1. Veteran Issues 1 Multiple deployments are common causing stress and family attachment issues. – As of Oct 2008, multiple deployment breakdown: 60% = 1x 36% >= 2x 4% >= 4x – As of Mar 2013, NG and Reserve deployments: 62% = 1x 24% = 2x 8% = 3x 6% >= 4x – “Typical Deployment Durations” Army and Marine1 year** Navy 6-9 months Aviation and Spec Forces 4-6 months Air Force ~6 months ** In 2012 Army went to 9 months – but in 2014 expected to be back to 12 months An April ‘08 Rand Study reported 37% have either PTSD, TBI, or significant Mental Stress (5% all 3). Some estimate >50% return with some form of mental distress – Feb 2013 CRS Report…17% have a TBI Diagnosis (77% of these are Mild) (CRS=Congressional Research Study) – Mar 2013 VA Report… 20% of patients have PTSD vs 7-8% in general population per the NC-PTSD – Mar 2013 NC-PTSD Report indicates Vietnam Vet lifetime rates are 27% for women, 31% for men – 2013 GWU Report indicates PTSD increases one’s healthcare costs 3.5x …. $8,300 in the 1 st year Other mental health, marriage, and family problems often occur with or leading up to PTSD requiring attention so they don’t get worse – July 2012 Med Surveillance Report indicates that Top 3 diagnosis over past 10 years are 1. Depression 2. Adjustment Disorder 3. Alcohol Abuse/Dependence – Insomnia has risen from 7.2 per 10K to 135.8 per 10K

2. Veteran Issues 2 In 2009, military children and teens sought outpatient mental health care 2 million times, a 20% increase from ‘08 and double from the start of the Iraq war (‘03) – 43% of Service Members have children – Average number of children per military family is 1.97 (AAMFT 2010 Annual Conference) –42% rise in children’s visits in 2009 over 2004 per Tricare –During deployments, 1 in 5 coped poorly or very poorly –84% of Regular Military Service Members’ children attend public school, not DoD base schools Casualties – a Feb 2013 CRS Report indicated that 98% were male OIF - 31,925 OND - 295 OEF - 18,230 Where Did They Come From? Family Income? -- based on nccp.org report as of May 2010 – Active NG/Reserve Active 33% < $42K / year Small Town 44% 40% 50% $42K - $65K / year Large Town 27% 30% Urban Area 29% 30% NG/Reserve has a median income of $46K / year

3. Veteran Issues (cont.) 3 Suicide is rising. In 2010: military suicides exceeded civilian suicides. – Army and Marine have higher suicide rates than Navy and Air Force – More are occurring Stateside and many go unreported for insurance reasons and are post-discharge – Female suicide rate triples when deployed (recent NIMH study), though still lower than male rate – In GA, per the CDC from 2006-2008, 500 suicides of people identified as current or former military. This represents 19.4% of all suicides during those years. The Age breakdown is as follows: 20-298.4%50-5921.2% 30-3910.8%60-6931.8% 40-4916.3%70+55.8% – VETS: On average, 18 Vet suicides out of 30 attempts per day; 5 are already being treated by the VA. – ACTIVE DUTY: On average there has been 1 suicide per day (2013 GWU Report) – Women try more with less success than men …Army Times 04/2010 – 2013 IAVA Report indicates: 30% have considered suicide 37% know someone (IAVA – Irag Afghan Vets of America) Addiction, alcoholism, drug abuse, domestic abuse, violent crime rates are rising: – Illicit drug use in the military was 5% in 2005, but now nonmedical use of prescription drugs is the most common form of drug abuse. SPICE is becoming very common. – PBS and others in Oct 2013 reported the VA in several locations is over prescribing pain killers – 24.8% reported binge drinking >1x per week in the past 30 days vs 17.4% for same-age civilians – SAMSHA reports: half of substance abuse treatment admissions among Veterans aged 21 to 39 involve alcohol as the primary substance of abuse (vs 34% non-vets). Marijuana and Other Opiates were at 12.2% each

4. Veteran Issues (cont.) 4 Military Sexual Trauma (MST) – includes Assault, Coercion and Unwanted Attention – 2008 Rand Report indicated the rate was 16-23% – VA Report in December 2012 breakdown as follows: Women Men Assault 3% 1% Coercion 8% 1% Attention 27% 5% Total 38% 7% – Almost as significant among males as among females (Newsweek, April 2011) – Mostly enlisted personnel under 25 yrs old (DOD 2010 Annual Report) – Single strongest predictor of PTSD in women - whereas combat is for men (Natelson, 8/05/10). – 80% of assault victims fail to report the offense. (Natelson, 8/05/10) DoD and VA facilities are stretched … – the Aug 2009 VA claims backlog was 900,000; – the April 2010 backlog was improved to 605,000 – the April 2011 back up to 756,000 with 450,000 claims taking over 125 days (USA Today, Apr 2011) – the Nov 2011 rise to 864,000 with 529,000 claims taking over 125 days (AJC, Nov 10, 2011) – The Oct 2013 backlog is 725,000 with 420,000 over 125 days (VA Weekly Report) – The VA Goal is 98% under 125 days by end of 2015.

5. Veteran Issues (cont.) 5 The U.S. Bureau of Labor Statistics reports the unemployment rate among post 9/11 veterans as 15.2% in January 2011, well above the 9.6 percent rate for non-veterans. – The 2013 IAVA Report is 16% with 45% > 1 year The VA said in Dec 2010 that more than 9,000 OIF/OEF vets were homeless (UPI) – Women are the fastest growing segment of this population. – Jan 2012 VA Report indicates 62,619 homeless vets and 180,000 are at risk – 2013 nchv.org Homeless Report: 13% are vets 20% of male homeless are vets 51% have disabilities 70% have substance abuse issues 51% are white males vs 38% of non-vets 50% are > 51 years old vs 19% non-vets Many more Reservists & Guard than previous wars (54% as of mid ‘08) and they and families are more distant from DoD and VA support facilities. This may be one of the most significant factors affecting the future mental health impact on our communities and our society – Current numbers are in the 40-45% range – By design, approximately 33% should be Guard and Reserve – With 2013-14 budget cuts, NG/Reserve numbers may come down further and faster than Active Duty – A large number of civilian contractors are also part of the deployed forces Rand Study (‘08) estimates that PTSD and depression among service members will cost the nation up to $6.2 billion in the two years after deployment. Investing in proper treatment would actually save $2 billion within two years.

6. Fraser Center Experience www.frasercenter.com www.frasercenter.com 6 THE FRASER CENTER SETTING: 1.Clients include Veterans, Active Duty Soldiers, and Military Dependents 2.Clients primarily from FT Stewart (3 rd Infantry Division) and Hunter Army Airfield GENERAL OBSERVATIONS MADE BY FRASER CENTER THERAPISTS WHO WORK WITH OIF/OEF VETERANS, ACTIVE DUTY SOLDIERS, AND MILITARY DEPENDENTS: 1.The children of military families are often the first to be brought in for therapy – secondary trauma. “Is daddy going to die?” 2.The length, number, and frequency of deployments decreases family resiliency upon re- deployment (returning home from a deployment). 3.The number of engagements “outside the wire” increases the likelihood of Combat Stress Symptoms (transient, acute, & PTSD). 4.Over time, the constant threat of incoming mortar rounds and IED incidents increases likelihood of CSS and PTSD for those who remain primarily in “green zones.” 5.The primary concerns of combat troops are: Mission First, staying safe, keeping their buddies safe, getting home, and what is happening at home with their spouse and families.

7. Fraser Center Experience www.frasercenter.com www.frasercenter.com 7 GENERAL OBSERVATIONS (continued…): 6.While deployed, soldiers also fight on the homefront via internet and cell phone with their spouses. Homefront stressors may be higher than combat stressors. 7.Viewing internet pornography and internet sex chat is becoming a norm for deployment and effects marriages upon return. 8.Many soldiers maintain their unit bonds following re-deployment to the detriment of their family bonds. 9.Returning soldiers rarely talk with spouses about combat experiences. 10.There is a high rate of infidelity among soldiers and spouses during deployments. This is not necessarily the “deal breaker” that it might be in civilian life. 11.Illegal/prescription drugs and alcohol are prevalent and are used as common coping mechanism by soldiers (deployed and at home) and by their spouses. 12.While deployed, many soldiers are constantly sleep deprived and share each others medications (i.e. ambient, provigil). Hooked on Energy Drinks. 13.The suicide rate of re-deployed) soldiers and spouses is on the increase. 14.Most soldiers know of at least one other soldier in their unit who “ate his gun” or was blown up by an IED. 15.There is a high incidence of rape and sexual molestation of deployed female soldiers. 16.Soldiers and spouses express a great deal of anger toward perceived incompetency in the chain of command, or in procedures, which have a direct negative impact upon their lives.

8. Fraser Center Experience www.frasercenter.com www.frasercenter.com 8 GENERAL OBSERVATIONS (continued…): 17.Home is no longer a safe place to live. Many now carry weapons when not on military installations at home. 18.The vast majority of returning troops are filled with undifferentiated anger and a short fuse. 19.There is a statistically verifiable increase in domestic violence and child abuse among military families. Child abuse increases as the stressors increase in the life of the non-deployed spouse. 20.A primary therapeutic issue is the soldier’s inability to re-connect emotionally with spouse and children. (exacerbated by anger and lack of patience). 21.Chaplains are the mental and spiritual health “first responders” at home and in the combat arena. 22.Special attention needs to be given to National Guard and Reserve Chaplains. There is a high incidence of their leaving the ministry. 23.Both spouse and soldier recognize that the soldier is “changed” by combat deployment. 24.Important family milestones and transitions have been missed. 25.Soldiers may pursue activities which replicate the adrenaline rush of combat and sometimes re- enlist without spousal consultation in order to maintain the rush. 26.Spousal dissatisfaction and resentment: power control issues upon redeployment. “I didn’t sign up for this.” The military spouse sacrifices education and career 27.With increased monetary incentives and a lowering of recruitment standards the quality of the troops has been increasingly lowered: no GED necessary, accepting recruits with DSM-IV diagnosable conditions and on meds, increase of gangs in the army.

9. Fraser Center Experience www.frasercenter.com www.frasercenter.com 9 GENERAL OBSERVATIONS (continued…): 28.Due to young age, immaturity, and low educational levels, many soldiers and spouses have poor life skills: money management, parenting, communication, etc. 29.Some soldiers return to empty bank accounts and houses. 30.The military has greatly increased mental health support resources at home and abroad. The Army recognizes that it is still not adequate. 31.The military is going out of their way to encourage soldiers to seek out mental health treatment, yet the stigma against seeking help continues to exist. 32.Spirituality is an important tool in the healing process as it is an important issue among those who have been in combat. It may not be express in typical “religious” language.