In the Wake of War

Our returning troops come home to families who have learned to manage without them, jobs that may have disappeared, communities that don’t understand what they’ve been through, and services that they may not even be aware of, much less know how to access.

by Jeff Mortimer

For most of the last century, nearly all of the troops in America’s wars have been military service members on active duty. For most of the last decade, upwards of 40 percent of the troops in Iraq and Afghanistan have been either members of the National Guard or reservists called to active duty.

When these soldiers are demobilized, they usually don’t return to a military base, where there are support services on-site and peers who can empathize with the stresses they’ve endured. They are prime candidates for depression, post-traumatic stress disorder, sleep disturbances, substance abuse and other mental health problems. And the reluctance that many civilians feel about seeking assistance is reinforced by the military’s culture of “we take care of our own.”

Helping them get help by countering entrenched beliefs and working through that remaining stigma is a key mission of the University of Michigan’s portion of Welcome Back Veterans (WBV), a national initiative to address the reintegration challenges of these returnees.

“Once you meet the people who are coming back, you get very involved,” says Marcia Valenstein, M.D., an associate professor of psychiatry. “You realize how much we’re asking from these people and their families.”

Valenstein is also a clinician and researcher at the Veterans Administration Ann Arbor Healthcare System, where many physicians hold a joint U-M faculty appointment. Because of her considerable experience with peer interventions there, Valenstein was asked to help write the application for WBV funding and has been instrumental in devising and implementing a program called Buddy-to-Buddy under the initiative’s auspices.

“The whole premise was that no one can be a more credible source of both support and overcoming the stigma around asking for help than another veteran who’s been there,” says John Greden, M.D., the Rachel Upjohn Professor of Psychiatry and Clinical Neurosciences and executive director of the U-M Depression Center, where the program is housed.

Helped considerably by Major Robert Lagrou, a member of the National Guard who was also a child psychiatry resident at the U-M, the Depression Center and psychiatry department — and Michigan State University, a frontrunner in such efforts — had been talking with the Michigan Army National Guard about what kind of programs might be most helpful to them. The guard expressed a particular interest in peer outreach and linkage. Valenstein was already involved in a project within the VA where people who were in treatment for depression are enlisted to support each other in addition to receiving their regular treatment. “The new initiative applied the same soldier-to-soldier concept in a new way,” she says.

There are two tiers of “buddies” in the system.

Buddy Ones are individuals within each returning unit who are trained in communication skills and recognizing signs of difficulty, and charged with staying in regular contact with seven to 10 of their comrades. “The thought was that these were the people they deployed with, know well, and trust most,” says Valenstein. “Their buddies check in on how they’re doing in the same way you might check in on a friend who has had a difficult experience.”

If there are, indeed, signs of trouble, the returnee can be referred to a number of resources, including a Buddy Two, one of a group that’s also known as Volunteer Veterans. Buddy Twos receive intensive training in interviewing techniques and how to access resources. They can maintain confidentiality because they are not affiliated with the National Guard or governed by its chain of command.

These volunteers aren’t required to have served overseas or in combat, but the overwhelming majority of them have, according to Brandon Brogan, the Buddy-to-Buddy program coordinator. “Soldiers returning from Iraq and Afghanistan are far more likely to open up to those who know what it’s like to come home and try to transition back,” he says. Brogan knows whereof he speaks. He’s an ex-Marine who served three tours of duty in Iraq.

“I got out a little over two years ago and know what it’s like to return home and try to create a life out of nothing,” he says. “I was pretty much on my own. I did a fair amount of research to make sure I knew where to go to get my GI bill started and how to get VA medical care, but it was quite time-intensive and not everyone is able to do that.”

While buddies are briefed on the availability of a range of services from housing to employment, encouraging veterans to seek assistance with psychosocial difficulties carries an added degree of complexity.

The military has a stigma regarding mental health, Brogan says, and this is a way of breaking down that stigma. “The leadership in the military sees the issues and will admit they’re there, but getting guys on the ground level to admit they have a mental health issue is a completely different thing.”

“What we would hear from people was, 'If you haven’t been there, you don’t get it,’ ” says Greden. “If you can find the right soldiers — people they identify with, people they served with — the simple message is, 'You’re not alone, treatment works, it’s a sign of real strength to get help. I would like to help you do that. I’ll even go with you. Let’s do it.’ ”

According to Brogan, they have definitely found the right group of veterans.

“We have a fantastic group of volunteers that go above and beyond any expectation,” he says. “It’s humbling to see the work these guys do. A lot of them are Vietnam veterans who definitely weren’t supported when they got home, and they’re dedicated to seeing that doesn’t happen to these veterans.”

That dedication includes attendance at monthly drill weekends, which both Brogan and Valenstein cite as a major step forward. Once guard members see the volunteers on a regular basis, they get to know them as interested, concerned citizens who are knowledgeable about resources. They have credibility in advance of any need for their assistance.

“We had to develop trust with the Michigan Guard before we could have the volunteer veterans go to the drill weekends,” says Valenstein.

Invisible Injuries

The long-standing link between the U-M and the VA is an obvious one, and it began to take on an added dimension when Greden got a phone call from Fred Wilpon, a Michigan alumnus and donor. “I think we actually talked on a Saturday,” says Greden, “which is an indication of how much someone cares about a topic.”

Wilpon and others interested in the problems being faced by returning veterans had visited Walter Reed Army Medical Center in Washington. He came away impressed by the sophisticated care that patients were receiving for their physical injuries, but distressed at what he saw as the despair and demoralization among those who were coming back with “invisible injuries” — post-traumatic stress disorder, depression, suicidal thoughts, sleep disturbances.

“The VA is a wonderful system that’s delivering terrific care,” Greden says, “but not everyone can access a VA facility, some are not eligible, and some prefer to go outside the VA for care. The idea was to get some of the interested universities who had expertise in this area to start working together with the VA to really jump into this.”

WBV was launched late in 2008 with funding from several organizations, including the McCormick Foundation and Major League Baseball Charities. Later, funding was supplemented by the Department of Veterans Affairs. Of the initial universities to receive WBV grants, Michigan chose a path that led to the Buddy-to-Buddy program. “Michigan’s belief was that addressing stigma issues was necessary before you could get people into treatment programs, no matter how effective those programs were,” says Jane Spinner, who oversees the veterans project for the Depression Center. “We chose to help address those challenges through the peer-to-peer approach, using military culture to help change the culture. This program fit well with the expertise of our faculty and our Depression Center mission.”

The team members recognized that even though many troubled returnees were isolated in terms of access to services, their problems did not exist in isolation, nor could they be addressed that way. Strong Families, in effect a support program for supporters of soldiers, was created to focus on that need.

“We’re doing a more intensive parenting intervention for the military service members who have young children because the impact on children is particularly worrisome,” Spinner says, “and we saw that the reintegration challenges faced by military families are just as significant as those of the returning veterans.”

Not surprisingly, all of those challenges are intertwined. Every member of a soldier’s family is affected by deployment, and their responses affect the soldier.

“What we’ve found is that both the parent-child dyad and the marital dyad tend to be pretty fragile in these families,” says Sheila Marcus (M.D. 1983, Residency 1991), professor of psychiatry and head of the child and adolescent psychiatry section, who leads the Strong Families team. “They really suffer because of the separation and reunion.” Strong Families participants attend eight weekly sessions. After a welcoming meal, the children participate in activities supervised by social workers and psychologists, while the moms and dads go to a parenting course that includes information about sensitivity to children’s cues, attachment security issues, self-care skills like deep breathing and meditation, and the availability of services, as well as interactions with other families who have been through the deployment cycle.

Marcus’ team also runs support and education groups for parents at the pre- and post-deployment weekends that the VA offers its members and their families, and is about to launch a series of workshops for spouses that will take place during deployment.

There’s already evidence that these efforts are paying off, according to Spinner. “We’re just analyzing the data now,” she says, “but it appears as if we have worked with very distressed families who have greatly benefited in terms of both the marital relationship and parenting skills.”

Bridging Culture Gaps

Successfully launching these programs required navigating the differences between the military culture’s emphasis on speedy implementation and a clearly defined chain of command, and academia’s more deliberate pace and fluid leadership structure.

Moreover, says Greden, “Sometimes those of us in university settings think inaccurately that we provide every answer, and sometimes those in military units don’t necessarily want to acknowledge they’re not meeting all the needs. But we’ve managed to build really strong partnerships across the boundaries of the military leadership, the VA, and the academic units. We’re pulling it off — Afghanistan and Iraq veterans are getting better access to resources because we’ve been able to work our way through things.”

It took only eight weeks for Valenstein and her associates to get the Buddy-to-Buddy program started, although it took far longer to get the program fully implemented and embedded. Early on, the Michigan Army National Guard sought and received funding for the Buddy One portion of the program and later assumed full responsibility for running it. The U-M continues to operate the Buddy Two tier, whose members helped about 350 of their peers in 2010, but the number of veterans touched by the U-M’s work will soon be vastly higher as more volunteer veterans are trained and attached to units.

A prior VA-funded study by Valenstein of suicide among veterans had shown that veterans with mental health problems were at their highest risk for suicide in the period immediately following hospital discharge. She notes that there is now more structural support and close follow-up for veterans after discharge. Buddy-to-Buddy extends support to soldiers who may not have full-fledged mental health difficulties, but need support for successful reintegration. This, in turn, may prevent more severe difficulties from emerging.

“Intriguingly, I think, the military right now is far more invested than in the past in partnering with other organizations,” says Greden. “It’s trying to work with civilian resources and communities, and the military leadership has gone out of its way to try to build bridges with academic settings.”

The results so far are more than merely promising.

“When I found out about this program and the concept behind it — using veterans as advocates for other veterans — it made so much sense,” says Brogan, “but I’m still surprised at how effective it is.”

Military Families Suffer Too