Buddy-to-Buddy: An innovative substitute for family support among at-risk, returning veterans of Iraq and Afghanistan

by Christopher Jarman, MSW, Adrian Blow, Ph.D., Michigan State University; Marcia Valenstein, M.D., M.S., The University of Michigan
NCFR Report
Content Area
Counseling and Therapy

Soldiers at war anticipate few events so much as returning home to family, friends, and a sense of peace. Yet for many returning veterans, peace eludes them as they begin new battles with combat sequelae such as post-traumatic stress, depression, substance abuse, anxiety, traumatic brain injuries, and social isolation, all of which can have devastating effects on close relationships. For one group of recent veterans€ˆmembers of the Army National Guard€ˆthese experiences appear to occur at still higher rates and with greater severity than the rest of the military.

Army National Guard (NG) soldiers comprise nearly a third of the nation's 1.12 million soldiers. Working part time (one weekend a month and a two-week annual training), these citizen soldiers lead more traditional lives when not in uniform. During the 10 years of the Global War on Terror, however, NG units across the nation have repeatedly been called to full-time duty, serving year-long tours far from home and family. NG veterans' experiences upon returning home, however, are at best only loosely similar to those of their full-time counterparts.

Active-duty soldiers typically return to large military communities replete with specialized support services for reintegration (e.g., military hospitals, outpatient clinics, family support groups and programs, addiction treatment, and military chaplains, to name but a few). Crucially, active-duty soldiers return to communities where they are surrounded both by military peers with similar experiences as well as the structure and close monitoring of their chain of command; in short, they are relatively ensconced by their "military family," a significant source of social support above and beyond reintegration services.

Guard soldiers, by contrast, return to largely civilian hometowns where they must quickly decompress from war while reintegrating into their civilian jobs and communities. Social interactions with members of their units often decrease precipitously, and many NG veterans report a sense of isolation and disillusionment with the more mundane, day-to-day experiences of civilian living. Potentially contributing to the challenge, many young soldiers are unmarried or unpartnered and no longer live with their families. These veterans are at potentially even greater risk of negative outcomes by virtue of social isolation and lack of close family support. For soldiers struggling with the traumatic effects of war, their "military family" may become as important as their family of origin.

Often, family members (spouses, parents, and extended family) are the first lines of support for soldiers when they return, particularly for NG soldiers. However, these family members are at times not able to be ideal supporters. Frequently, service members may choose not to speak with family members about their struggles out of concern for burdening these individuals. In addition, service members may find it very difficult to talk to family members about disturbing or traumatizing deployment events. Family members themselves may have their own difficulties and as a result they may not be receptive to the difficulties of the service member. NG family members live in a civilian world and may not be as understanding about the perils of war as the service member needs. In other cases, family may be absent from the lives of service members by virtue of distance or strained relationships, leaving the service member with limited support. Whatever the reason, it is increasingly apparent that in some cases service members are more easily able to talk to their fellow service members about struggles with deployment and reintegration, and in cases where family is not ideal as a support, the military family takes on a much larger significance.

In response to growing awareness of the struggles facing National Guard veterans, our team of researchers, clinicians, and military leaders in Michigan felt compelled to respond. After several years of close collaboration we developed what is known as Buddy-to-Buddy, an innovative peer support program carefully tailored to meet the challenges and needs of our National Guard veterans. By enhancing the effectiveness of these soldiers' "military family," we are hoping to improve outcomes among these deserving veterans.

The military has long been aware of the struggles of returning soldiers and provides soldiers in the NG and active duty alike with considerable support. Despite these resources, fear of stigmatization, a warrior ethos, distrust of healthcare professionals, and career concerns persist as powerful barriers to seeking care, and more than half of those in need choose not to seek it.

In response to these alarming realities among returning veterans, various organizations in Michigan began considering a way to augment existing support programs. Michigan€ˆwhich has no active-duty military installations, but a relatively large National Guard presence€ˆwas rife with opportunities to serve returning veterans. In 2005, faculty at Michigan State University (MSU) began developing tailored programs for returning veterans and their families through what are known as Reintegration Weekends. These NG sponsored events provide soldiers and their families opportunities to reconnect with their "military family" while simultaneously receiving briefings and referral information for common needs. The MSU faculty sought to enhance these events by providing soldiers and families with information and assistance grounded in the latest research.

At many of these events, two of Michigan's Vietnam veterans volunteered to provide informal, unstructured outreach efforts to soldiers, typically by giving talks about their own experiences with the challenges and pitfalls of reintegration. The veterans' talks had a powerful effect on soldiers as well as visiting faculty members, who were intrigued by their approach. The two veterans' status as relative outsiders to formal systems enabled them to deliver their message of hope while bypassing the resistance so common among returning veterans. Soon, University of Michigan (UM) and Veteran's Administration (VA) investigators joined the MSU faculty at reintegration briefings, and by 2008, discussions about more deliberate outreach programs based largely on the concept of peer support were ongoing. The collaboration soon received grant funding from the Robert R. McCormick Foundation's Welcome Back Veterans initiative and began regularly meeting to set a course for enhanced support for returning soldiers in Michigan.

Through an iterative process among group members, the collaboration between MSU, UM, the VA, and the Michigan National Guard eventually developed a peer-support program for units returning from Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF). Our intent was not to develop another mental health program, but rather a unit-level mechanism for identifying soldiers with needs and confidentially connecting them with available resources. A variety of hurdles€ˆincluding concerns about confidentiality, ambivalence regarding treatment, relational issues between the NG and nonmilitary organizations, respect for the NG chain of command, programmatic feasibility and effectiveness, and "in-unit" versus "out-of-unit" peers€ˆrequired negotiation and creative solutions. The result of these early efforts became known as the Buddy-To-Buddy Veteran Volunteer Program, or B2B. Designed specifically for service members returning from OIF and OEF, we developed B2B to improve outcomes by activating veterans' "military families."

Today, Buddy-to-Buddy is a two-tier peer-support program run by within-unit soldier volunteers (Buddy Ones, or B1s) and veteran volunteers external to units (Buddy Twos, or B2s). This tiered design provides a balance between effectiveness and the concerns mentioned above. Buddy One soldiers are selected because peers view them as informal leaders to whom they willingly turn for advice or support. These volunteers receive roughly four hours of training on the Buddy-to-Buddy program, their roles as B1 volunteers, open-ended questioning and reflections to sustain and enhance conversations with soldiers, available resources, and limited training regarding symptoms suggestive of the need for further evaluation. Soldiers are then assigned a panel of four to 10 soldiers in their units whom they contact each month by phone or in person. During these conversations, B1s rely on a list of 11 potential problem areas to guide them. Importantly, these volunteers do not serve as mental health counselors or case managers and do not diagnose conditions. Instead, B1s provide soldiers in need or at risk with an opportunity to speak to a trained, trusted peer and with substantially reduced concerns about stigmatization, breeches of confidentiality, or career implications. If B1s have concerns about one of their soldiers, they can contact NG mental health personnel for consultations and referrals. Such concerns cover an array of matters, however, and may include financial issues, employment concerns, substance abuse problems, marital difficulties, and so on.

The second tier of volunteers consists of veterans no longer serving who are selected and supervised by VA and UM staff. These volunteers are selected because of their demonstrated maturity, responsibility, interpersonal skills, knowledge of mental health services, and trainability in more nuanced strategies for motivating soldiers to seek and remain in care. B2s receive two days of intensive training, including the use of Motivational Interviewing (MI), an empirically validated technique for effectively responding to ambivalence. B2s often interact with their assigned units at training weekends and reintegration events, and soldiers know they can call B2s directly if they prefer. B2s also receive soldier referrals from B1s, military chaplains, commanders, family service organizations, and other sources. Each Buddy Two receives weekly supervision teleconferences with an experienced clinician in the VA.

B2s encourage soldiers to open up about their problems, seek help when needed, and remain in care if necessary. They also provide soldiers with confidential information about a wide range of resources, all without involving the chain of command.

After the initial development and implementation of the B2B peer-support program, the Michigan Army National Guard assumed control of the program and has assigned an officer and noncommissioned officer to conduct training and implementation. NG Bureaus in other states have expressed interest in the program and efforts to disseminate Buddy-to-Buddy are ongoing. We are currently conducting a multistate evaluation of the program, including longitudinal surveys for several thousand veterans, qualitative interviews of soldiers, leaders, and key informants in the program, and analysis of health data. Preliminary data is already enabling the Michigan National Guard to improve the program's reach and effectiveness. The data are also providing encouraging evidence that the concept of an extended "military family" can help struggling veterans survive and even thrive under truly challenging circumstances. We hope to continue supporting this wonderful group well into the future through our close relationship with the National Guard. While we do not wish to supplant the role of family in providing support, we hope to extend the picture to include the valuable support found among close peers.

Contact Christopher Jarman at [email protected]