Healing the Trauma of War A Project Sponsored by Mental Health America of Hawaii

August 2009 to November 2010

Executive Board

Jim Bibbee Coordinator, Military OneSource Capt. Que Schae Blue-Clark Family Services Director, Army National Guard Hon. Michael Broderick Family Court Judge Leigh Ching Provider Contracting Supervisor, HMSA Col. C.J. Diebold Chief of Psychiatry, Tripler Army Medical Center Chief Lee Donohue Former Honolulu Police Chief Warren Evans President, Argosy University-Hawaii Noe Foster CEO, theStrategist, LLC Marya Grambs Executive Director, Mental Health America of Hawaii Ken Hirsch, MD PTSD Director of the Pacific Cherise Imai School Military Liaison, Department of Education Cynthia J’Anthony University of Hawaii Graduate Student Walt Kaneakua Military Liaison, U.S. Senator Daniel Inouye Lee-Ann Kida McClean Former Military Liaison, U.S. Congressman Neil

Abercrombie Karl Kiyokawa Vice President, Tri West Hawaii Hon. Ed Kubo Circuit Court Judge Maj. Gen. Robert Lee State of Hawaii Adjutant General Kim Lipsky U.S. Veteran Affairs Senate Committee Staff Clay Park Military Liaison, Papa Ola Lokahi Alan Shinn Executive Director, Coalition for a Drug Free Hawaii Rep. K. Mark Takai House of Representative; Major Army National Guard Jim Tollefson President/CEO, Chamber of Commerce Ann Yabusaki Director, Family Intervention and Training Services Project Background

Mental Health America of Hawaii contracted with theStrategist, LLC to lead an Executive Board of senior military, business, and community leaders to identify problems faced by National Guard and Reserve soldiers and their families after combat and develop an action plan of solutions to improve the quality of life for these soldiers and families. Over the course of a year, Healing the Trauma of War Executive Board shaped an action plan that proposes 10 solutions ideas that will positively impact reintegration for National Guard and Reserve soldiers and their families. Through interviews, focus groups, surveys, legislative testimony, workgroups, and other discussions, hundreds of individuals offered their invaluable input and perspective to inform the final action plan. Since 9/11 more than 1.8 million U.S. men and women have served in Iraq and Afghanistan. For the first time ever, National Guard and Reserve soldiers comprise 30 percent of all combat forces. Project Focus

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Target Outcome

Improve life for U.S. National Guard and Reserve soldiers and their families once they return home from combat in Afghanistan and Iraq.

Problem Statement

Finance

In transitioning back into civilian life, National Guard and Reserve troops experience financial challenges that add stress to and strain family relationships. The current economic climate, with many Hawai`i companies going out of business, compounds the situation. We estimate that 15-20 percent of National Guard and Reserve soldiers return home jobless. Some have received “Dear John/Dear Jane” letters while in Iraq or Afghanistan from employers who have closed up shop. Others deployed immediately after graduation and are now in search of their first job outside of the military.

Employment/Unemployment

For some, their employers have closed for business leaving them jobless, which often entails loss of health insurance. Many find it difficult to translate their combat experience on a resume into marketable skills employers want to hire. Others return to work but undergo difficult transitions and feel “out of place.” Some employers are hesitant to hire or retain National Guard and Reserve soldiers because absences resulting from multiple deployments place a financial burden upon the business and/or fear of PTSD and other mental health challenges they have read about.

Debt

Finding affordable housing, paying for housing, and managing credit debt are issues facing returning soldiers. Some financial and lending institutions are violating Federal laws already established to protect soldiers from foreclosures and repossessions, or are inappropriately enticing soldiers to incur debt beyond their capacity to pay with home and car loan solicitations.

Homelessness

In the U.S. one in three homeless adults is a Veteran. Today the fastest growing homeless segment is women Veterans.

Post 9/11 GI Bill

The Post 9/11 GI Bill restricts the benefit period retroactive only to August 2009. This bill should be amended so that soldiers who incurred qualifying educational expenses between September 2001and August 2009 receive the financial relief that this bill offers.

Communications

Communication outreach efforts have improved, yet much more needs to be done to reach and motivate National Guard and Reservists to use resources and benefits available to them. Often when benefit information is presented right after the soldier has returned,

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the soldier is disengaged and does not feel an immediate sense of urgency to access these benefits until he or she is in a crisis situation. The commands’ restrictive interpretation of privacy laws has also hampered outreach efforts. There are many support programs that are underutilized because National Guard and Reservists don’t know they exist or find it too labor intensive to apply for these benefits.

Mental Health

Soldiers are returning home with psychological war wounds that include: post traumatic stress disorder (PTSD) various degrees of traumatic brain injury (TBI), military sexual trauma (MST), substance abuse, depression, and other mental health conditions, which may lead to attempts at self-harm (including suicide) and/or violence against others. Soldiers who are struggling with mental health and substance abuse conditions are at greater risk for involvement in domestic violence, high-risk behavior (fighting and high speed driving), and other involvement in the justice system. To complicate matters, most National Guard and Reserve troops see non-military physicians and health care providers, who may not be familiar with combat-related issues. Additionally, because DOD and VA medical record systems are not compatible soldiers' medical records are often incomplete. Although there are many programs to offer support, these services are fragmented and often difficult to navigate and, in some cases, may not be culturally sensitive. In addition, stigma and denial are powerful factors that prevent early intervention or ongoing treatment.

Family

Deployment tests the foundation of the family.

Impact on Children

Children are impacted when a parent deploys and when he or she returns. Reactions are highly individual with each child and with each deployment, but it is safe to say that it is traumatic to lose a parent to a war zone and face a returning parent who may be suffering from problems. Child abuse rates are at an all time high, with one study reporting that the at-home parent was three times more likely to abuse a child while the other parent is deployed when compared with non-deployed parents. Research confirms that children with one or both parents deployed to war experience mental health conditions more often than other children. The rate increases when the parent’s deployment is extended and when it has occurred multiple times.

Impact on the Spouse

Family roles change. The at-home spouse often carries an enormous burden. Marriages experience pressures that generate high rates of strife, infidelity, break-ups and divorce, which negatively affect the children. Domestic violence rates are on the rise, fueled by substance abuse and untreated mental health issues. Wives of deployed soldiers are at higher risk for mental health conditions. The rate increases when the deployment is longer than a year. There is a false perception that National Guard and Reserve soldiers are advantaged because they have on-island extended family support. However, these family members often lack a full understanding of the dynamics and challenges of

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military life and are often ill prepared to offer support. Delivery of Care

Few private, non-military physicians and mental health providers are sufficiently prepared to treat the unique needs of National Guard and Reserve soldiers. Also, most are unaware of the military resources available and how best to connect their patients with these services.

Insurance Coverage

National Guard soldiers lose health insurance coverage after 180 days after he or she returns home from a deployment and transitions off of active duty status.

Over-arching Factors that Influence All Issues

Availability and Access to Services

To exacerbate the problems, there is a shortage of psychiatrists, psychologists, marriage and family therapists, and mental health and substance abuse providers. Of these providers, few are sufficiently prepared to treat the unique needs of National Guard and Reserve soldiers. Provider shortages are even more critical on the Neighbor Islands, with very few psychiatrists and psychologists available. Telemedicine programs to expand coverage to Neighbor Island families are not yet operational and planning initiatives are still in the infancy stage. Of great concern is the fact that there are no established health assessment protocols for private, non-military primary care physicians, pediatricians, Ob/Gyns, mental health providers, and others that direct them to ask, “Have you or a family member been deployed to combat?” Finally, National Guard and Reserve soldiers are vulnerable to eligibility restrictions and do not have full access to family support programs, as do active duty military members. Stigma and Denial

Stigma and denial are huge barriers that prevent soldiers from seeking mental health and substance abuse help, impeding treatment for the family as well. Concern over “fit for duty,” loss of rank, shame, or individual or family denial can often interfere with a soldier’s decision to seek help. In addition, National Guard and Reserve soldiers are anxious to return to a non-military lifestyle when they arrive home after a deployment, and sometimes avoid unit events like Yellow Ribbon reintegration sessions.

Lack of Data

Children of National Guard and Reserve soldiers have not been not consistently identified in the school system. As a result, National Guard and Reserve children fail to get the same level of school-based outreach and support as active duty children. No data is currently collected or tracked regarding the primary care physician and health insurance for National Guard and Reserve soldiers and their families. Although data is collected at various stages of deployment, the data is not aggregated, analyzed, or publicly reported.

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10 Solutions Local Solutions

1. Provide intensive job-ready support for soldiers. Work with Veterans Affairs, Department of Labor, Hawaii Workforce Development Council and other agencies to target a specific industry with job growth potential and provide training and employment placement for soldiers and their spouses. Leverage existing programs that offer opportunities for soldiers and their spouses to upgrade their skills or start a new business. Focus new efforts on target demographics, like women soldiers, whose needs are not yet met with existing programs.

2. Establish a Veterans Court or hybrid track within the judiciary system that initiates a problem-solving approach that involves Veteran Affairs intervention, mandated mental and behavioral health treatment, peer mentors and rehabilitation instead of incarceration. Introduce a protocol that is tailored to meet the unique needs of National Guard and Reserve soldiers in addition to active duty personnel.

3. Expand access to medical, mental health and behavioral health care on the Neighbor

Islands by employing wireless and 3G technology platforms that link service providers in urban areas to soldiers who live in isolated and rural communities. Engage private, non-military physicians, psychiatrists, psychologists and behavioral health providers.

4. Train non-military physicians, mental health providers, school counselors and others

through on-demand, web video clips, at conferences and through community forums. On a grass roots level, engage communities in brainstorming sessions that look at cultural, ethnic and geographic differences that impact a soldier’s decision to seek help. Develop better ways to identify combat-related conditions early.

5. Launch a multi-media communication campaign that informs National Guard and

Reserve soldiers of the full scope of benefits available to them and how to access these benefits.

6. Identify children of National Guard and Reserve soldiers at the school-level through

the DOE and expand outreach programs already in place for active duty military children. Add information to benefit military youth on Hawai`i’s Teen Help Line.

7. Ensure periodic health screenings are conducted for all returning soldiers according

to Department of Defense policies. Track, trend and report aggregate data.

National Solutions

8. Retroactive benefit effective date for Post 9/11 GI bill to September 2001.

9. Extend health insurance coverage to unemployed National Guard and Reserve soldiers and their families. Auto-enroll National Guard and Reservists into VA health and administrative benefit programs.

10. Remove 5-year time limit policy for PTSD diagnosis.

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Results

• The U.S. Department of Labor Veterans’ Employment Training Services awarded

a $300,000 federal grant to Mental Health America of Hawaii for an employment project to benefit homeless and unemployed women Veterans and Veterans with families in Hawaii. The project is called POWER Up! The initial project period is July 1, 2010 to June 30, 2011 with two additional years of funding possible.

• Chief Justice Ronald Moon appointed an advisory committee comprised of judges to investigate and evaluate the feasibility and viability of establishing a Veterans Court or a hybrid Veterans track within the justice system. The 2010 Hawaii legislature passed HR200 directing the Judiciary to report its findings and recommendations relating to the establishment of a Veterans court to the 2011 legislature.

• Mental Health America added a suicide prevention initiative to benefit youth of military families.

• Increased media and public awareness. Through local and national news coverage of this project, more individuals have become sensitive to the unique re-integration challenges National Guard and Reserve soldiers face when returning home from combat in Afghanistan and Iraq.

• New collaborations and synergies have been built with the Judiciary, Department of Education, legislature, Tri West, Chamber of Commerce, Argosy University, University of Hawaii and the Pacific Task Force for Psychological Health.

• The Department of Education is now identifying and tracking children of National Guard and Reserve soldiers.

• The Chamber of Commerce included in its 2010 Health Care Policy Statement the need to expand access to care for National Guard and Reserve soldiers who live in rural communities.

• Healing the Trauma of War project was awarded the 2010 Innovation During Challenging Economic Times award by national Mental Health America.

theStrategist Noe Foster

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