The mental health needs of U.S. military veterans returning from Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) are substantial: 25%—40% of veterans returning from these conflicts report significant mental health symptoms or interpersonal difficulties (1,2). Psychiatric morbidity, particularly posttraumatic stress disorder (PTSD), depression, and substance use disorders, has a significant impact on these soldiers' mental and general health status, role functioning, and employment (3).
High rates of suicide among veterans have become a pressing concern (4), as have family difficulties (5) and the stigma surrounding the use of mental health services (1). Improved screening, facilitated connection to services, and increases in the availability of evidence-based treatments are needed. To achieve this, a coordinated response from military, U.S. Department of Veterans Affairs (VA), academic, and community organizations is necessary. Partnerships among these groups can facilitate the engagement in treatment of soldiers and families, provide evidence-based services, and expand the evidence base to improve outcomes (6,7).
During several periods of the OEF and OIF conflicts, National Guard soldiers have constituted between 40% and 50% of U.S. fighting forces (8). Most National Guard soldiers do not return to guaranteed employment and do not live on or near military installations. They return to civilian communities, where they rapidly reintegrate into the civilian workforce and depend on their community's supports and mental health services. For these citizen-soldiers, additional innovation is required in developing and providing services.
In Michigan, the Michigan Army National Guard (MIARNG), the VA, and university faculty from Michigan State University (MSU), and the University of Michigan (UM) initially had separate efforts to assist returning National Guard soldiers. Over the course of four years, an increasingly close and active partnership was forged to jointly assess and meet the needs of returning MIARNG veterans and their families. In this column, we describe how we have worked together on projects aimed at assessing soldier needs and assisting with reintegration. We also discuss challenges and obstacles faced when forming the partnership and our continued efforts to synergize.
Before the September 11, 2001, attacks, MIARNG's concerns were focused on enlisting, training, and equipping a strategic reserve force. After September 11, 2001, MIARNG became increasingly aware of the challenges faced by their civilian soldiers returning from OIF and OEF deployments. A new, emerging, and critical focus for the National Guard became the reintegration of soldiers after return from deployments.
The collaboration between MIARNG and MSU was the result of a graduate student's (LG) interest in military families. Her research interest was supported by faculty from the Departments of Human Development and Family Studies, Epidemiology, and University Outreach and Engagement. A conference meeting in 2005 between MIARNG leaders and MSU faculty and graduate students led to a collaboration to develop and deliver programming during weekend reintegration events that followed unit demobilization and to develop referral options for community resources where needed. Activities like these are part of the military's Yellow Ribbon program to support soldiers and their families throughout all phases of the deployment cycle.
MIARNG launched its first two-day reunion and reintegration workshop for soldiers and their supporters in 2006. These workshops were implemented with a small staff from the state family program office, chaplain support, faculty and clinical interns from MSU, and volunteers from the private sector. These two-day events, held at a retreat location approximately 45 days after the MIARNG soldiers' return home, aim to assist soldiers and their supporters with reintegrating back into civilian work, family, and community life. Attendance is mandatory for soldiers and optional for family. Programming includes education about depression, suicide, PTSD, addictions, traumatic brain injury, and information about community resources and entitlements. In facilitated process groups, soldiers and their families have an opportunity to talk openly about their reintegration experiences.
In 2007, with the support of an internal MSU grant, survey data were collected at these weekends to understand how MIARNG soldiers and their families were faring postdeployment. These data were summarized and discussed with MIARNG leadership to guide and change programmatic efforts. Further input came from members of the MIARNG-MSU collaboration, who were all actively involved in delivering programs. Additional input was gained from two Vietnam veteran advocates who were active in reintegration weekends and provided informal peer outreach to soldiers.
UM Medical School faculty, several of whom also had appointments with the VA Ann Arbor Healthcare System, became involved with the MIARNG and MSU faculty in the summer of 2008. UM activity was spurred in 2007 by a U.S. philanthropist with ties to the UM. His initiative ("Welcome Back Veterans" [WBV]), sought to involve the general population in a nationwide campaign to support Centers of Excellence in developing and providing services for returning OIF and OEF veterans. WBV partnered with Major League Baseball and the McCormick Foundation to administer procured funds through its gift and grant process.
UM-VA faculty initially planned to develop an inventory of current service activities extant in 2007 for veterans in Lower Michigan. The information gathered made UM-VA faculty aware of the broad array of community initiatives that were already in place but not accessible in a centralized location.
These efforts were aided by the liaison activities of a UM psychiatry fellow (RL) who was also a member of MIARNG. Through him, UM-VA project leaders became aware of MIARNG's work with MSU and the reintegration workshops. MSU colleagues and MIARNG leadership were consulted about their programming preferences, and a grant was funded through the WBV-McCormick Foundation initiative, which provides important seed monies to develop a more systematic peer-outreach program and additional family initiatives for MIARNG veterans.
Utilizing the principles of community-based participatory research (9), group members from each institution met regularly so each party could contribute to developing a shared mission, setting goals and priorities, and developing new programming for returning soldiers. This group also provided oversight for program implementation and evaluation. MSU and UM-VA staff regularly attended reintegration weekend events to spend time with MIARNG soldiers and to facilitate breakout groups. In addition there were joint UM-VA and MSU brainstorming sessions, regular in-person monthly meetings with all group members, and numerous e-mails or telephone conference calls among collaborators.
Challenges in forming the partnership included the National Guard ethos that it was "important to take care of our own" and feeling besieged at times by offers of assistance from disparate community groups. The relatively flat management structure and informal atmosphere of academic departments also contrasted with the hierarchical military structure. Guard leadership were sometimes frustrated about who was "in command" in the university structure or bristled when academics accessed high-level officers without "going up the chain of command." In addition, both the MIARNG and WBV sponsors were reluctant to consider the idea of conducting research evaluations as part of program development. It was clear that research was secondary and would need to follow program implementation. Trust was facilitated through forming a clear joint agenda and repeatedly demonstrating commitment and respect.
As the partnership evolved, it became clear that the academics had a new opportunity to deliver services designed to have a direct impact on a population in need. In turn, the National Guard found that the academics had useful knowledge about mental health treatment and program evaluation. Academic partners also had expertise in writing grant applications, which brought more resources to MIARNG programs.
Surveys and needs assessment
UM-VA and MSU combined evaluation activities to further inform intervention development. They documented baseline symptoms and services used by sequential waves of MIARNG soldiers. Surveys also asked about soldiers' treatment preferences, assessing to whom soldiers turned when they experienced mental health symptoms or other life difficulties. These data informed programming needs and allowed MIARNG to obtain funding for services from higher National Guard echelons.
A comprehensive compilation of community agencies and providers was developed, including information about experiences and expertise in treating military populations, fees and insurances, and types of treatment offered. This guide was distributed to National Guard personnel.
Family programming initiatives
Family programs that focused on parenting, family reintegration, and dealing with stress were offered at reintegration events. Additional predeployment programming was included to prepare families for their loved one's deployment and to connect them to services, providers, and other families with similar experiences.
Peer outreach and linkage
Based on MIARNG programming preferences and the military culture that supports "leaving no one behind," a proactive, systematic peer-outreach and linkage program, called Buddy-to-Buddy, was developed. Peer outreach was thought to be well suited to address the stigma associated with treatment seeking. A UM-VA faculty member (MV) with expertise in developing peer support programs with veterans and other populations led the planning. Also involved were the two Vietnam veteran peer advocates. Their prior activities and influence throughout the MIARNG helped the new program gain acceptance. Buddy-to-Buddy was implemented in January 2009 for returning MIARNG soldiers. Each returning soldier is assigned a first-tier Buddy (Buddy One) from within the same unit. Buddy Ones are trained in communication techniques and systematically telephone returning soldiers in their panel to identify those who may benefit from further evaluation. Soldiers and Buddy Ones also are able to access second-tier Buddies, who are volunteer veterans trained in motivational interviewing techniques, are well versed in VA and other local mental health resources, and receive regular supervision by UM staff. Buddy Two volunteer veterans help soldiers who might be ambivalent about care, have difficulty accessing treatment resources, or require more complex treatment coordination.
After services projects were implemented, a joint research agenda began to be developed. On the basis of the collaborative's priorities, research applications to more rigorously evaluate the Buddy-to-Buddy program were submitted and funded by the VA Health Services Research and Development office.
The important mental health needs of returning soldiers and their families attract the interests and energies of a wide range of professionals. Collaboration required flexibility and humility to adapt and change initial individual and institutional aims into joint aims.
We recognized the need to integrate different cultures. The academic institutions had similar aims for their respective involvement, but their institutional cultures differed in some ways. The goals and timeline of the MIARNG were dramatically different from those of either academic partner, and the MIARNG had a culture less tolerant of the research focus and leadership ambiguities that typically characterize academic endeavors. The final product has benefited from these somewhat disparate cultures: program development and implementation moved at a more rapid pace than is typical for academia, and an evaluation and research component has been developed to a greater extent than might ever be planned by a military organization. It was critical to establish trust between university partners and the MIARNG, including all levels of commanders and civilian staff working in the family programs office. There has been no substitute for ongoing face-to-face work to blend efforts and achieve mutually desired goals.
The joint mission and shared gratification in working effectively to assist returning soldiers and their families have sustained and enhanced the motivation and energy of each team member and continually fueled the collaborative's resolution to work together to meet the needs of soldiers and families who have given and sacrificed so much to serve their country.
The authors thank Donald Behm and Thomas Devine for their service and inspiration in this work.
The authors report no competing interests.