriety maintenance, rehabilitation services, and work-for-pay programs at 35 locations, mostly at VA medical centers.
Nearly all 1,003 participants in the McGuire et al. (2010) study reported substance-use problems, a mental-health problem, or a serious medical condition, in addition to homelessness. One year after the residential treatment program ended, the investigators found improvement across eight outcome measures, including income, mental and physical health, quality of life, and independent housing. The outcomes did not differ by program type or diagnosis. Across each of the three programs evaluated, roughly 78% of all participants maintained housing at the 12-month followup. The investigators concluded that the benefits of the three programs were substantial. The type of program and diagnoses of participants had no differential impact on the salutary outcomes; the only factor that emerged as a positive predictor of program efficacy was length of stay. The longer the stay in the residential program, the stronger the gains were 1 year later. In other words, all three program types succeeded in improving the health and housing status of homeless veterans, with the greatest effects being tied not to program type but rather to length of stay.
The Homeless Veterans Reintegration Program (HVRP) is the only federal program that provides dedicated employment assistance to homeless veterans (National Coalition for Homeless Veterans, 2008). The program serves veterans who are ineligible for other assistance programs because of severe PTSD, long histories of substance abuse, serious mental-health problems, legal problems, and other health issues. Veterans with these issues require more rigorous attention and counseling to prepare them for the workforce than most employment programs other than HVRP can provide. After the emergency needs (shelter, food, substance-use treatment) of the veteran are met, HRVP assists in the finding and sustaining of employment for homeless veterans. The program then allocates the funding to community-based organizations and government agencies to provide job training, employment services, and other support. In 2007, 16,000 homeless veterans received these services through the program. In 2006, HRVP reported a 72.8% job-placement success rate. In 2007, the Government Accountability Office (GAO) named HRVP one of the most effective veteran homeless assistance programs in the country (National Coalition for Homeless Veterans, 2008).
Community-Based Mental-Health Care
Although the VA and the Department of Defense (DOD) provide a significant amount of mental-health care to returning service members, those agencies’ eligibility rules or limited capacity leave many service members and families with unmet needs for mental- and physicalhealth care. Communities often seek to fill such gaps by funding services of their own or by obtaining grant and contract funds from federal and state agencies to fund community-based services.
Although the DOD and the Veterans Health Administration (VHA; a component of the VA) are the primary sources of physical- and mental-health care for veterans and active-duty personnel, veterans and active-duty personnel have the option of receiving outside care if they are unable to access needed services. The VA and DOD contract with a myriad of community-based providers, but there is no central inventory of such providers that receive funding.
Apart from the VA and DOD, no other federal programs are dedicated to funding physical- and mental-health care for veterans. However, some federal grant programs are encouraged for use by veterans. One pertinent example is Access to Recovery, a $379 million discretionary grant program administered by the Substance Abuse and Mental Health Services Administration (HHS and SAMHSA, 2010). Grant recipients at the local level, which are often community-based service providers, distribute vouchers for substance-abuse treatment and recovery services. The latter includes family services (including marriage education, parenting, and child-development services), employment services, transportation, housing support, relapse prevention, and self-help and support groups. The vouchers can be used to obtain any kind of eligible care from any service provider in the community. Even though the program is not explicitly for veterans, grantees are encouraged to place special emphasis on directing vouchers to veterans.
In the 1990s, service fragmentation was recognized as a barrier to care in the VA Greater Los Angeles Healthcare System (GLA) (Blue-Howells et al., 2008). Before improvements to the program, GLA services were housed in several different buildings, requiring veterans (homeless and otherwise) to make multiple appointments and trips to receive all of the services (housing, mental health, ambulatory care) that were provided. Under this fragmented system, wait times of several months were typical, for both specialty and routine care. The wait time led to severe service underutilization, especially among the homeless with severe medical or cognitive disabilities. Based on a model at the West Haven, Connecticut, VA facility that consolidated physical- and mental-health services into one location (Druss et al., 2001), the VA funded a plan to integrate services for homeless veterans within a single building. Local funds were also used to finance the project.
The GLA designed the clinic, which opened in July 2002, to be a “one-stop shop” for VA services (Blue-Howells et al., 2008). When a veteran first arrives at the facility, he or she is assessed by the Access Center (intake office), which directs the patient to the appropriate providers that same day. Primary care, mental-health, substance-abuse, and housing services are offered. A monitoring and evaluation program was in place to help address any need for program adjustments.
For homeless veterans requiring specialty services (optometry or dentistry, for example) that operate outside the new integrated system, the GLA program established a system enabling homeless veterans to fill same-day cancellations and “no-shows” at the specialty clinics. This arrangement helps to ensure that veterans receive same-day service even when they require specialized attention. By 2007, some staff restructuring adjustments aside, the program was mostly unchanged from what it had been at its initial launch. Partially based on its success, the VA continues to mandate integrated mental-health and primary care for VA medical centers servicing 10,000 unique veterans or more (VA, 2008).
In recognition of barriers to the accessing of services, several states have taken the initiative to offer community-based services by entering into contracts with local providers. Washington state offers free PTSD counseling services through contracts with community-based providers (Washington State VA, 2012). One of the unique components of this arrangement is to educate teachers and school counselors with respect to the potential needs of school-age children of war-exposed parents. The State of New York offers mental-health screening and a host of other services under its New York National Guard Yellow Ribbon Reintegration program (State of New York, 2012). Colorado has established the Civilians for Veterans Fund, which offers free community-based mental-health and substance-abuse services (Colorado Behavioral Healthcare Council, 2012). California has a well-developed portal for providing veterans’ services, ranging from suicide prevention to treatment and recovery (California Department of Mental Health, 2012). It has an inventory of county-based offices where veterans can obtain care. Maryland has forged a Maryland Veterans Resilience Initiative, the purpose of which is to identify gaps in veterans’ services and to train mental-health professionals, primary care doctors, and clergy to deal with veterans’ unique needs (University of Maryland School of Public Health, 2012). The Maryland initiative is also tasked with developing peer-support networks to help
Veterans and the Criminal Justice System
There is a dearth of information regarding crime, incarceration rates, and risk factors expressly for OEF and OIF veterans. The only study that included information on OEF and OIF veterans found that they constituted only 4% of the entire veteran population in federal and state prisons in 2004 (Noonan and Mumola, 2007). Overall, in that same year, there were about 140,000 veterans in federal and state prisons, according to the Bureau of Justice Statistics (Noonan and Mumola, 2007). The bureau reports that the age-adjusted incarceration rate for veterans was about 10% lower than that in nonveterans in 2004 (1,253 per 100,000 vs 1,390 per 100,000, respectively). Veterans were, however, more likely to be serving sentences for violent or sexual crimes and more likely to victimize women or minors than were the nonveteran prisoners. Of incarcerated veterans in state prisons, 57% committed violent crimes, compared with 47% of incarcerated nonveterans (Noonan and Mumola, 2007).
One of the risk factors for incarceration among Vietnam veterans is combat exposure. Egendorf et al. (1981) found that 24% of those over age 23 with heavy combat exposure were arrested after service, compared with 10% of veterans with light or no combat exposure and 14% of comparable nonveterans. Other risk factors for incarceration include homelessness, mental illness, substance-use disorder, being a member of a minority group, and not being married (Balshem et al., 2011; Noonan and Mumola, 2007). These risk factors also apply to the general population (Hawthorne et al., 2012). One difference, however, is that veterans, most typically Vietnam veterans, are likely to be older than their nonveteran counterparts in jails and prisons (Greenberg and Rosenheck, 2011; Noonan and Mumola, 2007).
Needs for Services in the Criminal Justice System
Although veterans are not overrepresented in the criminal justice system relative to their representation in the general population, the US Center for Mental Health Services (CMHS) recognized the importance of satisfying unmet mental-health needs of combat veterans in the criminal justice system. Through one of its programs, in 2008 CMHS convened a consensus panel made up of 30 participants—representing community health providers, law enforcement, the courts, veteran service organizations (VSOs), veterans’ health programs, and federal agencies—to develop recommendations for criminal justice and community-based mental-health systems to connect justice-involved combat veterans with mental-health services (CMHS National GAINS Center, 2008). The five major recommendations of this group are as follows:
1. Screen for military service and traumatic experience (use an existing instrument).
2. Train law enforcement, probation and parole, and corrections officers to identify signs of combat-related trauma and the role of adaptive behaviors in justice-system involvement. Although such training is already occurring in some locations, it should be expanded.
3. Help connect veterans to VHA health care services for which they are eligible, either through a community-based benefits specialist or a transition planner, the VA’s OEF and OIF coordinators, or through a local Vet Center.
4. Expand community-based veteran-specific peer-supported services.
5. Beyond meeting mental-health needs, service providers should be ready to meet substanceuse, physical-health, employment, and housing needs. Because many of these conditions are co-occurring, comprehensive services should be available.
Veterans Treatment Courts
Veterans Treatment Courts (VTCs) are modeled after drug and mental-health treatment courts that emerged in the US judicial system in the 1990s. These courts, typically geared for lower-level criminal offenses, offer mandatory mental-health and substance-use treatment in lieu of incarceration (Clark et al., 2010). The courts, in other words, treat veterans not as criminals in need of punishment but rather as patients in need of treatment and rehabilitation. Defendants are closely monitored and held accountable for their continued treatment and sobriety (Office of National Drug Control Policy, 2010). There are currently at least 95 VTCs in 30 states (Justice for Vets, 2012). Funding for some of them comes from the Substance Abuse and Mental Health Services Administration, which seeks to address the behavioral-health service needs of justiceinvolved veterans.
The VA offers its full range of services to eligible veterans in VTCs (Holt, 2011). These include inpatient and outpatient treatment services and mental-health and substance-use treatment. This arrangement allows a veteran in a VTC to access his or her court-supervised treatment plan through a single point of service. Although the VA’s involvement varies depending on the jurisdiction, the VA typically works with the court to develop a court-approved treatment plan for the offender. In nearly all operating VTCs, VA staff is present during proceedings. Veteran eligibility for consideration in a VTC varies by jurisdiction; most VTCs consider all individuals with prior military service, but a few only see defendants eligible for VHA services. Some require a specific mental-health or substance-use-disorder diagnosis, and some require the diagnosis to be linked to the veteran’s military service.
VTCs vary regarding the types of charges that they will hear. Some courts, for example, will only hear misdemeanors, whereas others will hear certain felony charges. Some will hear only nonviolent charges, but others will consider certain violent charges, such as assault. Some states have legislatively mandated the eligibility criteria that the VTC must follow. In other states, courts often review defendants on a case-by-case basis when no laws have dictated the type of charge that triggers referral to a VTC.
Several states have passed legislation that either encourages or requires their judicial systems to establish VTCs. States and communities with preexisting drug treatment courts have led the charge. Federal legislation (111th Congress, S. 902) introduced to create a grant program to fund VTCs died in committee in 2009. The legislation would have required all federally funded VTCs to assign a veteran peer mentor for each defendant. It also would have barred from VTCs violent offenders or offenders with prior convictions for violent crimes.
Because VTCs are relatively new, studies have yet to examine their effectiveness in treating veterans and reducing or preventing recidivism. But the evidence is strong that comparable civilian programs are effective. Huddleston et al. (2008) examined drug courts (not specifically for veterans) in the United States in 2008. The authors reported that individuals who participate in drug courts are re-arrested at a lower rate than the rate of re-arrest of those that have committed similar offenses but proceed through traditional criminal courts. Additionally, drug courts were found to be more cost-effective than the traditional judicial process for drug
offenders, saving $4,700–$11,000 per defendant that might otherwise have been spent on future judicial proceedings and law-enforcement efforts. A related finding by McNiel and Binder (2007) pointed to salutary effects of mental-health courts: they lower the rates of recidivism and violence by individuals with mental illness.
Care After Release from Prison
Because of a constellation of social and legal barriers to reintegration, veterans released from prison are at high risk for homelessness (Balshem et al., 2011). Homeless veterans are, in turn, at increased risk for recidivism as a result of engaging in such activities as theft and prostitution to survive on the street. The authors note that there has yet to be widespread awareness of this problem, but, as described below, one administrative change has already occurred.
The VA has found that when veterans are released from transitional housing or halfway houses after incarceration, they become ineligible for the medical care that they need, which can often lead to homelessness. An administrative change announced in the Federal Register authorizes the VA to provide outpatient and hospital care to veterans recently released from prison and enrolled in a temporary housing program (VA, 2011). The VA is permitted to work with the veterans after they are released from the temporary housing program in an effort to prevent them from becoming homeless. This changes a previous rule that barred the VA from providing “hospital and outpatient care for a veteran who is either a patient or inmate in an institution of another government agency if that agency has a duty to give the care or services” (17.38(c)(5)).
Summary of the Review of Existing Literature
In summary, the existing literature is sparse on the effects of OEF and OIF deployments on communities. However, by examining the limited literature on OEF and OIF deployments and other surrogate markers, the committee finds significant economic losses to communities that deploy a relatively high concentration of service members. The most adverse effects of these deployments are borne by small businesses that lose essential employees, businesses that rely on employees with highly specialized skills, and self-employed businesses owned by reservists. Homelessness has been identified as an area that affects veterans and communities. Homeless and low-income veterans need a supply of permanent and supportive housing; recently returned veterans need adequate transition assistance to help identify and mitigate issues that put them at increased risk of homelessness; and women veterans need specific services, such as treatment for physical and sexual trauma and child care for dependent children. Communities also must address the mental-health issues that affect returning veterans and seek to fill gaps in the available services by funding services of their own or by obtaining grant and contract funds from federal and state agencies to fund community-based services. Finally, incarceration of returning service members is another area of concern for communities. Although there are very limited data on incarceration, one study noted that OEF and OIF veterans constituted only 4% of the entire veteran population in federal and state prisons in 2004; the age-adjusted incarceration rate for veterans was about 10% lower than that in nonveterans in 2004. Veterans released from prison are at high risk for homelessness.
As noted in Chapter 2, ethnographic assessments were undertaken in an effort to gain an understanding of the effects of deployments on communities. The committee directed Westat to conduct ethnographic research in six military-dense communities to determine the ways in which multiple deployments have interacted with five community domains:
• The economy, including overall commerce, housing, and labor;
• Information and communication about deployments and available resources;
• Community health;
• Formal services and supports in the community (“community competence”); and
• Informal services and supports (“social capital”).
Additionally, the committee sought information about areas of continued need within each community, and Westat study teams solicited from community members suggestions of additional supports and services for mitigating the effects of multiple deployments (see Chapter 2).
Description of the Study Site Communities
The primary basis for the selection of study sites was that a community had to have experienced multiple deployments of service members in support of the wars in OEF and OIF. Additional factors taken into consideration included the size of the community (which needed to be small enough to accommodate a 1-week ethnographic visit) and the study’s objective that the sites selected represent diverse geographic regions of the country. The locations of the six sites3 selected for the study are depicted in Figure 7.1.
The six study sites vary significantly in population size: Little Falls, Minnesota, and Georgetown, South Carolina—which are the two National Guard sites—have the smallest populations, at approximately 8,400 and 9,000, respectively. Of the active-duty sites, the one with the smallest population is Watertown, New York (27,000); followed by Lacey, Washington (42,000); Lakewood, Washington (58,000); and Jacksonville, North Carolina, which has slightly more than 70,000 residents. By far the largest study site is El Paso, Texas, which has an estimated 650,000 residents. As a whole, El Paso is too large to accommodate a 1-week site visit, but telephone calls made to key informants prior to the visit indicated that the two districts (Districts 2 and 4) adjacent to Fort Bliss, Texas, are the areas of El Paso that are most affected by military processes. Those districts were the focus of the study team’s visit; each of them contains approximately 81,000 residents (Ramirez, 2012).
The sites also show some demographic variability, as indicated in Figure 7.2.
Four of the communities have a majority white population, but with some racial and ethnic diversity. Of note, however, are El Paso, in which 80% of the residents self-identify as
3Although “six sites” are referred to throughout the report, the study teams explored two communities in Washington. Unless otherwise indicated, Lakewood and Lacey, Washington, will be combined in this report as a single site. For descriptions about the ways in which these two communities differ from each other, please see Appendix E.
FIGURE 7.1 Geographic locations of the six study sites.
FIGURE 7.2 Race and Hispanic ethnicity, by study site.
Georgetown, which has only a local National Guard armory rather than a nearby military installation, reportedly has experienced no economic boost from the presence of the military. Key employers include the Georgetown county government, the local hospital, and the International Paper plant that is located on the southern edge of town. As discussed throughout this section, this South Carolina community is an outlier, which might be the result of the absence of a nearby military installation.
Interviewees in the five communities with nearby installations, however, said that the military is an important economic contributor to their regions. That was particularly noticeable in Little Falls, Watertown, and Jacksonville, where the military is the key economic driver.
Although there are numerous economic engines in the state of Washington and in El Paso, both Fort Bliss in Texas and Joint Base Lewis-McChord (JBLM) in Washington have gained local economic prominence in recent years because of net gains resulting from the Base Realignment and Closure (BRAC) process.
The Army has deployed the greatest number of service members in support of OEF and OIF, and the Army was represented in five of the six study sites: Fort Drum (New York), Camp Ripley (Minnesota), Fort Bliss (Texas), Joint Base Lewis-McChord (formerly Fort Lewis; Washington), and the National Guard unit in Georgetown (South Carolina). The Air Force was represented at both Camp Ripley (Air National Guard unit) and Joint Base Lewis-McChord (formerly Airbase McChord). The Marines are represented by Camp LeJeune (North Carolina), one of only a few Marine training installations in the country.
All five installations that are nearby five of the study sites are very active military bases that have experienced large-scale troop movements since OIF began in 2003. Because OEF began in the fall of 2001, OIF opened up a second combat theater, requiring a greater number of active-duty service members. In Georgetown, the local National Guard unit saw its first deployment to OIF in 2004. At the other sites, interviewees reported noticing an increase in activity starting around 2005.
Relationship Between Communities and the Military
As noted previously, the military is an important economic contributor to each of the five communities located near a military installation. In many respects, the local economies have been shielded from the recession as a result both of the activity associated with war being waged on two fronts and of the two installations benefiting from the BRAC process. One unanticipated characteristic shared by all of the communities, however, is the extent to which the towns have a military identity. At all six sites, interviewees repeatedly described their communities as “military towns” and pointed to the rich military history in their respective regions. Citizens of these communities pay attention to military issues and to their neighbors’ service to the country, thus creating a context in which service members and their families can feel understood and appreciated. Equally important, at five of the sites, the civilian “side” of the community has a long-standing symbiotic relationship with the nearby military installation and has learned to adjust to the installation’s ever-changing dynamics,4 including the multiple deployments associated with the wars in Iraq and Afghanistan. Although all six study sites have been affected by multiple deployments to some degree, each town’s support for the military might have helped mitigate some of the potential effects of these deployments. It is possible that such effects might be more pronounced in communities in which military ties are not so strong.
Findings of the Ethnographic Assessment
Overall, it was difficult to ascertain the degree to which multiple deployments have had an effect on the economies of the six study sites. Interviewees from these communities frequently talked about local economic growth resulting from expansion of the military
4One might view a university town as an interesting point of comparison and contrast. In an academic community, citizens are likely to be attuned to and conversant about the accomplishments of the school’s athletic teams or faculty (such as a winner of the Nobel Prize in literature). The town will also have long since adapted itself to the annual rhythms of students coming and going.
installations generally, and there was some talk of a shift from home ownership to apartment rentals because so many service members were increasingly single, young, and mobile. But when pressed, interviewees were unable to tie either of those community trends to multiple deployments. The exception to that pattern was Little Falls, Minnesota, where interviewees suggested that multiple deployments were taking a toll on local family-owned and familyoperated small businesses. Interviewees in Georgetown, South Carolina, talked about the effects of deployments on small businesses or agencies (such as fire and police departments), but they described the deployments as an “inconvenience” rather than as events resulting in long-term adverse consequences for the employers. In two of the four active-duty locations, interviewees did not identify any major effects on the labor force from multiple deployments. In El Paso and Washington, however, interviewees reported efforts by the local military installations to increase on-base mental-health-service capacity in response to the demand resulting from multiple deployments. In both of those locations, community members said that the installation was actively and successfully recruiting mental-health providers to work on base, thus diminishing the supply of providers available to meet community needs.
In terms of information and communication, community-level discussions about the military are quite common, a not-unexpected finding given the military orientation of the study site towns. However, interviewees expressed a need for a more formal flow of information from the military to the civilian community about troop deployments and reintegration. In the five sites with installations nearby, communication about resources for service members and their families reportedly occurred through both formal and informal, word-of-mouth channels. In Georgetown, interviewees said that although formal communication about resources had “improved” between the local unit’s first and second deployments, additional steps could be taken to ensure that information, particularly about military benefits, is more readily available to National Guard members and their families.
Mental-health concerns were a primary topic of conversation with interviewees at the five installation sites.5 First, residents and behavioral-health providers alike said that they worried about service members who have been deployed multiple times returning home with posttraumatic stress disorder and other behavioral-health issues such as drug and alcohol abuse. This was a particular concern in Washington, where a couple of negative high-profile events focused media attention on PTSD among service members at JBLM. Similar concerns about increasing violence were expressed by community members in Jacksonville, North Carolina. Community members at the other sites mentioned isolated disturbing incidents, but their major concerns were about increased substance use by service members and an increase in drunk- and reckless-driving accidents. Consequently, interviewees perceived the need for additional services and supports for service members who are currently struggling with the stresses of multiple deployments and for individuals whose stress responses might be delayed by months, or even years, postdeployment. Community-based providers also emphasized the importance of increasing community service capacity because of service members’ reluctance to seek help on the installation, where the information might get back to their commands, and because of a perception that such information could jeopardize service members’ careers.
5Georgetown community members acknowledged that many of the local National Guard members had returned home with symptoms of PTSD, but none of the interviewees perceived the symptoms to have risen to a level of community concern.
A second and related issue raised by interviewees at the five installation sites was their expressed concern about the spouses and children of service members who have been deployed multiple times. They noted that the steady pace of deployment and reintegration can exact a toll on young families, creating stress on the nondeployed spouses and potential attachment issues among the children. Interviewees noted the need for additional mental-health services for young people to help them cope with the strains of having a parent—or parents—deployed multiple times.
Findings with respect to supports and social services were consistent across the sites. Behavioral-health services, although available at all six sites, were widely described as being insufficient to meet the needs of civilians, much less military-affiliated individuals. In Georgetown, South Carolina, for example, interviewees reported that there were virtually no private-sector mental-health providers in town. Moreover, state budget cuts were said to have put an enormous strain on county services, resulting in more stringent eligibility criteria. In El Paso, the service-delivery system was struggling to address the trauma of women and children fleeing the drug violence in Juarez, Mexico, yet interviewees expressed significant concerns about the mental health of military youth. With reportedly only one child psychiatrist in town, the system was already stretched to capacity. Both Little Falls, Minnesota, and Georgetown, South Carolina, have community hospitals, but neither has any dedicated emergency psychiatric beds. Individuals in crisis must be held in the hospitals’ emergency rooms (reportedly up to a couple of days) until an inpatient slot opens up elsewhere in these states. And, as indicated previously, interviewees both in Washington and in El Paso reported a move by the military to increase mental-health service capacity on the installation, but at the expense of the community. Because the military can offer much higher salaries than those offered by community-based providers, clinicians reportedly were leaving their community positions for the better-paying government civilian jobs serving the military.
Finally, at all sites, interviewees said that not only are the local systems insufficient at the present time, but that they are also unprepared to handle any delayed onset of symptoms associated with multiple deployments. The interviewees worried about various issues—about the possibility that service members might develop symptoms of PTSD some years after their combat experience; about families, whose struggles with multiple deployments might finally take a toll on marriages; and about children, who might have dealt with a parent’s—or parents’—deployments by detaching, a coping mechanism that many believed might have long-term effects on those youths’ ability to form healthy relationships.
Despite challenges to the formal service-delivery systems, informal services and supports were quite robust at all of the study sites. Examples of such supports include face-to-face and online peer supports, services provided through the faith community (including faith-based counseling), military discounts offered by local businesses, neighbors helping neighbors, and family members pitching in to assist a nondeployed spouse. Those bonds appeared particularly strong in the smallest communities (Little Falls, Georgetown, and Watertown), but they were also widely present in the three other self-declared “military towns.” The following sections provide more detailed information about each of the five areas targeted for study, including economic health, information and communication, community health, formal services and supports in the community (community competence), and informal services and supports (social capital).
The measures of economic health studied include general commerce, housing, and the labor market.
It did not appear that multiple deployments had had large-scale economic effects on the communities at the six sites visited. In the four active-duty sites, interviewees described economies that were reasonably robust—infrastructure was growing and new businesses were being created. In El Paso and in Washington, the growth had been spurred by BRAC; in Watertown, New York, and Jacksonville, North Carolina, interviewees said that the changes were related to a sheer increase in the number of active-duty service members and their families coming into the communities. In any event, they believed, the growth had masked any potential financial effects of multiple deployments.
An additional factor that likely has mitigated the effects of multiple deployments is the civilian–military partnership that has been established in all four communities, partly as a result of lessons learned from previous military conflicts. In Jacksonville during the First Gulf War, for example, the town experienced a substantial drop in its population when military spouses and their children left to return to their families of origin for support during deployments. One city official said:
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.
In an effort to prevent this type of flight from recurring, in 2003 the Onslow County (North Carolina) Chamber of Commerce put in place an innovative program called Project CARE (Jacksonville-Onslow Chamber of Commerce, 2012). That program, which has been activated several times since 2003, combines the efforts of various local government, military, Chamber of Commerce, and community organizations to provide support to families of deployed service members, assist businesses in dealing with the deployments, and increase community spirit toward the troops. Project CARE was cited by many interviewees as a successful strategy for mitigating 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]
That intervention has helped create a social and economic stability in Jacksonville throughout the OEF and OIF engagements. The El Paso Chamber of Commerce has similarly worked to stem the outflow of military families during a large deployment. A local business leader explained:
It used to be where we would see a deployment, then we would feel the impact because the families would go home and so all of a sudden the grocery stores weren’t as busy, clothing stores, the shopping centers … we don’t see that so much anymore because a lot of families stay here… . Part of the reason for that is
the community is extremely welcoming. Soldiers with families who actively engage in the community, they see a genuine, a sincere approach towards, “You’re part of our community and you’re welcome here and we want to support you.”
The El Paso Chamber of Commerce has an Armed Services Division that serves as the liaison between Fort Bliss and the business community. In addition, the garrison commander attends the monthly Chamber of Commerce meetings and discusses any needs of the installation or its constituents. Although BRAC-related growth has perhaps overshadowed the effects of this partnership, community leaders anticipate that the relationship will curtail any potential deployment-related instability affecting the city in the future.
In Washington, the South Sound Military and Communities Partnership (SSMCP) was established in an effort to coordinate growth and planning between Lakewood and Joint Base Lewis-McChord. Although the SSMCP was intended to identify a broad scale of community needs related to growth at JBLM, lessons learned from the needs assessment and the resulting action plans have helped to mitigate the impacts of multiple deployments on this region. In Watertown, New York, the community has formed two nonprofit organizations to identify and address military–civilian challenges: the Fort Drum Regional Liaison Organization (FDRLO), which grew out of a committee formed in the 1980s and addresses community planning in general and any specific issues as they arise; and the Fort Drum Regional Health Planning Organization (FDRHPO), which focuses on meeting physical- and behavioral-health needs of Fort Drum soldiers and their families. The boards of both organizations represent the local civilian and military communities.
All four partnerships described above reflect not only the civilian communities’ commitment to the military, but also their desire for service members and their families to see themselves as part of the larger civilian community. When these efforts are successful, spouses of deployed service members will view the community as “home,” thus mitigating the potential economic effects of a large exodus of community members.
No large-scale economic effects were reported in the two National Guard sites of Little Falls, Minnesota, and Georgetown, South Carolina; however, the limited opportunity afforded by the local economies appeared to contribute to National Guard members’ volunteering to go on additional deployments. Limited local employment opportunities and low-wage jobs reportedly have prompted some National Guard members to return to active-duty status, in part because of the potential earnings. Thus, although the Georgetown National Guard unit deployed as a unit twice, several members have volunteered for additional deployments with other nearby units.
Some Jacksonville respondents also reported that the economy has contributed to changing the dynamics among military families in that town. Many family members of deployed Marines, they said, 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]
The surplus of local labor reportedly has left many of those relocated family members chronically underemployed, which interviewees said often creates additional strains in the household of the nondeployed spouse. This phenomenon was not mentioned at any of the other study sites.
Overall, it did not appear that multiple deployments had had a noticeable effect on the local housing market at the six sites. Both in Washington and in El Paso, interviewees said that service members had been moving away from owning homes to occupying rental housing, but plausible explanations other than multiple deployments were offered. For instance, many of the incoming service members are young, single males who, interviewees said, are much more likely than are their older counterparts to rent an apartment. Many of the families coming into town are also young and simply lack the capital to invest in a home. The fact that permanent change of station (PCS) rotations might occur every 3 years also discourages home ownership. It is important to note that the national recession might also be playing a significant role in this trend. With banks now tightening up their lending practices, mortgage loans are no longer easy to obtain.
There were no obvious markers directly tying multiple deployments and the general labor supply. In Jacksonville, North Carolina, the many families moving into the area were creating a surplus labor situation, but their arrival could not be clearly tied to multiple deployments. At both National Guard sites (Little Falls, Minnesota, and Georgetown, South Carolina), interviewees did talk about how multiple deployments of local National Guard members had affected small businesses or departments. Emergency-services agencies, for example, reported having to adjust their staffing to accommodate the loss of one or two employees, but managers in Georgetown mostly described these adjustments merely as an “inconvenience.”
In contrast, some individuals in Little Falls believed that small, family-owned businesses had “taken a hit.” One interviewee said, “It’s tough, it’s really tough, especially in a small town because it’s a lot of small businesses.” When a business only has a couple of employees, she said, and one or two of them deploy, there is no redundancy to keep the business going. She concluded, “I would say a lot of small companies are closing their doors because of deployments.”
Information and Communication
Study findings indicate that at all six sites, communities pay great attention to military issues. Local media outlets extensively cover the local military installation or National Guard unit, and community members pay close attention to the wars overseas. Yet, interviewees reported that formal communication about deployments and demobilizations is confined to a few, very specific areas, such as communication with the business community and with local schools. Citizens reported that they often found out about local service members leaving or returning home by word of mouth. Interviewees also offered a mixed assessment of how information about available supports and services is communicated to service members and their families. Although some official channels exist and are used by military-affiliated individuals (for example, Army One Source), interviewees suggested that word of mouth continues to be the
The Military as a Topic of Conversation
In all communities with a military installation nearby, attention is clearly being paid not only to the local installation but also to the military more generally. Jacksonville, North Carolina, and Lacey and Lakewood, Washington, for example, all have statues in town honoring the military and their families; signs have been put up in business windows throughout these communities expressing thanks to the troops; and advertisements for military discounts were seen in business windows and in local newspapers in those communities. And, at all six study sites, substantial coverage appears in the local media, including newspapers (for example, Jacksonville Daily News, El Paso Times, Watertown Daily Times) and television news (for example, Watertown News and all three El Paso television stations, which covered the presence in town of the Westat study team. These findings are consistent with interviewees’ expressed views that “we are a military town.” Not only is there a large population of active-duty service members and their families at these locations, but interviewees noted that many retired military members have settled in their communities. This level of attention to the military clearly reflects the composition of the communities as well as the fact that the military is such a strong economic contributor in the study site regions.
Communication About Deployments and Deployment-Related Issues
Despite the widespread attention of the study site communities to the military as described above, study findings suggest that, in general, communication about the challenges and needs associated with multiple deployments is occurring only in specific areas (such as commerce and education). Local residents report learning about troop movements either by word of mouth or from local media outlets (such as newspapers and television news). Indeed, Georgetown interviewees reported that for the local National Guard unit’s first deployment, the rumor mill outpaced even the local media’s efforts to get official confirmation from South Carolina National Guard Headquarters in Columbia. A local newspaper reporter described being puzzled by the reticence of the Headquarters office to confirm news of the deployment: “It’s going to be common knowledge amongst the community, so why not [give us information]?”
In the active-duty sites, the lack of timely communications was not described by civilians as being particularly troublesome. At both National Guard sites, however, interviewees said that the lack of information has affected their communities’ ability to support their local National Guard members. Citizens in Georgetown reported being wholly unprepared for their local unit’s first deployment, indicating that many citizens were even unaware that the deployment was happening. As a result, interviewees said, the community was not prepared to send their citizen soldiers off to war. Improved communications thereafter helped the community come together to welcome service members home from Iraq and, 4 years later, to send them back to the combat theater.
Interviewees in Little Falls described a similar scenario—civilians wanting to engage in community ceremonies honoring the local National Guard unit but being reluctant to do so because they were uncertain about whether the events were “for family members only.” Interviewees attributed this uncertainty to weak communication between the National Guard
Communication About Deployments with Government and Business Leaders
As previously described, the economies of five of the six study communities are strongly tied to the local military installation. As a result, ongoing channels of communication have been established between the local business community and the local installation to facilitate joint strategies for addressing any potential adverse effects of multiple deployments. In Jacksonville, North Carolina, for example, city officials and the Chamber of Commerce receive biweekly reports from the installation on the number of Marines to be deployed and the number to return from deployments; they then disseminate that information to aid local businesses in planning. According to one Chamber of Commerce member, those updates “are well received and help our businesses not be taken by surprise by a large influx of people.” The Chamber of Commerce in El Paso and that of Watertown, New York, serve as liaison between their respective communities and local installations so as to ensure timely communication of deployment-related information; and the South Sound Military and Communities Partnership serves a similar function between Lakewood, Washington, and JBLM.
Communication About Deployments with School District Officials
Strong communication channels also have been established between the local military installations and several of the local school districts. In El Paso, for example, all nine school districts participate in the Fort Bliss Process Action Team together with military leadership and military parents. This team serves as a conduit of information between the community and the installation, addresses questions with changes of command on base, and gives the incoming command information about the school districts and their activities. A school administrator in El Paso offered the following perspective:
Communication is critical, whether it be what’s happening at the school, construction on the base, new families coming in, dates when they anticipate growth to happen, deployments, reintegrations, all those things … and we’ll continue to accommodate them…. We feel like it’s part of our community and so we’ll continue to work with them.
Such communications channels have been particularly important in both Watertown, New York (Indian River Central School District), and Lakewood, Washington (Clover Park School District), where the public school districts operate the schools located on the installation. One program implemented in schools in Lakewood and Watertown to help those affected by multiple deployments is the Military Family Life Consultants (MFLC) program. Military Family Life Consultants have been trained to address family issues related to multiple deployments confidentially, and they are available to provide information, support, and guidance to all students, parents, teachers, and school staff, regardless of military affiliation. A similar liaison program has been instituted in El Paso; school liaison officers (SLOs) interface with the installation, military families, and the teachers and counselors. The SLOs help school staff understand military culture, notify them about upcoming deployments or returns, and help defuse challenges that arise—for example, when children transition to a new school or their parents are
deployed.6 The school liaison program is regarded as being highly successful and has been adopted by DOD schools in Germany as a best practice.
Despite programs such as those described above and other efforts implemented to help children and schools affected by multiple deployments, several respondents emphasized that more is needed, both in schools and throughout the community. In Watertown, for example, although most large public schools in the area have MFLC programs, the study team was told that parochial schools and smaller school districts either have no MFLCs or too few to address deployment-related issues. And in Washington, the SSMCP report indicated that regional schools are affected negatively by multiple deployments that result in either overburdened or underused classrooms. The report also indicated that district schools receive short notice of population changes that will affect staffing and budgets.
Communication About Deployments with Law-Enforcement Agencies
Study results indicate that communication is rare between the military and local law-enforcement agencies regarding the potential behavioral-health effects of multiple deployments. In El Paso, Fort Bliss has worked with the El Paso Police Department to train officers to recognize situations that might have a mental-health component and to try to stabilize potentially explosive situations long enough for the department’s crisis-management team to arrive on the scene. Such situations involving the police could range from a traffic citation that might rapidly escalate out of control to a crisis situation, such as a service member who takes someone hostage or threatens to commit suicide. The impetus for the training reportedly stemmed not solely from the department’s concerns about the soldiers stationed at Fort Bliss, but also from officers having numerous encounters with traumatized citizens fleeing the drug violence in Juarez. The Westat study team heard from an emergency-services provider about a similar effort to provide needed skills to local law-enforcement officers in Watertown, New York:
We routinely have meetings between state police, the sheriffs, and myself and military police. When there is a soldier they’re worried about, they share that with us… . We had a PhD from the Fort Drum Behavioral Science come and talk to a group of 40 people in law enforcement and medical staff about posttraumatic stress … to help us basically understand it and to try to defuse it.
Yet not all emergency personnel in Watertown appeared to have the same kind of communication with the installation. One respondent noted:
I don’t have any specific contacts with the military … at Drum. And like I said, the only way I know that there’s people deployed or people coming home is by watching the news. So we don’t get any special bulletin. [Emergency services provider no. 1]
In contrast, another respondent reported regular communication between him and his military counterpart:
6More information about the El Paso Independent School District Military Family Liaison Program is available at http://www.episd.org/_schools/mil.php?KeepThis=true&TB_iframe=true&height=290&width=350.
As far as Fort Drum, my interactions with them is sometimes several times a week… . We communicate via phone and email on a regular basis—3 to 4 times a week, and more if necessary. He does alert me to times that they are expecting deployed troops home. We have discussed posttraumatic stress syndrome at length. [Emergency services provider no. 2]
Those findings suggest that communication in Watertown could be more systematic. And in Washington, although law-enforcement officials noted a strong relationship with their counterparts at JBLM, they said that they learn about deployments and demobilizations by word of mouth. Interviewees also told the Westat study team that there is relatively poor communication between JBLM and local police departments about services available for managing deployment-related disorders such as PTSD.
Information About Resources
The many resources available to service members and their families at all six study sites include peer-support groups, recreational activities for youth, pastoral counseling, therapy dogs, financial planning services, food banks, and numerous others. Information about the services and supports is communicated both formally and informally. At most sites, interviewees reported that information about military resources is available through various official military channels: for example, pre- and postdeployment briefings; Morale, Welfare, and Recreation (MWR) activities; Army One Source; and Family Readiness Groups (FRGs). Also, in Jacksonville, North Carolina, and El Paso, interviewees described collaborative efforts between the community and the military installation to link military members and their families with community resources. For example, and as noted previously, Jacksonville’s Project CARE has been activated at times of high deployments to make a community-wide effort to inform military families of the resources available to them. El Paso is served by the Northeast Coalition, an organization of approximately 200 schools, elected officials, agencies, community organizations, and Fort Bliss, that is responsible for identifying existing service capacity and helping to link individuals to the services and supports that they need.
Although formal channels reportedly worked well at the study sites with military installations nearby, some channels were less effective at the National Guard sites. Interviewees in Georgetown, South Carolina, said that official communication channels were not well formed at the time of the initial deployment. For example, interviewees reported that up until that time, the existing FRG had served primarily to build social connections among Guard members’ families, not to provide information about resources and supports. Information flow reportedly was poor throughout the first deployment but had improved by the second one.
Following the first deployment, a National Guard member noted that he thought the state and the National Guard realized:
Wait, we need to get something going here where we actually train these volunteers to kind of know what to do at an FRG meeting and to anticipate what questions are going to be asked and how to answer them… . And so they put together basically a training program for the volunteers… . At the end of it, you’ve got an FRG leader who has contacts across the state [and] has a list of resources.
Noting that communications are much improved, the current FRG leader in Georgetown was still worried that important information (relating, for example, to benefits) might not be reaching National Guard members and their families in a timely fashion. In addition, community members from schools and emergency services expressed concern about communications still being too sparse between National Guard leaders and their agencies.
In Little Falls, Minnesota, interviewees identified FRGs as a potential but limited source of information because members of deployed units come from such a broad geographic area. One FRG leader said that 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.” 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. Consequently, families of deployed National Guard members reportedly relied more on the Family Assistance Center (FAC) at Camp Ripley, Minnesota, for information.
At all sites, interviewees said that informal, word-of-mouth communications continue to be one of the most consistent ways in which information is exchanged about available resources. Individuals might learn about or obtain supports through their participation in shared interest organizations (such as church congregations) or by attending community events. Westat study team members who attended the Armed Forces Day event in Washington said they saw little information about community services at that event, whereas team members in Jacksonville, North Carolina, saw booths at the Jacksonville Jamboree for community-wide organizations and for organizations specifically dedicated to military-related issues. Services advertised at the Jamboree included P.S. Charities, which was raising money to build an accessible home for a veteran with triple amputations and severe burns sustained from an improvised explosive device (IED) blast in Afghanistan; Paws for Veterans, which was promoting its efforts to provide therapy dogs for veterans with PTSD, traumatic brain injury, or mobility issues; and a chiropractic practice at which military members could discuss their medical and chiropractic needs with the clinic’s staff. Interviewees also said that they use established community networks to ensure that the needs of service members and their families are addressed. In Georgetown, for example, a community member described how these networks are used:
If it ever comes [up] that something needs to be done [for the Guard unit], then the community is right behind it. Nobody steps back from that. Just go to one council meeting, say what’s gonna happen; before you know it, whoever they’re having breakfast with downtown … the old men sit there, and all you gotta do is tell them once and the whole street knows… . They’re like the fathers in this little city here, and if there’s issues going on, every business knows about it because they’ll be talking fast and personal to them [the businesses].
In addition to those “live” communications, interviewees often mentioned the importance of online networking, particularly through Facebook. Team members learned about Facebook pages set up by FRGs, unit spouses, veterans’ organizations (for example, Veterans of Foreign Wars [VFW], American Legion), church congregations, and other mutual-interest groups at all six study sites. Service providers and community leaders also recognized the importance of online networks for this generation. For example, in Jacksonville a mental-health care provider said, “Brochures don’t work for 18 to 20-year-olds; we have stopped printing them.” At Fort Bliss, the now-former Garrison Commander Colonel Joseph Simonelli established a Facebook
page called “Colonel Joe Wants to Know.” He said that his initial intention in setting up the site was to allow him to address problems faced by service members and their families quickly and efficiently. Over time, the colonel said, visitors to the site started to help each other by directing people to appropriate resources either in the installation or in the community. He also noted that the page was open to community service providers so that these organizations could respond to emerging needs within the military community. The new garrison commander, Colonel Brant Dayley, has continued the practice by setting up his own Facebook page, “Tell It to Col. D.”
Traumatic brain injuries and limb amputations caused by IEDs are often called the “signature” physical wounds of the wars in Iraq and Afghanistan. However, community members did not indicate that there are challenges presented by physically injured service members. Inasmuch as those wounds are being treated within military medical facilities, such injuries might not be seen in the broader community. What interviewees did express concern about is how the wars’ “hidden wounds,” such as behavioral-health problems brought on by multiple deployments, are affecting their communities. Community members’ concerns went beyond just the service members and included service members’ families as well. These health issues are explored in the following subsection.
Health of Service Members
The current presentation of deployment-related behavioral-health challenges by service members was reported to be quite different among the six study sites. In Georgetown, South Carolina, for example, interviewees stated consistently that they were unaware of any community-level challenges posed by service members. At the other five sites, community members described behavioral-health challenges that varied in degree of severity. Interviewees from Little Falls, Minnesota, said that they believe that there has been an increase in drug and alcohol use by formerly deployed service members, as well as an increase in suicidal behaviors. They noted, however, that those issues had always plagued the community, and many were reluctant to attribute those behaviors strictly to multiple deployments.
In Watertown, New York, behavioral-health issues, such as depression, anxiety, substance abuse, PTSD, and suicide, were identified by multiple community members as being among the most serious negative effects of multiple deployments. Suicide of soldiers was mentioned by several interviewees as a particular issue of concern associated with multiple deployments. According to the Watertown TV news station, “Fort Drum saw its highest level of active-duty suicides in almost a decade … seven Fort Drum soldiers took their own lives in 2011 … that makes 31 suicides among Fort Drum soldiers since 2003” (Fox 28 News WNYF, 2012). Although suicide is a concern for the community of Watertown, it seems as if most, if not all, military-related suicides are confined to the post. The Westat study team found no evidence of deployment-related suicides in the city of Watertown. One emergency-service provider said, “I have read in the paper that military suicides are up. [But] I don’t know of any in the city of Watertown … in the last 6 years.”
Several interviewees in El Paso expressed concern about the potential effects on the community of service-related PTSD, but they did not report any events specifically linked to multiple deployments. Community members believed that both alcohol use and reckless driving were more prominent within the military community, but the interviewees generally attributed
those behaviors to the young age of the service members and not to the number of deployments that they might have experienced. A city police representative said that his department had anticipated having to deal with large numbers of service members returning from theater with behavioral-health problems, but that this had not occurred. The officer also reported no noticeable increase in violent crime in the community committed by service members.
Community members in Jacksonville, North Carolina, described numerous behaviors that were attributed to the deployment patterns and to possible PTSD. The behaviors included an increase in automobile accidents originating from reckless driving, driving under the influence, and substance use, according to representatives from Onslow County Emergency Medical Services (EMS), the Jacksonville Police Department, and the Health Department. A representative from Onslow County EMS noted that the area has North Carolina’s highest rate of accidents related to substance use, and the second-highest crash rate in the state. Another interviewee noted:
In 2002 we went from 10 or 11 DUIs to … 484 last year … that was one thing we did see, prior to a deployment, people would get intoxicated. A lot of times we would take them straight to the base. [Police Department representative]
Also in Jacksonville, both Onslow County EMS employees and police discussed the rise in suicide attempts, and a Health Department representative described an increase in gun accidents:
We had two officer-assisted suicides where the people charged the officer with guns, and we’ve seen some other suicides. [Police Department representative]
We’ve had a lot of fatalities from gun accidents … you’ve got military guys … and it’s really hard to always know what exactly is going on in those situations… he was cleaning his gun, but was he? [Health Department representative]
And an emergency-services representative spoke about recent acts of violence by Marines, including a man stabbing dogs in his house. The representative added:
We’ve seen some other things that are quite disturbing… We had another Marine who was intoxicated, sitting on top of his roof with an M4 pointing it at people… those kinds of things we have seen on an occasional basis.
The greatest focus on deployment-related behavioral-health issues was in Washington as a result of several high-profile events involving deployed service members from Joint Base Lewis-McChord. In March 2012, Sergeant Robert Bales, who was deployed with a Stryker brigade out of JBLM, was accused of gunning down 17 Afghanistan civilians during a “rogue” shooting spree. In an interview with the local news, a community member linked Bales’s behavior to the deployment cycles:
The problems keep happening on this base, and that’s why it was no surprise when I heard he was from Joint Base Lewis-McChord. Soldiers [are] being redeployed over and over and [are] not being given the time to [be] adequately taken care of, physically or mentally (Kiro 7 News, 2012).
The Bales incident and other troubling events tied to JBLM-based service members had led to a heightened awareness within the community about potential mental-health problems among service members. During the Westat study team visits, interviewees talked about several recent incidents, two of which involved suicide attempts by service members: one necessitated a response from a Special Weapons and Tactics (SWAT) team; the second involved the fatal shooting of a service member who had a gun pointed at police. Interviewees also cited two hostage situations involving active-duty service members, one of whom was an officer. Interviewees from both Washington communities—Lakewood and Lacey—expressed the opinion that there has been an increase in violent crimes locally involving service members. They added, however, that because these events are being sensationalized in the press, the association between local crime and PTSD might be an unfounded perception.
Although interviewees regularly expressed concerns that multiple deployments are leading service members in their communities to display negative behaviors, it was not always clear when those behaviors could be attributed to multiple deployments, to one individual’s particularly violent single deployment, or simply to youthful fascination with fast cars and motorcycles and a tendency to engage in risk-taking behaviors. An interviewee in Watertown, New York, suggested that the duration of deployment in combination with the level of associated risk is a better indicator of the extent to which deployments affect service members and their families and in what ways. Regardless of the actual cause, community members’ concerns are quite real and might be having an adverse effect on their perception of local service members. A mental-health counselor in El Paso said,
I think there’s also a community perception that what’s coming to Fort Bliss now … are a lot of men and women who’ve been in Afghanistan and Iraq and that they may be coming with a whole range of problems. And there’s a little bit of fear, I think, in the community at large about that… . There’s this kind of stereotype that everybody coming back is coming back with this raft of problems, when in fact they may not be coming back with any such thing.
A longer-term worry, brought up by interviewees at all six study sites, is that there might be a delayed onset of symptoms related to multiple deployments. Service members might be fine right now, interviewees said, but what will happen in these communities if PTSD symptoms begin to emerge en masse 2 years from now? Community members perceive their current mental-health-service delivery systems to be inadequate to meet the present needs of both civilians and service members; they are concerned about how would they manage in the face of a sudden rise in demand (see the subsection below entitled “Community Competence”).
Health of Military Families
Interviewees at multiple study sites did not focus solely on the issues facing the service members themselves, but also reported the “ungodly amount of stress” that the deployments place on military families. One issue that some families have to face is trying to cope with a returned service member’s PTSD. Respondents from multiple study sites noted the tendency for young couples to get married just before the service member’s first deployment or immediately after his or her return from combat. With the quick turnaround time between deployments, they said, the couple barely gets a chance to become reacquainted before the service member is
We’ve been hearing about people getting married without knowing the other person. [One soldier on leave for 2 weeks in the United States] met a girl in a bar, fell in love … they were married, he went back to Afghanistan, they had a baby … and now they’re getting divorced. And this is [soldier is suffering from] PTSD issues, shrapnel from IEDs, he’s been blown up three times in IED incidents, he’s had horrible [experiences, such as] stuffing intestines back into the guy that was driving … And so he comes home … he drinks all the time. She doesn’t know him; his personality is such that he just blows up. And it scares … her. Well, of course—she doesn’t know him! [El Paso divorce lawyer]
A long-term relationship does not necessarily serve as a protective factor for the family, however. A mental-health provider in Jacksonville, North Carolina, reported to the study team that she had been getting more calls from senior members of the military and officers: “They’re tired and never thought they’d need counseling,” she said, “but now their families are falling apart.”
PTSD is not the only issue challenging service members’ families. Numerous interviewees described the strain that the rhythm of multiple deployments appears to be placing on the family as a unit. They pointed particularly to the stress associated with the separation created by deployment, the difficulties of postdeployment reintegration, and the toll that this rhythm takes on a family when it occurs numerous times. First is the strain placed on the service member. Interviewees in Jacksonville said that returning Marines might not be able to reintegrate into the family easily; they are “trained to wake at a pin-drop, and come back to 2-year-olds jumping on [the] bed in the middle of the night.” According to a service provider in Washington, multiple deployments only exacerbate the challenge:
They [service members] don’t have enough time to shut it off [constant state of vigilance] before they go out again.
Interviewees also pointed to the stress that the pattern of repeated deployments places on children in these families, who must try to adjust to the changing dynamics of the household and, potentially, the altered behavior of the deployed parent. The following story, from the spouse of a service member in Watertown, New York, illustrates the concerns that interviewees expressed:
Previous to this particular deployment, I didn’t notice it [signs of PTSD] because of the jobs that he had previous to this one. His first tour out … was a civil affairs thing, and they were … not really in the line of fire… . They were helping with the infrastructure… . His second tour … he never fired his weapon one time…. I talked to him three and four times a day… . This [third] time … was scary. I was definitely on the edge pretty much every day. His job was to take a bullet before the colonel did… . So this time, I’ve really noticed quite a bit … noises get him. We were just in Washington, DC … and we got out of the car and he’s doing one of these things—looking [and] scanning constantly… . He’s tense and I could feel it in his body and I could see it in his arms and I said, “Sweetheart, calm down. It’s ok. Nobody is trying to kill us.” … He had to sit down on a
bench. He’s like, “I can’t do this … I don’t know what’s wrong. I don’t know if it’s the smells. I don’t if it’s the number of people. I don’t know if it’s all the faces. I don’t know, but I can’t do this” and he was unglued for the rest of the day. … My kids had never seen this. My 15-year-old was just like, “Dad, what’s wrong?” My 11-year-old was just beside himself. He was like, “Daddy, did we do something wrong? You didn’t want to go to the zoo with us?” [His father responded], “No buddy. I wanted to. I just couldn’t do it.” That was really hard because that’s never happened before. That was really difficult.
Several interviewees in El Paso said that the deployments are particularly difficult for young children, who, they believe, are having trouble attaching to the deployed parent because of the repeated separations. A counselor explained:
It’s very hard, and when there are multiple deployments … there’s not even time for the soldier to recoup, much less the family, and when the kids know this they don’t even have the opportunity to think, “Let’s get comfortable” because they’re on their guard—“I want to be prepared, I don’t want to get hurt again.”
In addition to having near-term adverse effects on the children, parents and mental-health counselors in El Paso expressed worry about how children will be affected by those experiences over the long term, such as their possibly developing an inability to form healthy attachments and relationships as adults.
How children handle those issues was a point of debate among interviewees. Some suggested that youth “act out” in response to their family situations, and pointed particularly to behaviors (including fighting, talking back to adults) that are exhibited in the schools. Others argued that the youth are “detached” and tend to “internalize” their feelings—that is, an affected youth might become more withdrawn. Still other interviews described these youth as “resilient” and “strong” and perceived these early hardships as being character building. Undoubtedly all such perceptions are based in fact: some youth act out, some become withdrawn, and some handle the situation effortlessly. Nevertheless, most site interviewees believed that some youth are adversely affected by the stresses of having a parent deploy multiple times and that this stress is rising to the level of a community concern.
Finally, but certainly not least important, interviewees pointed out the strains that the deployments place on the nondeployed spouse. That individual takes on the role of a single parent during deployment and then relinquishes some of the responsibilities when the service member returns. And as one military spouse said, multiple deployments only add to the struggle:
Here you are as a spouse, you have control of your kids and the household and the yard and the bills and everything, and here comes the soldier who’s supposed to be the king of the castle and you’re wanting to give it back to him, but you’re not. How much do you keep? How much are you wanting to give back knowing that he’s going to be gone in a few months again?
We’re sort of missing a piece of our population to some degree in that the spouses have this emotional burden that is this bubble that is beyond comprehension right now… . And that’s a whole other piece that I don’t know if you guys have looked
at … the extent to which a huge piece of the population that—it’s sort of this “stuck” situation that we as the spouse are in because we have to always tell our soldier, “Don’t worry, we got it, Honey, you go. We got it.” And no matter what’s happening we’re not allowed to talk about that because he has to be safe downrange. And to our kids—“Don’t worry, we got it! We got you, we got me, we got Dad, we got it all!” And it’s affecting our spousal population to a huge, huge degree. And although the resources are out to get the counseling and things like that, right now we’re so busy being stellar … that we’re not going after it. We’re not seeking the support that we need right now because we don’t have time to seek that. We’re too busy being stable … we’re [so] busy [keeping] our feet on the ground that we don’t have the chance to crumble.
The next two subsections include descriptions of the formal and informal resources that are available to help service members, their families, and the communities cope with these many challenges.
For the purposes of this study, “community competence” refers to the formal services and supports that might be available in a community, such as emergency care or behavioral-health services offered by licensed clinicians. The committee asked Westat to assess the formal service delivery capacity in each community, including what services are (or are not) available, and what the barriers are that interviewees believe keep individuals from accessing services. Additionally, Westat was requested to assess what the mechanisms are in each community that might help mitigate barriers to care.
In the four active-duty communities, it was learned that many services are available to address the challenges presented by multiple deployments both on the bases and in their respective surrounding communities. With regard to education, for example, and as noted earlier, efforts are being made to ensure that educators have sufficient training and knowledge about military life so that they can be aware of and attend to issues presented by military children. Specific programs that interviewees said have been successful include the use of school-based military liaisons, such as Military Family Life Consultants in both Watertown, New York, and Lakewood, Washington; school liaison officers in El Paso; and military transition counselors in Jacksonville, North Carolina, schools. Also, training efforts are under way at those four sites to increase teacher and counselor awareness about behavioral issues that might arise in children of service members experiencing multiple deployments.
Some services are targeted specifically for families dealing with the strains of multiple deployments. In Little Falls, Minnesota, interviewees mentioned the Lutheran Social Service (LSS), a Minnesota not-for-profit organization that provides services for veterans. LSS Case Management, Outreach, Referral, and Education (LSS C.O.R.E.) is a statewide program for military members, veterans, and family members. LSS C.O.R.E. provides, by telephone, mental-health counseling and referrals and also offers financial counseling services. The Families OverComing Under Stress (FOCUS) project is an on-base program that provides resiliency-training and skill-building resources to military families and children. The program is not offered at all US military installations, but it does exist at both Camp LeJeune, North Carolina, and Joint Base Lewis-McChord, Washington, and was mentioned in Jacksonville as an important resource.
Interviews with off-base mental-health clinicians suggested some interface with military families, but it was often said that the family might be reluctant to seek counseling because of the perceived possible adverse effect on the service member’s career. That particular barrier is discussed in greater detail below and in Chapter 9.
Interviewees frequently mentioned the high divorce rate among military families. Two programs were mentioned that attempt to mitigate the additional strain that divorce places on the children of the families involved: the Help Establishing Responsive Orders and Ensuring Support for Children in Military Families (HEROES) program, run through the Texas Attorney General’s office, helps parents navigate custody disputes that might arise across state lines; and the El Paso County Domestic Relations Office has been working with the Office of the Judge Advocate General (JAG) at Fort Bliss, Texas, to train JAG lawyers on Texas child custody law and pro se divorce (that is, representing oneself in court). They also reported working with the Fort Bliss Morale, Welfare, and Recreation office to provide seminars on issues that might emerge between military and civilian law.
With regard to supporting military youth in these communities, a common strategy is employed, operating through the provision of various recreational opportunities. Interviewees mentioned activities sponsored by Boys and Girls Clubs, community athletic leagues, and common-interest clubs. Also mentioned were Department of Defense grants to school districts that provided additional monies for recreational activities. One of the most unique youth outlets was described to the Westat study team in Watertown, New York, where military and civilian youth got together to create a “docudrama” play, In My Shoes, in which young people described their experiences in trying to cope with multiple deployments. As reported by several respondents, the play served as an important opportunity for teens in the community to “voice what their experiences are.” Interviewees also reported that the performance of the play has opened up the conversation between military children and their parents in Watertown about the deployment-related stresses that youth undergo.
Despite the programs described above and related efforts, at all six study sites interviewees described significant challenges with the behavioral-health service-delivery system, primarily with respect to insufficient service capacity. Interviewees regularly described community-based systems that are underfunded and strained and installation-based mental-health services that are also insufficient to meet the needs of service members and their families. Examples of such insufficiency were profound: all four active-duty sites have hospitals that offer inpatient psychiatric beds, but capacity is limited. In Watertown, New York, for example, all behavioral-health care for military families is provided in the civilian community, but there is only one hospital that has an inpatient behavioral-health care unit (Samaritan Medical Center). In Georgetown, South Carolina, and Little Falls, Minnesota, local inpatient services are not available at all. In both communities, interviewees said, an individual in acute psychiatric distress will not receive mental-health treatment at the hospital, but will be held in the facility’s emergency room for a couple of days until a bed becomes available elsewhere in the state. In Little Falls, a Mobile Crisis Outreach (MCO) and stabilization team from Northern Pines Mental Health Center provides support for these emergency-room admissions. Nevertheless, that stopgap approach to managing acute psychiatric crises potentially affects those emergency rooms’ capacity to treat others coming into the facility, not to mention the delay in treating service members and/or their family members.
In addition, interviewees reported a dearth of psychiatrists in these communities. El Paso respondents said that there is only one child psychiatrist in town, Watertown interviewees described a lack of mental-health providers for children, and an interviewee in Georgetown said that there is only one full-time psychiatrist (for both adults and children) in the community. “Temporary” psychiatrists rotate through the local County Mental Health Department, she said, but at the expense of continuity of care for the patient. Challenges in the capacity of community-based mental-health services have reportedly been exacerbated on occasion by the military’s efforts to increase service capacity on the installations. In both El Paso and Washington, mental-health clinicians reported that, a couple of years ago, they received calls from officials at Fort Bliss and JBLM, respectively, requesting their community provider agencies’ assistance in providing counseling to service members. According to a provider in El Paso:
Last summer, Fort Bliss called us and said, “We have a whole brigade of people coming back from Iraq; there’s no way we can handle them; can you help us?” So at that time we had an influx of military families come in.
Interviewees said that they did offer assistance, although military-affiliated individuals never made up a large proportion of their client population (3–5%, according to one interviewee). Nevertheless, the arrangement proved to be a “win–win”: service members, they said, developed therapeutic rapport with their assigned counselors at the community provider agency, and the agency benefited from the additional revenues. More recently, however, and at both the El Paso and Washington sites, interviewees noted that not only are installations expanding on-base capacity, but that the military reportedly is requiring service members to receive services on base. That requirement has potential negative effects, as agency staff noted that some service members are concerned that the receipt of services on base will affect their careers and thus are not continuing with counseling on base even if they need it. Interviewees said that the concern extends to the individual’s entire family—that spouses might also be reluctant to seek care for themselves or their children because of the potential adverse effects on the military spouse’s career. This perception was pervasive at the study sites:
If you are an officer or an officer’s wife, you don’t want to be seen walking into the building where everyone knows it is where the mental health providers are. For enlisted, you don’t want to be seen as showing any weakness. [Washington study site interviewee]
With the rapid succession, there has been no time to debrief, or to reintegrate with your family, … or [with regard to] seeking services … it continues to be a double-edged sword for that service member, fearful that their career will inadvertently be harmed. [Jacksonville, North Carolina, study site interviewee]
If your husband’s looking to get promoted, and you as the wife goes and gets help with some mental health issues—for your husband that could affect his promotion. They’d like to say it doesn’t, but it does. [Watertown, New York, study site interviewee]
Although the expansion of on-base services was intended to be a positive response to a growing need, interviewees said, the concomitant “requirement” was likely to reduce the use of
mental-health services by service members and their families. Stigma is still a very important issue that has to be addressed (see Chapter 9).
It is noteworthy, however, that not everyone supported the perception addressed above. Several interviewees firmly believe that the military has changed its view on those seeking treatment for symptoms of PTSD. In El Paso, a high-ranking service member said, “We’ve all got PTSD when we come back from combat,” a comment that the study team perceived as an attempt to normalize the experience. An interviewee in Georgetown similarly suggested that many unit members had PTSD symptoms when they came back from their first deployment, and that the “appropriate” response was to seek help. In Watertown, the spouse of an officer reported that her husband openly sought counseling to address combat stress so that the soldiers under his command would feel comfortable seeking assistance if they needed help. However, that was not the predominant view expressed by interviewees, which suggests that the military still needs to do more to counter the prevailing opinion that counseling will upend a service member’s career.
Another issue raised by community-based providers was that individuals who do receive mental-health services through the military reportedly see a different therapist at each visit, and those visits might be more than a month apart. The protocol for effective counseling, they believed, was for a client to see the same therapist at each weekly (not monthly) appointment. Interviewees worried that the services provided on the installations are not intensive enough to address the needs of service members and their families effectively.
Finally, interviewees reported that the military’s increased service capacity was not augmenting overall service availability in the region, but instead it was occurring at the expense of community capacity. Because the military can pay a higher salary than the community provider agencies, interviewees said, their agencies are losing staff to the installations. That movement, from the community to the military installation, places additional stress on community systems that already lack the capacity to meet the needs of the civilian population.
Despite the challenges, interviewees described an array of efforts being made to reach out to service members and their families and to ensure timely delivery of services. In Texas, for example, in 2007–2010, the San Antonio Federation partnered with the Dallas Foundation and the Permian Basin Area Foundation to establish the Texas Resources for Iraq-Afghanistan Deployment (TRIAD) Fund. The goal of the TRIAD grants was to support Texas-based military families affected by deployment to OEF or OIF. More than $11.9 million in grants were made to Texas community organizations, including mental-health providers, food banks, and children’s services. Fourteen agencies in El Paso received grants, which interviewees reported were important in building behavioral-health capacity and expanding the availability of community resources to military families.
Similarly, in Jacksonville, North Carolina, there are numerous grant-based services designed to help military families and individuals during deployments. For example, the military transition counselors in the school system are funded through a Department of Defense Education Activity (DoDEA) grant that started in 2009. The counselor positions were initially funded to help students deal with deployments, but they now assist children with reintegration challenges, such as a parent’s altered behavior. Interviewees reported that those staff positions filled a major gap in services.
Both Lacey and Lakewood, Washington, have also been able to put programs in place through grant funding. In the Clover Park School District (CPSD), schools located on base, in
partnership with JBLM, can access a school-based mental-health program that provides psychiatric care, if requested, to all students in the schools. The administration of this program is being piloted through CPSD, which is the second district in the country7 to use it. CPSD has also benefited by receiving several DoDEA grants, one for academic support and professional development and another for providing school-based mental-health counselors in three of the secondary schools off base that have large populations of military-dependent students. At the time of the site visit, this grant program was in its second year, and was cited as being very successful. The counselors’ presence in the school was described as providing support either informally, such as talking with students in the hallway between classes, or by formal counseling sessions with children and family members, or by both types of support. At the time of the site visit, the CPSD also was waiting to hear about an award of a $2.5 million grant to fund mental-health services.
The North Thurston Public School (NTPS) District, which serves the city of Lacey, Washington, also has programs in place to support the estimated 20% of the district’s student population who are from military families. The NTPS District secured a DoDEA grant to provide children in 6 of the district’s 13 elementary schools with positive behavioral, social, and emotional supports. These include support groups for children with parents who have been deployed that allow the children an opportunity to share with others who are in similar situation at home. Those lunch-time groups also have engaged parents, including nondeployed spouses, to talk about what it is like to adjust to being the only parent at home. Returning service members also might attend, and describe what it was like to be separated from the family.
Interviewees did indicate that although these grant-funded programs have been invaluable in helping the communities meet the needs of service members and their families, the drawdown in troops and the end of funding will not mean an end to the needs. The TRIAD grants in El Paso, for example, ended in 2010. However, providers who were seeing clients with the assistance of those monies said that they continue to serve those clients, but that the agencies are no longer being compensated for the care. Jacksonville interviewees also expressed concern about how to continue to provide school-based services in the future.
Finally, interviewees at five of the six sites stressed the importance of having behavioral-health service providers who understand the military, both from the service member’s perspective and from that of the spouse and children. A clinician in Little Falls, Minnesota, noted that it is the shared experience that increases the credibility of the provider and makes service members more willing to confide in a mental-health professional. To address that concern, Jefferson Community College (JCC) in Watertown, New York, is working to train more health care professionals, both to meet local service needs and to provide career opportunities for military and nonmilitary residents; the college reportedly provides courses at Fort Drum. And, in El Paso, interviewees described training efforts to increase teacher and counselor awareness of deployment-related issues with children in their schools. Fort Bliss also is working with the University of Texas at El Paso to develop a curriculum to train teachers about working with military children. The goal of the program is to ensure that teachers will be prepared to understand the ways in which deployments—indeed, multiple deployments—might adversely affect children in military families.
7The program is modeled after a successful program administered in on-base schools in Hawaii.
For the purposes of this study, “social capital” refers to the range of informal supports and services that are available in a community. In all six sites, study teams found strong informal support networks that helped to mitigate the impact of multiple deployments on these communities.
As noted earlier in this report, interviewees at all sites expressed the sentiment that their towns are “military communities.” Common bases for that claim include the long-standing presence of a military installation in or near the community, a community history deeply rooted in patriotism, support for citizens who enlist in the active-duty military or join the National Guard, and large populations of retired service members living in the community. The sentiment expressed by interviewees that their towns are military communities likely has an impact in the communities: service members and their families do not have to explain their experiences and needs continually, but have a social nexus in which many friends and neighbors understand and empathize with what the family is going through. Shared experience, as Little Falls, Minnesota, mental-health providers explained, goes a long way toward creating an environment in which military-affiliated individuals can feel comfortable and supported. Additionally, because these communities have decades of experience with the military, they have had to make only slight adjustments to existing processes or programs in an effort to mitigate potential community-level effects of multiple deployments. Partnerships between the military installations and city entities such as the Chamber of Commerce or school districts offer excellent examples of ways in which communities have continually modified their programs to accommodate the ever-changing dynamics with their military neighbors.
Georgetown, South Carolina, stands as an exception to this rule, both because there is no nearby installation and because the role of the National Guard effectively changed (from strategic to operational) as a result of the wars in Iraq and Afghanistan. Interviewees’ descriptions of problematic communications with National Guard leaders about the logistics of the unit’s first deployment are therefore not surprising. Nevertheless, citizens’ support for the unit reportedly never wavered, thereby reinforcing the importance of affective supports in helping a community cope with the potential effects of multiple deployments.
Numerous community-based peer-support groups were reported or observed at each of the six study sites. These groups included mental-health peer-support groups, community-sponsored programs for families with a deployed service member (for example, Hearts Apart in El Paso, Project New Hope Military Family Retreats, a program sponsored by the Lions Club in Washington), several opportunities in each community for children in military families to come together and talk about their experiences, and countless virtual support groups through Facebook or other online resources.
Outreach was also being conducted by several military-focused organizations, including Family Readiness Groups, the VFW, American Legion posts, other local veterans’ groups, and the VFW Ladies Auxiliary. Outreach efforts described by interviewees included FRG meetings and newsletters, VFW membership drives oriented toward OIF and OEF veterans, and, in Georgetown, a baby shower for National Guard wives sponsored by the VFW Ladies Auxiliary.
Community members described the response to these outreach efforts as “mixed.” The FRG, for example, reportedly is not the best venue for everyone. In Little Falls, participation is said to be severely limited by the geographic dispersal of unit members. And Georgetown’s FRG was said by interviewees to have struggled through the first deployment to move beyond its traditional social function to become a source of information and support for families of deployed National Guard members. Enthusiasm for the FRG was mixed in the active-duty sites as well, with one El Paso interviewee saying, “The FRG is helpful to many and for many it’s their worst nightmare,” as the rank of the deployed appears to influence whose issues are addressed. A Marine wife in Jacksonville, North Carolina, expressed a similar concern, noting that wives of Marines might have difficulty talking to each other about their problems when their spouses are of different rank.
Traditional veterans groups, such as the VFW and the American Legion, also reported a mixed response from OEF and OIF veterans. Several Vietnam-era interviewees said that they made a concerted effort to reach out to this group to ensure that “they didn’t have to go through what we went through” (experiences like being spat on or yelled at by civilians). They reported numerous efforts by their veterans’ groups to engage the younger generation of service members, including “Welcome Home” picnics for returning service members and their families and membership outreach targeted specifically to this cohort. Yet interviewees expressed dismay over what they perceived to be “lean” participation by OEF and OIF veterans. When a Vietnamera veteran in Georgetown was asked why he thought that engagement with OEF and OIF veterans was so hard, he responded:
It’s hard to take, it really is. We’ve opened the posts and we just can’t get them. I do know we got two members at the VFW out of it, but that’s about all we picked up… . We welcomed them back and tried to do everything we can. Hopefully they’d want to come join us, but there’s a separation there for some reason or another, I don’t know. We even tried to give them a free membership, we opened that door, and then finally we had to make a decision, we just can’t leave it open like that.
Other Vietnam-era veterans in Georgetown and at the rest of the study sites offered various explanations for this phenomenon. One veteran in El Paso, for example, said, “They feel they can take care of whatever issues emerge on their own.” Others concluded that between work obligations and responsibilities to their families (especially young children), many of the OEF and OIF generation simply lack sufficient free time to be able to participate fully in various organizations engaged in outreach efforts. Despite the limited response, veterans interviewed maintained they would continue their outreach to those younger service members.
At all of the sites except for Washington and Little Falls, Minnesota,8 the Westat study teams learned that the faith community offers a wide array of supports and services for service members and their families, some in direct response to the challenges caused by multiple deployments. A pastor in El Paso said:
8This is not to suggest that the faith community at those two sites is not supportive of the military, but simply that study visit teams heard little about such efforts from interviewees at those locations.
We consciously 3.5 years ago, as a staff, saw the deployments and what they were doing to the families. So, on a staff planning meeting for the next year we said, We’re going to do everything we can to reach out to our military community and meet them where their need is.
A Jacksonville, North Carolina, minister noted that the church can offer immediate supports “without the red tape,” that is, without the bureaucratic overlay that might occur within the military. He also pointed out that for families or service members who are worried about how seeking help might affect the service member’s career, church-based assistance is confidential and lies completely outside of the chain of command. Specific faith-based support services that were reported to study teams include pastoral counseling for individuals and couples, men’s PTSD support groups, spouses’ support groups, military luncheons, support for single service members, care packages for deployed units, and financial respite and household support. Equally important, interviewees said that families and service members benefit from the comfort of both faith and prayer.
Family, Friends, and Neighbors
At all six study sites, interviewees described an array of supports offered by family, friends, and neighbors. At both National Guard sites, which are small, rural communities, interviewees frequently commented that extended families live in the area and help pick up the children from school, provide child care while the nondeployed spouse is at work, and offer emotional support to the service member, spouse, or children as needed. In Georgetown, South Carolina, in a telephone conversation with a study team member, a National Guard member about to leave on his third deployment was asked where his wife finds support during his extended absences. He described a social geography of support, including his wife’s sister and brother who live on either side of his and his wife’s home, and his relatives who live very close by. “She has plenty of support when I’m gone.” Similar support networks were described in Jacksonville, North Carolina, where the national recession left some family members unemployed and reportedly prompted them to move into the community to help the nondeployed spouse. Families were foremost in people’s minds at the other sites as well, such as in El Paso, where business leaders said that they intentionally sought to create a service-rich environment so that nondeployed spouses might stay in the city rather than “return home to their families.”
Friendships were also described by service-member interviewees as providing valuable support. In the four active-duty sites, however, because so many service members and their families live outside of the military installation, interviewees often reported having only one or two close friends in their neighborhoods or apartment buildings. Although these friendships are strong, they also leave individuals vulnerable to the vagaries of military life. In El Paso, for example, a young woman described the kinds of supports that she and her best friend, a neighbor, provided to each other while their husbands were deployed. Recently, however, her friend’s husband had been severely wounded in an IED attack and the woman was spending all of her free time at Beaumont Medical Center. The interviewee said that she was continuing to support her friend, but she also realized that the mutual nature of their relationship had changed. And with no other military-affiliated individuals in her apartment complex, this young woman’s “network” had diminished considerably.
Finally, interviewees routinely described different ways in which neighbors and community members take care of each other, including “Welcome Home” parades, community
fundraisers, neighbors’ shoveling snow or cleaning someone’s gutters, a random patron picking up the restaurant tab for a service member, and a Little League coach who provides rides to and from practices and games. Unfortunately, not all military-affiliated individuals described feeling so supported by their communities. For example, two spouses of service members interviewed in El Paso perceived the community to be “disingenuous” about their support for the military and mentioned various frustrations with the schools, landlords, and business community. For the most part, however, interviewees recognized community members’ good intentions and appreciated the efforts people were making on behalf of the military.
Conclusions Related to the Ethnographic Assessment
It is clear from a review of the case study reports from the six communities visited that multiple deployments have notable effects—both positive and negative—on the communities visited.
Formal Partnerships Between the Community and the Installation
In each of the four active-duty sites, community leaders have worked closely with the local installation command to establish formal, named partnerships that promote the timely flow of information between the two entities and facilitate joint planning efforts. The partnerships include the following:
• The South Sound Military and Communities Partnership established between the city of Lakewood, Washington, and JBLM. The SSMCP was developed in response to BRAC and the resultant growth of the installation and aims to foster collaboration around community development projects.
• The Armed Services Division within the Greater El Paso Chamber of Commerce that integrates directly with Fort Bliss. The Chamber of Commerce has made a concerted effort to reach out to Fort Bliss leaders, service members, and their families to try to discourage military families from leaving the area when the service member deploys. This communication channel also allows local businesses to prepare for upcoming deployments or demobilizations that might affect their business patterns.
• In North Carolina, Project CARE, developed by the Onslow County Chamber of Commerce. Project CARE combines the efforts of various local government, military, 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.
• In Watertown, New York, two “homegrown” nonprofit organizations formed by the community to identify and address military-civilian challenges. One of these organizations, the Fort Drum Regional Liaison Organization, which grew out of a committee formed in the 1980s, addresses community planning in general and any specific issues as they arise. The other organization, the Fort Drum Regional Health Planning Organization, focuses on meeting physical and behavioral-health needs. The boards of both organizations represent the local civilian and military communities.
Those partnerships reinforce the symbiotic relationship between the military installation and the local community and help to ensure that the needs of all local citizens—whether military or civilian—are acknowledged and addressed. The open channels of communication also promote the timely discussion and resolution of any emerging problems.
In Lakewood, Washington, Watertown, New York, and El Paso, Texas, the local public schools have implemented programs to assist school-age children of military parents through School Liaison Officers. In all instances, the SLOs have been trained to address family issues related to multiple deployments confidentially and are available to provide information, support, and guidance to all students, parents, teachers, and school staff, regardless of military affiliation. The SLOs help school staff understand military culture, notify them about upcoming deployments or returns, and help defuse challenges that arise, such as when children transition to a new school or their parents are deployed. Interviewees commented that the liaisons have been instrumental in helping address the challenges of multiple deployments because faculty are apprised of events (such as deployments or combat casualties) that might adversely affect one or more of their students.
Training of Law-Enforcement Officers in Posttraumatic Stress Disorder Symptoms and Crisis Management
At each of the active-duty sites, representatives of the city police departments described fairly open lines of communication with their military counterparts. But only in El Paso and in Watertown, New York, did the study teams learn that law-enforcement officers are being trained in how to recognize the symptoms of PTSD and how to respond appropriately to a mental-health crisis. Communities with large populations of service members who have experienced multiple deployments might consider the value of training all law-enforcement personnel in crisis prevention and intervention techniques.
As noted elsewhere in this report, interviewees at all six study sites said that their communities were “military towns” and that they both recognized and valued the sacrifices made by service members and their families. With rare exceptions, military spouses who were interviewed by study team members acknowledged the importance to them of living in a community where they felt they were “understood.”
In addition, the Westat study teams discovered a vast array of community-based supports and services in these locations, including faith-based efforts, outreach conducted by traditional veterans’ organizations, and virtual support groups that make use of Facebook and other social networking technologies. The reader will find accounts of numerous other such efforts in Appendix E containing the detailed case study reports.
Continued Needs and Challenges
Interviewees enumerated a fairly consistent set of challenges that their communities continue to face with respect to the effects of multiple deployments. Many of these challenges are tied to formal service-delivery systems that lack adequate capacity to meet the demand.
Community-Based Behavioral-Health Services
None of the six study communities reportedly has sufficient behavioral-health service capacity to meet the needs of its civilian clientele, much less the needs of service members and their families. Fiscal challenges at the state level have only added to financial strains on these
agencies. Yet community provider agencies believe that it is important to maintain a robust community system because they are aware of the issues related to stigma in the military. In the absence of community services, those individuals in need of treatment might forgo counseling altogether. Targeted grants, such as the TRIAD grants in Texas, have provided an important funding bridge for the military population, but interviewees expressed concern that these funding streams will dry up as the US military continues its drawdown in the Middle East. Interviewees pointed out that some service members might need support for years, whereas others might not show symptoms for years after returning from deployment. Community-based services need to be augmented, interviewees said, in order to properly address the continued and potentially growing demand.
Supports and Services for Military Youth
With the exception of Georgetown, South Carolina, where youth distress was not reported, interviewees at all sites said that they are worried about the well-being of youth from families in which one or both parents have been deployed multiple times. Interviewees described the availability of numerous resources for military youth, but still expressed the belief that not enough is being done to support that vulnerable population. Commonly mentioned was the need to increase the availability of counseling services that are age-appropriate in order to address issues that arise from deployments and that might have a developmental component.
Attention to the Needs of Underserved Populations
Interviewees described several populations of service members who, they believe, have unique needs, but who are receiving scant attention from both military and community service agencies. Community members often pointed to single service members, whose social networks were deemed to be leaner and thus less supportive than those of their married counterparts. Some worried that single service members might not receive needed services while deployed, but most expressed concern about the level of social safety nets for these single individuals when they return home from deployment. In the absence of strong supports and social activities, interviewees were worried about a rise in behavioral-health symptoms in the young single population. Community members also mentioned concern for single parents who deploy and for families in which both parents are deployed simultaneously; in those two cases, however, the concerns expressed were primarily for the well-being of the children. Finally, a very few interviewees argued for special attention for the needs of women service members returning home from combat. In particular, they believe that those women might have symptoms of PTSD associated with combat as well as potential sexual trauma from fellow service members. A peersupport network for female service members was being initiated by a community provider in El Paso that might serve as a model for other communities.
Despite numerous efforts to establish lines of communication between military installations or National Guard leaders and the local community, interviewees continued to note the need for more formal channels of information exchange. Although much information—including deployment dates, details about resources, and recommendations for useful service and supports—was being communicated by word of mouth, interviewees indicated that informal channels are not always timely or accurate. Areas of particular concern include better communication with school administrators and faculty about deployments and which of their
students might be affected, need for the development of a central point of information at which individuals could learn about both formal and informal community-based supports, and better dissemination of information about PTSD to nonmilitary community members.
Local communities are affected by OEF and OIF deployments as troops depart from military installations, return to base, and return home after separation. However, the peerreviewed literature that has systematically assessed the consequences of deployments and reintegration on communities is sparse. The data that were available to the committee did not have sufficient specificity to allow for a rigorous quantitative analysis of the impact of deployments on local communities that have military installations nearby. Although the committee found no sectorwide economic assessments of communities during the OEF and OIF conflicts, the one study available (Kriesel and Gilbreath, 1994) suggests that there are significant economic losses to communities that deploy a relatively high concentration of service members. Another study from the Congressional Budget Office (CBO, 2005) noted that reservists and National Guard members are often activated for deployment with little forewarning—a practice that can be disruptive and costly to employers. The most adverse effects of deployment are borne by small businesses that lose essential employees, businesses that rely on employees with highly specialized skills, and self-employed businesses owned by reservists. Another study reviewed found that for every 10% increase in activations of 30 days or more, small firms face a 3.7% decrease in sales (Hope et al., 2009). Additionally, among those in the labor force, veterans serving after 2001 have higher rates of unemployment than those of their civilian counterparts (see Chapter 8).
The findings from the ethnographic analyses that the committee undertook did not necessarily agree with economic findings from national studies; however, in the communities visited, a clear need for communication between local installations and community leaders was highlighted. Additionally, the perceived shortfall of behavioral-health resources available to returning veterans has also been emphasized. With regard to the community impact of veterans returning home after separation from the service, there is good evidence from past conflicts indicating that communities which receive a substantial number of returning veterans contend with homelessness and behavioral disorders. However, interviewees in the five communities with nearby installations noted that the military is an important economic contributor to their regions. In many respects, the local economies have been shielded from the recession as a result of activity associated with war being waged on two fronts and two installations benefiting from the BRAC process.
Finally, a persistent theme in the ethnographic assessment was that clear communication between installations and surrounding communities is important for reducing potential adverse effect of deployments on local communities. Open formal channels of information exchange between base commanders and National Guard leaders with local community leaders, including business leaders, school administrators, law enforcement, and local social service agencies, regarding expected deployments and returns from theater appear to be useful in mitigating some adverse effects on communities.
As the committee reviewed the sparse literature on community effects of OEF and OIF deployments and examined the range of federally funded research on outcomes for those deployed in OEF and OIF (Appendix D), it identified several areas for future research and direction:
• Studies are needed to quantify the effects of deployment and the return of active duty service members and recently separated veterans on military families and civilians living in the affected communities. Such studies should be a priority for a future comprehensive research agenda that aims to understand readjustment after OEF and OIF deployments.
• Studies designed to comprehensively address the questions around readjustment after OEF and OIF deployment should include geographic identifiers that indicate where each service member was residing when deployed, the location to which the service member/veteran returned, and where the veteran went after separation. In addition, such studies should include a systematic set of currently collected indicators of community well-being, including measures of economic performance, availability of social and support services, law-enforcement activity, and school and educational functioning. Those data are available, but data linkages are needed to allow for specific analyses that can more clearly illuminate opportunities to mitigate potential adverse community consequences after service members deploy, return, and separate.
• Longitudinal studies of veterans returning from overseas deployment are needed to assess the risk factors for homelessness. Future studies of homelessness should focus on the entire population of veterans and not only on those who enroll in VA health care.
There has been too little research on community effects of deployments to OEF and OIF. To supplement the published research, the committee completed ethnographic assessments in six communities that are near large military installations or that have recently deployed National Guard populations. Those efforts provided some insight, but the lack of community-wide assessments of the effects of OEF and OIF deployments on communities made it difficult to respond to this aspect of the committee’s charge.
The committee recommends that the Department of Defense, the Department of Veterans Affairs, and other relevant federal agencies fund research on the effects of Operation Enduring Freedom and Operation Iraqi Freedom deployments on communities. Such research should include current indicators of community wellbeing, such as measures of economic performance, availability of social and support services, law-enforcement activity, and school and educational functioning.
Relevant data are available, but data linkages are needed to allow specific analyses that can more clearly illuminate opportunities to mitigate potential adverse community consequences after service members deploy, return, and separate.
Allison-Aipa, T. S., G. M. De La Rosa, M. C. Stetz, and C. A. Castro. 2005. The impact of National Guard activation for homeland defense: Employers’ perspective. Military Medicine 170(10):846-850.
Balshem, H., V. Christensen, A. Tuepker, and D. Kansagara. 2011. A Critical Review of the Literature Regarding Homelessness Among Veterans. Portland, OR: Department of Veterans Affairs, Evidence Based Sythesis Program.
Blue-Howells, J., J. McGuire, and J. Nakashima. 2008. Co-location of health care services for homeless veterans: A case study of innovation in program implementation. Social Work in Health Care 47(3):219-231.
Bond, G. R., D. R. Becker, R. E. Drake, C. A. Rapp, N. Meisler, A. F. Lehman, M. D. Bell, and C. R. Blyler. 2001. Implementing supported employment as an evidence-based practice. Psychiatric Services 52(3):313-322.
Burnett-Zeigler, I., M. Valenstein, M. Ilgen, A. J. Blow, L. A. Gorman, and K. Zivin. 2011. Civilian employment among recently returning Afghanistan and Iraq National Guard veterans. Military Medicine 176(6):639-646.
California Department of Mental Health. 2012. Services for Veterans. http://www.dmh.ca.gov/services_and_programs/VeteransResources/default.asp#services (accessed July 24, 2012).
CBO (Congressional Budget Office). 2005. The Effects of Reserve Call-Ups on Civilian Employers. Washington, DC: CBO.
Clark, S., J. McGuire, and J. Blue-Howells. 2010. Development of veterans treatment courts: Local and legislative initiatives. Drug Court Review 7(1).
CMHS National GAINS Center. 2008. Responding to the Needs of Justice-Involved Combat Veterans with Service-Related Trauma and Mental Health Conditions: A Consensus Report of the CMHS National Gains Center’s Forum on Combat Veterans, Trauma, and the Justice System. Delmar, NY: CMHS National GAINS Center.
Colorado Behavioral Healthcare Council. 2012. Resources for Veterans and Families Through CVF. http://www.cbhc.org/cvf/resources-for-veterans-and-families (accessed July 24, 2012).
Davis, L. L., A. C. Leon, R. Toscano, C. E. Drebing, L. C. Ward, P. E. Parker, T. M. Kashner, and R. E. Drake. 2012. A randomized controlled trial of supported employment among veterans with posttraumatic stress disorder. Psychiatric Services 63(5):464-470.
Doyle, C. M., G. A. Gotz, N. M. Singer, and K. W. Tyson. 2004. Analysis of Employer Costs from Reserve Component Mobilization. Alexandria, VA: Institute for Defense Analyses.
Druss, B. G., R. M. Rohrbaugh, C. M. Levinson, and R. A. Rosenheck. 2001. Integrated medical care for patients with serious psychiatric illness: A randomized trial. Archives of General Psychiatry 58(9):861-868.
Edens, E. L., W. Kasprow, J. Tsai, and R. A. Rosenheck. 2011. Association of substance use and VA service-connected disability benefits with risk of homelessness among veterans. American Journal on Addictions 20(5):412-419.
Egendorf, A., C. Kadushin, and R. Laufer. 1981. Legecies of Vietnam: Comparative Adjustment of Veterans and Their Peers, vol 1-5. Washington, DC: US Government Printing Office.
Erbes, C. R., M. E. Kaler, T. Schult, M. A. Polusny, and P. A. Arbisi. 2011. Mental health diagnosis and occupational functioning in National Guard/reserve veterans returning from Iraq. Journal of Rehabilitation Research and Development 48(10):1159-1170.
Fargo, J., S. Metraux, T. Byrne, E. Munley, A. E. Montgomery, H. Jones, G. Sheldon, V. Kane, and D. Culhane. 2012. Prevalence and risk of homelessness among US veterans. Preventing Chronic Disease 9:E45.
Fox 28 News WNYF. 2012. Fort Drum Sees Highest Level of Active Duty Suicides. http://www.wwnytv.com/news/local/Fort-Drum-Sees-Highest-Level-Of-Active-Duty-Suicides-137775573.html (accessed July 25, 2012).
GAO (US Government Accountability Office). 2010. Homelessness: A Common Vocabulary Could Help Agencies Collaborate and Collect More Consistent Data. Washington, DC: GAO.
Greenberg, G. A., and R. A. Rosenheck. 2011. Incarceration among male veterans: Relative risk of imprisonment and differences between veteran and nonveteran inmates. International Journal of Offender Therapy and Comparative Criminology 56(4):646-667.
Hawthorne, W. B., D. P. Folsom, D. H. Sommerfeld, N. M. Lanouette, M. Lewis, G. A. Aarons, R. M. Conklin, E. Solorzano, L. A. Lindamer, and D. V. Jeste. 2012. Incarceration among adults who are in the public mental health system: Rates, risk factors, and short-term outcomes. Psychiatric Services 63(1):26-32.
HHS (Department of Health and Human Services) and SAMHSA (Substance Abuse and Mental Health Services Administration). 2010. SAMHSA Awards $379 Million for Access to Recovery Grants. http://www.samhsa.gov/newsroom/advisories/1010081330.aspx (accessed July 23, 2012).
Hickman, M. J. 2006. Impact of the military reserve activation on police staffing. Police Chief Magazine. http://www.policechiefmagazine.org/magazine/index.cfm?fuseaction=display_arch&article_id=1021&issue_id=102006 (accessed April 2, 2011).
Hoge, C. W., J. L. Auchterlonie, and C. S. Milliken. 2006. Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. Journal of the American Medical Association 295(9):1023-1032.
Holt, K. 2011. A Second Change: Veterans Treatment Courts. http://www.blogs.va.gov/VAntage/2018/a-second-chance-veterans-treatment-courts (accessed July 23, 2012).
Hope, J. B., D. B. Christman, and P. C. Mackin. 2009. An Analysis of the Effect of Reserve Activation on Small Business. Annandale, VA: SAG Corporation.
Huddleston, C. W., B. M. Douglas, and R. Casebolt. 2008. Painting the Current Picture: A National Report Card on Drug Courts and Other Problem Solving Court Programs in the United States. Alexandria, VA: National Drug Court Insititute.
Jacksonville-Onslow Chamber of Commerce. 2012. Project Care Jacksonville. http://www.projectcarejacksonville.com (accessed July 25, 2012).
Jacobson, I. G., M. A. Ryan, T. J. Hooper, T. C. Smith, P. J. Amoroso, E. J. Boyko, G. D. Gackstetter, T. S. Wells, and N. S. Bell. 2008. Alcohol use and alcohol-related problems before and after military combat deployment. Journal of the American Medical Association 300(6):663-675.
Justice for Vets. 2012. Justice for Vets. http://www.justiceforvets.org/veterans-treatment-court-locations (accessed May 24, 2012).
Kiro 7 News. 2012. Afghan Shooter Was Sniper from JBLM Stryker Brigade. http://www.kirotv.com/news/news/local-military/afghan-shooter-was-stryker-brigade/nLQ87 (accessed July 25, 2012).
Kriesel, W., and G. L. Gilbreath. 1994. Community impacts from a temporary military deployment: The case of Fort Stewart, GA. Southern Journal of Rural Society 10(1):37-54.
Kuhn, J. H., and J. Nakashima. 2010. The Sixteenth Annual Progress Report Community Homelessness Assessment, Local Education and Networking Group (CHALENG) for Veterans (FY 2009). Washington, DC: VA National Center on Homelessness Among Veterans.
Kulka, R. A., W. E. Schlenger, J. A. Fairbank, R. L. Hough, B. K. Jordan, C. R. Marmar, D. S. Weiss, and D. A. Grady. 1990. Trauma and the Vietnam War Generation: Report of Findings from the National Vietnam Veterans Readjustment Study. New York: Routledge.
Loughran, D. S., J. A. Klerman, and B. Savych. 2006. The Effect of Reserve Activations and Active-Duty Deployments on Local Employment During the Global War on Terrorism. Santa Monica, CA: RAND Corporation.
McGuire, J., R. A. Rosenheck, and W. J. Kasprow. 2010. Patient and program predictors of 12-month outcomes for homeless veterans following discharge from time-limited residential treatment. Administration and Policy in Mental Health 38(3):142-54.
McNiel, D. E., and R. L. Binder. 2007. Effectiveness of a mental health court in reducing criminal recidivism and violence. American Journal of Psychiatry 164(9):1395-1403.
National Coalition for Homeless Veterans. 2008. Homeless Veterans Reintegration Program: Best Practices Profiles of Employment Assistance Programs. Washington, DC: National Coalition for Homeless Veterans.
———. 2011. 11,000 New Permanent Supportive Housing Vouchers for Veterans Signed into Law. http://nchv.org/content.cfm?id=110 (accessed May 24, 2012).
Noonan, M. E., and C. J. Mumola. 2007. Veterans in State and Federal Prison, 2004. Washington, DC: Bureau of Justice Statistics.
North, C. S., and E. M. Smith. 1993. A comparison of homeless men and women: Different populations, different needs. Journal of Community Mental Health 29(5):423-431.
O’Connell, M., W. Kasprow, and R. A. Rosenheck. 2010. National dissemination of supported housing in the VA: Model adherence versus model modification. Psychiatric Rehabilitation Journal 33(4):308-319.
Office of National Drug Control Policy. 2010. Veterans Treatment Courts Fact Sheet. http://www.whitehouse.gov/sites/default/files/ondcp/Fact_Sheets/veterans_treatment_courts_fact_sheet_12-13-10.pdf (accessed April 23, 2012).
Perl, L. 2010. Veterans and Homelessness. Washington, DC: Congressional Research Service.
Ramirez, C. 2012. Redistricting: El Paso City Council Oks New Map, Some Neighborhoods Affected. http://www.elpasotimes.com/news/ci_21143061/redistricting-city-representative-districts-boundaries-shift (accessed July 30, 2012).
Resnick, S. G., and R. A. Rosenheck. 2008. Posttraumatic stress disorder and employment in veterans participating in Veterans Health Administration compensated work therapy. Journal of Rehabilitation Research & Development 45(3):427-435.
Rosenheck, R., and A. Fontana. 1994. A model of homelessness among male veterans of the Vietnam War generation. American Journal of Psychiatry 151(3):421-427.
Rosenheck, R., W. Kasprow, L. Frisman, and W. Liu-Mares. 2003. Cost-effectiveness of supported housing for homeless persons with mental illness. Archives of General Psychiatry 60(9):940-951.
Rosenheck, R. A., and A. S. Mares. 2007. Implementation of supported employment for homeless veterans with psychiatric or addiction disorders: Two-year outcomes. Psychiatric Services 58(3):325-333.
Seal, K. H., D. Bertenthal, C. R. Miner, S. Sen, and C. Marmar. 2007. Bringing the war back home: Mental health disorders among 103,788 US veterans returning from Iraq and Afghanistan seen at Department of Veterans Affairs facilities. Archives of Internal Medicine 167(5):476-482.
Smith, M. W., P. P. Schnurr, and R. A. Rosenheck. 2005. Employment outcomes and PTSD symptom severity. Mental Health Services Research 7(2):89-101.
State of New York, DMNA. 2012. New York Army National Guard Yellow Ribbon Events. http://dmna.ny.gov/family/reintegration.php (accessed July 24, 2012).
Tanielian, T., and L. H. Jaycox. 2008. Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery. Santa Monica, CA: RAND Corporation.
Tsai, J., R. H. Pietrzak, and R. A. Rosenheck. 2012. Homeless veterans who served in Iraq and Afghanistan: Gender differences, combat exposure, and comparisons with previous cohorts of homeless veterans. Administration and Policy in Mental Health July 24[Epub ahead of print].
University of Maryland School of Public Health. 2012. New Partnership Targets Maryland Veterans’ Mental Health. http://sph.umd.edu/index.cfm (accessed July 24, 2012).
US Department of Housing and Urban Development and VA (Department of Veterans Affairs). 2011. Veteran Homelessness: A Supplemental Report to the 2009 Annual Homeless Assessment Report to Congress. Washington, DC: US Department of Housing and Urban Development and VA.
US Small Business Administration. 2011. Military Reservists Economic Injury Loans. http://www.sba.gov/content/military-reservists-economic-injury-loans (accessed August 25, 2011).
VA (Department of Veterans Affairs). 2008. Uniform Mental Health Services in VA Medical Centers and Clinics. Washington, DC: VA.
———. 2011. Hospital and Outpatient Care for Veterans Released from Incarceration to Transitional Housing. RIN 2900-AN41 Federal Register.
———. 2012a. Project CHALENG. http://www.va.gov/homeless/chaleng.asp (accessed January 25, 2012).
———. 2012b. VA Announces New Grants to Help End Veterans Homelessness. http://www.va.gov/opa/pressrel/pressrelease.cfm?id=2355 (accessed July 20, 2012).
VA National Center on Homelessness Among Veterans. HUD-VASH Resource Guide on Permanent Housing and Clinical Care. Washington, DC: VA.
Vogel, S. 2011. Veterans Affairs claims progress in ending homelessness among vets. Washington Post, December 26, 2011.
Washington, D. L., E. M. Yano, J. McGuire, V. Hines, M. Lee, and L. Gelberg. 2010. Risk factors for homelessness among women veterans. Journal of Health Care for the Poor and Underserved 21(1):82-91.
Washington State VA. 2012. PTSD Counseling Services. http://www.dva.wa.gov/ptsd_counseling.html (accessed July 24, 2012).
Wenzel, S. L., P. Koegel, and L. Gelberg. 2000. Antecedents of physical and sexual victimization among homeless women: A comparison to homeless men. American Journal of Community Psychology 28(3):367-390.