1

Policy Advocacy Paper:

Integrating Mental Health Professionals into the MN Army National Guard

Zahra Said, Jessica Brown, Cash Robinson, & Diana Kuhl

St. Cloud State University: SW 642-55

Dr. Consoler Teboh

April 27th, 2022

 2

Policy Advocacy Paper:

Integrating Mental Health Professionals in the MN Army National Guard

Mental health and suicide in the Army National Guard have been a significant concern

for many military members, their families, and supporters. According to the DoD Annual Suicide

Report in 2020, the suicide rate for National Guard members was 27 suicides per 100,000 service

members (regardless of duty status). The rate is nearly doubled compared to the United States

population of 13.5 per 100,000 reported by the Centers for Disease Control and Prevention

(CDC). Additionally, stigma and lack of access to mental health personnel interfere with mental

health services in military units. To illustrate, five full-time civilian Behavioral Health

Coordinators (BHCs) that oversee the entire Minnesota Army National Guard assess roughly

36,000 service members' mental health readiness. In addition to the BHCs, nine Behavioral

Health Officers (BHOs) are in three different MN National Guard medical units. However, BHO

Dr. Dahlstrom states, "we are severely underutilized, and many service members do not know we

exist."

Incorporating BHOs into the Minnesota Army National Guard battalions will reduce the

stigma of seeking help for mental health by having regular interactions with service members. In

addition, having a skilled mental health professional overseeing programs will increase their

quality and effectiveness. Otherwise, programs created to protect service members (for example,

sexual assault, substance abuse, suicide, discrimination, etc.) will continue to be mundane

mandatory training that the unit must check off.

Engagement

After conducting resilience training with her soldiers, Jessica Brown brought the project

idea to the group. During the training, the group discussed seeking help. One of the soldiers
 3

stated that more than 20 people he had served with in Iraq in 2012 have died by suicide. He

shared his own experience with suicidal ideation after leaving the Active Army because of his

symptoms from Post-Traumatic Stress Disorder (PTSD) and felt like he had lost the identity and

purpose that he had from serving. However, he shared that he started getting his life back after

joining the MN Army National Guard and becoming a volunteer firefighter.

However, during the most recent periodical health assessment needed to deploy, the

Behavioral Health Coordinator deemed this soldier mentally unfit and started getting him

medically discharged from the military. The service member expressed anger towards the

military, stating, "I am getting kicked out of the military because, for once, I am being honest."

The group then discussed that people do not talk about mental health, such as having suicidal

ideation, because they do not hear other people talking about it and feel ashamed and weak. In

addition, the military culture is to be strong or "manly," while emotions do not have a place to be

discussed freely without fear of being perceived as weak. The themes from this discussion

matched those from LeFerber & Solorzano (2019), which state "their experiences innate "Catch

22" that means if you know that you need help, then you are rational; but if you seek help, then

you are crazy and not trustworthy to do your job." The themes center on the lack of

confidentiality of Service Members in the workplace and seeking military mental health services.

A group member has personally experienced many service member deaths due to suicide.

One was a couple of months ago (in February 2022), and another was a good friend in 2017 who

deployed with her husband. She has seen so many service members struggle with mental health

issues such as PTSD, depression, anxiety, and substance use but would prefer to hide it than seek

help, including herself. Pruitt et al. (2019) stated, "Psychosocial History of those individual
 4

service members who died by suicide in 2015, 49.1% had a history of at least one behavioral

health disorder. Nearly a quarter (24.6%) had substance abuse or dependence."

Jansson (2020) states several red flags requiring advocacy in the mental health sector,

including "people currently in the military service and veterans often fail to receive service for

PTSD, traumatic brain injuries, substance abuse, and family violence. High rates of absenteeism,

dropout, resignation, discharge, and poor performance stem from untreated mental conditions."

Naifeh et al. (2019) state that 92% of service members with severe impairment reported

structural barriers to initiation treatment, such as wanting treatment that the Army would not

know about. The 42 % of untreated soldiers reported stigma-related concerns, while those with

multiple deployments were more likely to seek treatment. The Army's emphasis on mental health

screenings related to deployments could be removing some of those barriers.

Stigma and lack of access to mental health personnel interfere with mental health services

in military units. Many National Guard members are not eligible for mental health services

through the Veterans Administration (VA). Eligibility for VA health care requires completing

active-duty service by a federal order limiting access to National Guard members who have not

met the active duty requirement and live in rural areas away from VA facilities (Selleck et al.,

2021). As of 2010, about half of the Army deployments to Iraq and Afghanistan were Army

National Guard and Army Reservist (Harris et al., 2014). Prior studies have looked at

demographics and other variables among service members to find a correlation between

enrollment and utilization of the VAHCS. Fried et al. (2015) state, "the US Department of

Veteran Affairs (VA) is the largest single provider of healthcare in the United States and

administers the nation's second-largest federal disability program." However, "only 37% of all

Veterans are enrolled at the VA (Kizer, 2012)" (Bloesr & Ray, 2018). The intermittent nature of
 5

the National Guard and reserve components in the military creates challenges for risk

assessments and interventions that are not present in full-time active members (Neifeh, 2019). To

engage in policy advocacy, the group seeks common ground with the ideological groups:

military affairs, Minnesota Army National Guard Behavioral Health Coordinators (BHC),

Behavioral Health Officers (BHO), Behavioral Health Specialists (BHS), and unit leadership.

Assessment

There are currently five Behavior Health Coordinators for roughly 36,000 service

members, nine BHOs, and five BHS. The BHO and BHS are assigned to three different medical

companies and are used to assist other companies based on requests or referrals. Therefore,

service members do not see any mental health professionals unless they are being assessed

before or after mobilization or referred to one after a crisis.

Solution

Our solution is to decentralize and integrate more BHOs and BHSs (Military Occupation

Specialist 68X) into each battalion. The key is to structure BHOs and BHSs into the MN ARNG

in the same way as the Chaplains and their assistants. The MN ARNG authorized 22 chaplains

and 23 chaplain assistants, so ideally, we want to make that with the behavioral health

professionals. BHOs are officers in the military, while BHSs are enlisted personnel which also

mirrors the officer rank of Chaplains and the enlisted rank of their assistants. Military behavioral

health professionals and chaplains can work together to manage service members experiencing

mental health problems, domestic violence, financial problems, or any other concerns. They will

ensure that service members have access to resources and referrals internally, removing the

barriers to ineligibility of the VA health care or lack of insurance for public mental health

services.
 6

In addition, the BHOs in each battalion can take off the pressure on company

commanders and their readiness NCOs by overseeing and supporting the Army's required

programs such as suicide prevention officer's duties, holistic health, fitness, resiliency, and

sexual assault advocate. Having more interactions with BHO/BHS, quality education, and

support will reduce stigmatization and the perceived barriers to accessing mental health services.

BHOs and BHSs have the capabilities to provide outreach, anti-stigma campaigns, and guidance.

Advocacy Targets

Representative Rob Ecklund: this is the Minnesota House of Representatives

(Democrat), the lower chamber of the Minnesota State Legislature. Rep. Rob Ecklund is the

committee chair of Labor, Industry, Veterans, and Military Affairs Finance and Policy. This

position makes him the target because he will be responsible for overseeing any budgetary

allocation for implementing the advocacy.

Don Kerr, MN Department of Military Affairs: This Is the Senior Civilian Executive

Manager of the Department of Military Affairs (DMA). This position makes him a target
 7

because he is responsible for managing the day-to-day operations of the State Agency

component of the DMA. In addition, he will facilitate its implementation based on the solutions

presented to him.

MN ARNG Behavioral Health: Behavioral Health Professionals play a critical role in

addressing the psychological health of their installation. In an interview with several Behavioral

Health professionals, we learned that BHOs are underutilized, and their services are reactive

rather than preventative. The behavioral health professionals do not provide therapeutic benefits

due to the nature of their position. Instead, they focus on assessing service members' mental

health for readiness to mobilize into combat. Dr. Andrew Dahlstrom, BHO, was the person to

come up with incorporating BHO and BHA's into the MN ARNG, similar to the structure of

Chaplains. The Chaplains and Chaplain Assistants at each battalion support two to five

companies. A benefit of having a Chaplain Assistant and Behavioral Health Assistant is that they

are part of the unit and can build a relationship with service members outside of the mental

health assessments and training. Having a behavior health assistant, such as the chaplain's

assistant, is critical because they are enlisted service members. In many cases, enlisted service

members do not feel comfortable speaking with an officer.

Readiness Non-Commissioned Officers (NCOs): This plays a critical role in running the

unit's day-to-day operations. The readiness NCOs are in charge of the programs and training in

the company that they support, about 100 service members. During interviews, they discussed

their job as "drinking out of a fire hydrant." They are in charge of all aspects of the soldier's

readiness to deploy. Behavioral health professionals will be able to alleviate some of the

pressures felt by Readiness NCOs by overseeing programs that contribute to service members'

health.
 8

Unit Leadership: The Army leadership's key role is to influence people by providing

purpose, direction, and motivation and working to achieve the mission and objectives of the

organization. The leaders, such as the non-commissioned officers and officers, will be

responsible for controlling and motivating service members to seek mental health services.

Interviews with the unit leadership have shown unfavorable reflection on mandated training

required from many of the prior listed programs. They state that too much-mandated training has

become redundant and ineffective, and they have other military occupation-specific jobs that

take priority. Therefore, further pushing off mental health.

Intervention

Before attending the Labor, Industry, Veterans, and Military Affairs Finance and Policy

Committee meeting on April 6th, an email was sent out to the committee chair, House

Representative Rob Ecklund. Keven Petrie, the Committee Legislative Assistant, received a

response the same day, stating our suggestions will be kept in mind and to reach out sometime in

November or December to get a conversation set up. The committee passed the HF4355 (Noor)

Omnibus veterans and military affairs supplemental finance, and policy bill sponsored by Rep.

Rob Ecklund, which included a $765,000 appropriation for the state fiscal year 2023 to

implement the Holistic Health and Fitness (H2F) program for the Minnesota National Guard.

Also present at the committee was a representative from the MN Department of Military

Affairs, Donald Kerr. In the fiscal year 2023, we learned that 2 million dollars are available for

recruitment bonuses for MN National Guard members. That is a 1.5-million-dollar reduction

because the money shifted to other veteran programs. In addition, recruitment allows 10,000

fewer recruitments due to fewer people being eligible for getting into the Army National Guard.

Reasons included potential recruits taking mental health medication, being overweight, and
 9

having prior involvement with law enforcement that made them ineligible to be recruited.

Therefore, more priority is on retaining current members, which is essential to know when

asking for additional Behavioral Health personnel in the MN ARNG and where the funds should

be.

In addition, MN Veteran Suicide Prevention Initiative has a 2.1-million-dollar budget.

The committee discussed the challenges of working with the Minnesota Department of Health to

coordinate services for veterans. For example, a committee member called a region's hospital

social worker a hero because she identifies and assists veterans immediately. They were looking

at the public health direction and noted the positive outcomes from the qualified and skill set of

the social workers. Their goal is to reduce suicide rates by 20%. Incorporating mental health

professionals into the battalions will elevate many challenges that the committee discussed by

coordinating with the Department of Health. They are already supporting a skilled professional

such as a social worker.

Jessica interviewed military behavioral health professionals, enlisted service members,

unit leadership, and a Chaplain to get their perspective on the issue of mental health in the

ARNG and their input on what needs to be done. As a result, a mobilization of stakeholder

groups to support policy and face-to-face meetings with key decision-makers to build

relationships was accomplished. Adding additional mental health professionals may require

federal-level intervention. However, we have made the first step toward progressing in the

political arena. To gain more support from the public, the group is working on publishing an

opinion piece in the Army Times. Army Times has a following of more than a million people

interested in the Army on Facebook.

News Release
 10

Mental health and suicide in the Army National Guard have been a significant concern

for many military members, their families, and supporters. According to the Department of

Defense Annual Suicide Report in 2020, the suicide rate among National Guard members was 27

suicides per 100,000, nearly doubled compared to the United States population of 13.5 per

100,000 reported by the Centers for Disease Control and Prevention (CDC). Additionally, stigma

and lack of access to mental health personnel interfere with mental health services in military

units. To illustrate, five full-time civilian Behavioral Health Coordinators (BHCs) oversee the

entire Minnesota Army National Guard, focusing on assessing roughly 36,000 service members'

mental health readiness. In addition to the BHCs, nine Behavioral Health Officers (BHOs) are in

three different MN National Guard medical units. However, a BHO, Dr. Dahlstrom, states, "we

are severely underutilized, and many service members do not know we exist."

In hopes of improving retention and the overall health of service members, the United

States Army is implementing a whole health approach called Holistic Health and Fitness (H2F)

that focuses on physical, nutritional, spiritual, mental, and sleep readiness. An additional 31

personnel per battalion, including athletic trainers, dietitians, physical therapists, occupational

therapists, and cognitive enhancement specialists (CES), are required to support the program.

The passing of HF4355 (Noor) Omnibus veterans and military affairs supplemental finance and

policy bill included a $765,000 appropriation for the state fiscal year 2023 to implement the H2F

for the Minnesota National Guard. The funding consists of five full-time positions to implement

the program and provide resources to service members before federal funding becomes available.

However, the program is missing the oversight and support from mental health professionals.

Sure, the program will have CESs, but what does that mean? Are they mental health

professionals disguised under a different name, further perpetuating the stigmatization of

 11

receiving help from mental health professionals? Or are they individuals taught a specific skillset

without the qualifications to assess service members' mental health and therapeutic assistance if

needed?

Incorporating BHOs into the Minnesota Army National Guard battalions will reduce the

stigma of seeking help for mental health by having regular interactions with service members. In

addition, having a skilled mental health professional overseeing programs increases the quality

and effectiveness rather than having them be mandatory training that the unit must check off.

The prior mentioned programs may include the H2F, Suicide Prevention/ REACH program,

Sexual Assault Response Officer, Equal Opportunity Leaders, resiliency training, and more).

Evaluation

Companies complete a Unit Risk Inventory (URI) on an annual basis that allows Soldiers

to give an honest, anonymous assessment self-report of their well-being to give commanders the

ability to gauge the unit’s readiness and resilience. The URI measures substance use, suicidal

ideation, mental health concerns, financial issues, and social relationships. To evaluate our

advocacy effort, a comparison of URIs before and after implementation of behavioral health

professionals to note any changes. For example, a reduction in URI scores after incorporating

BHOs and BHSs will prove that our advocacy effort was effective. URIs scores will monitor

units after the advocacy effort is over.

Focus group data will provide qualitative measurements based on the Army's mandatory

training before implementing the BHOs and BHS. Behavioral Health Officers will be able to

take over the evaluation of the required programs such as the Leadership development program

(LPD), the suicide prevention REACH Program, sexual assault and response officer (SAPRO),

Equal Opportunity Leaders (EOL), Holistic Health and Fitness (H2F), and more. The use of a
 12

focus group a year and five years after incorporating the mental health professionals to note any

changes in mandatory training and programs to evaluate the effectiveness of the programs.

In addition to the focus group surveys, the MN ARNG will be able to access

documentation from each program showing increased or decreased use. For example, service

members seeking support from the SAPRO or EOL along with the resolution. There may be an

increase in reported sexual assaults, discrimination, and substance use because of mental health

professionals' availability and ability to connect them with care. While this could be seen as a

negative consequence, it is very positive because the issues are being addressed. We expect to

see a decrease in suicide rates on the DoD Annual Suicide Report in the long term two to three

years of implementation.

Conclusion

The MN National Guard faces barriers to effective mental health care. Obstacles such as

stigma and inadequate mental health personnel lead to adverse mental health outcomes for this

population. While various solutions have been proposed to address this problem, integrating

BHOs will help eliminate barriers and enhance mental health access for this population. These

professionals can promote better mental health access through counseling, appropriate referrals,

and overseeing current programs to ensure effectiveness. Therefore, we advocate for a policy to

incorporate behavioral health professionals in each battalion, brigade, and division to provide

mental health care to service members. The successful implementation of this plan depends on

advocacy to policymakers and leaders such as Representative Rob Ecklund and Don Kerr. The

intervention will focus on meeting these leaders and advocating for the integration of BHOs in

the military to prevent suicide.

 13

Our group has learned various things about advocacy. Firstly, social workers need to

identify gaps and develop solutions to share with leaders to initiate change. For example, our

solution will help address the significant cases of suicide among service members and veterans

by improving mental health access and care. Secondly, we have learned that not all advocacy

solutions can be implemented. Notably, policymakers try to allocate available funds to various

programs. Lastly, advocating for policy change is very complex. Overall, the knowledge we have

gained from this experience will help support more populations in the future.
 14

References

Benz, M., Borsari, B., & Metrik, J. (2016). Predictors of barriers to mental healthcare service

utilization in returning veterans. Drug and Alcohol Dependence, 171, e18–e19.

https://doi.org/10.1016/j.drugalcdep.2016.08.066

Bloeser, K., & Ray, K. (2018). Contemporary Social Work Practice with Veterans: An

Introduction to the Special Issue. Clinical Social Work Journal, 46(2), 69-73.

http://dx.doi.org/10.1007/s10615-018-0659-4

Brignone, E., Fargo, J., Blais, R., Carter, M., Samore, M., & Gundlapalli, A. (2017). Non-

routine Discharge From Military Service: Mental Illness, Substance Use Disorders, and

Suicidality. American Journal of Preventive Medicine, 52(5), 557–565.

https://doi.org/10.1016/j.amepre.2016.11.015

Centers for Disease Control and Prevention. (2022, February 24). Changes in suicide rates -

United States, 2019 and 2020. Centers for Disease Control and Prevention. Retrieved

April 25, 2022, from https://www.cdc.gov/mmwr/volumes/71/wr/mm7108a5.htm

Department of Defense Suicide Reports. U.S. Department of Defense Article. (n.d.). Retrieved

April 25, 2022, from

https://www.defense.gov/Help-Center/Article/Article/2763190/department-of-defense-

suicide-reports/

Fried, D., Helmer, D., Halperin, W., Passannante, M., & Holland, B. (2015). Health and Health

Care Service Utilization Among U.S. Veterans Denied VA Service-Connected Disability

Compensation: A Review of the Literature. Military Medicine, 180(10), 1034–1040.

Gegenfurtner, Könings, K. D., Kosmajac, N., & Gebhardt, M. (2016). Voluntary or mandatory

training participation as a moderator in the relationship between goal orientations and

 15

transfer of training. International Journal of Training and Development, 20(4), 290–301.

https://doi.org/10.1111/ijtd.12089

Harris, A., Chen, C., Mohr, B., Adams, R., Williams, T., & Larson, M. (2014). Predictors of

Army National Guard and Reserve members’ use of Veteran Health Administration

health care after demobilizing from OEF/OIF deployment. Military Medicine, 179(10),

1090–1098. https://doi.org/10.7205/MILMED-D-13-00521

Holistic Health and Fitness - United States Army. (n.d.). Retrieved April 25, 2022, from

https://armypubs.army.mil/epubs/DR_pubs/DR_a/ARN30714-FM_7-22-000-WEB-1.pdf

LeFeber, & Solorzano, B. (2019). Putting Suicide Policy through the Wringer: Perspectives of

Military Members Who Attempted to Kill Themselves. International Journal

of Environmental Research and Public Health, 16(21), 4274–.

https://doi.org/10.3390/ijerph16214274

Naifeh, Colpe, L. J., Aliaga, P. A., Sampson, N. A., Heeringa, S. G., Stein, M. B., Ursano, R. J.,

Fullerton, C. S., Nock, M. K., Schoenbaum, M., Zaslavsky, A. M., & Kessler, R. C.

(2016). Barriers to Initiating and Continuing Mental Health Treatment Among Soldiers in

the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS).

Military Medicine, 181(9), 1021–1032. https://doi.org/10.7205/MILMED-D-15-00211

Naifeh, Ursano, R. J., Kessler, R. C., Gonzalez, O. I.,Fullerton, C. S., Herberman Mash, H. B.,

Riggs-Donovan, C. A., Ng, T. H.H., Wynn, G. H., Dinh, H. M., Kao, T.-C., Sampson, N.

A., & Stein, M. B. (2019). Suicide attempts among activated soldiers in the U.S. Army

reserve components. BMC Psychiatry, 19(1), 31–31.

https://doi.org/10.1186/s12888-018-1978-2
 16

Pruitt, Smolenski, D. J., Bush, N. E., Tucker, J., Issa, F., Hoyt, T. V., & Reger, M. A. (2019).

Suicide in the Military: Understanding Rates and Risk Factors Across the United States’

Armed Forces. Military Medicine, 184(Supplement_1), 432–437.

https://doi.org/10.1093/milmed/usy296

Selleck, McGuinness, T. M., McGuinness, J. P., Stanley, G. J., & Miltner, R. S. (2021).

Identifying Veterans in Your Practice: What Clinicians Need to Know. Journal for Nurse

Practitioners, 17(5), 574–578. https://doi.org/10.1016/j.nurpra.2020.10.011

Tsai, J., & Rosenheck, R. (2018). Characteristics and Health Needs of Veterans with Other-than-

Honorable Discharges: Expanding Eligibility in the Veterans Health Administration.

Military Medicine, 183(5-6), e153–e157. https://doi.org/10.1093/milmed/usx110

Verification Assistance Brief. (2018). Determining Veteran Status. Retrieved March 24,

2021, from https://www.va.gov/OSDBU/docs/Determining-Veteran-Status.pdf

Veteransand Military Affairs omnibus Bill moves to next stop. Veterans and military affairs

omnibus bill moves to next stop - Session Daily - Minnesota House of Representatives.

(n.d.). Retrieved April 25, 2022, from https://www.house.mn/SessionDaily/Story/13867

Waitzkin, Cruz, M., Shuey, B., Smithers, D., Muncy, L., & Noble, M. (2018). Military Personnel

Who Seek Health and Mental Health Services Outside the Military. Military Medicine,

183(5-6), e232–e240. https://doi.org/10.1093/milmed/usx051