March/April 2013 Issue

Working With Veterans and Military Families
By Kate Jackson
Social Work Today
Vol. 13 No. 2 P. 12

With veterans and military families, “meeting clients where they are” may require additional training, and social workers are preparing to address this challenge.

Soldiers coming home from the Iraq and Afghanistan wars share the age-old grievances of all warriors throughout history, such as grief, bodily injury, combat stress, fatigue, and emotional anguish. Added to these assaults, many are ambushed by the aftereffects of combat experience characterized by multiple and extended deployments, conditions such as PTSD and traumatic brain injury (TBI), as well as injuries from a new kind of weaponry called improvised explosive devices.

While approximately 15% to 20% of the veterans of these conflicts meet the criteria for PTSD, others may experience depression, anxiety, and other mental health issues. According to Joan Beder, DSW, LCSW, a professor at Yeshiva University’s Wurzweiler School of Social Work, “It’s hard to imagine anyone faced with such terribly complex situations who could not be severely impacted.”

Furthermore, she says, advances in technology and medical care have resulted in new challenges. Thanks to better medications, expedient medical care, and Kevlar body armor, which protects the vital organs, “ninety percent of people who are wounded survive their injuries, which are typically to the limbs and the head,” she says. “They’re coming back for medical care in droves, inundating the care systems that are in place in the United States.”

Adding further emotional insult to injury, soldiers return to a country mired in economic woes that portend further struggles and to a society that, while supportive, may not necessarily understand the true nature of their military service or adequately attend to their needs.

According to Elizabeth J. Clark, PhD, ACSW, MPH, CEO of NASW, “In addition to the invisible wounds such as PTSD and TBI, which affect approximately one in six of our troops returning from Iraq and Afghanistan, service members and veterans have a heightened risk of substance abuse, unemployment, homelessness, and suicide.”

Veterans who experience TBI may need extensive care, a burden that falls not only on spouses and partners but also often on parents who are ill-equipped practically and emotionally. Because many of these veterans are married with children, the trauma of war ricochets to the family, creating collateral damage to spouses, children, and parents. And while their problems mount, it’s common for veterans to resist assistance for mental health issues out of fear of being stigmatized.

Joining Forces Shines a Light
In 2011, First Lady Michelle Obama and Second Lady Jill Biden, EdD, teamed to launch Joining Forces, a comprehensive initiative to heighten awareness of the sacrifices made by the military; galvanize support from all sectors of society for servicemen and women, veterans, and military families; heighten awareness of their critical needs in the three core areas of employment, education, and wellness; and advocate for a broad range of services to meet those needs.

Joining Forces approached NASW to become a member of the initiative. In July 2012, according to Elizabeth F. Hoffler, MSW, ACSW, special assistant to the CEO and manager of NASW’s military and veterans initiatives, “Biden joined us at our 2012 national conference to announce our commitment to Standards for Social Work Practice with Veterans and Military Families, a professional credential, and a free five-course training module for all social workers.”

It was an impassioned voice and a call to action that got social workers’ attention. “There was huge support for everything Biden said,” Beder recalls, noting that the conference also boasted several workshops and plenary sessions devoted to issues related to the military. “It was clear that as a profession we are stepping up to help our military service members and families.”

Led by social workers, Joining Forces, NASW, and a host of teachers, researchers, and helping professionals are answering the call to make a difference.

Social Workers Taking the Lead
When Biden took the stage, she acknowledged that “social workers are uniquely positioned to help reach our troops, veterans, and military families exactly where they are in every single county in America.” That statement, echoed by educators and other experts, positions the profession as the cornerstone of the solution—a burden and an honor the profession is proud to bear.

Because they’re “systems savvy,” social workers, the largest provider of mental health services in the United States, are the only professionals entirely capable of such extraordinary responses, says Keith Armstrong, LCSW, a clinical professor in the department of psychiatry at the University of California, San Francisco, and coauthor of Courage After Fire: Coping Strategies for Troops Returning From Iraq and Afghanistan and Their Families and the forthcoming Courage After Fire for Parents: Strategies for Coping When Your Son or Daughter Returns From Deployment. “They have the skill set to provide the psychotherapy, but that alone does not solve the problems of 20% to 30% of our veterans coming home with mental health problems. We need to solve a whole series of issues for them.”

A member of the PTSD program at the San Francisco VA Medical Center, Armstrong says that “it isn’t just the internal psychological torments they may face; it’s also a question of how we get them basic services and how we help integrate them into the community so that it supports them.”

Veterans come back with multiple needs and reintegration challenges that cut across issues of family service, employment, economic distress, housing, health, mental health, domestic violence, and substance abuse, Armstrong says. “Who better to understand the interconnectivity of problems than social workers who view the client from a person-in-the-environment perspective and see the big picture beyond just the client in front of them?”

Filling in the Gaps
Despite their special skill sets, many social workers lack adequate knowledge of the consequences and treatment of TBI or PTSD and may be unfamiliar with aspects of the military experience that may influence the way a client approaches and responds to intervention. To help fill in these gaps, NASW, in addition to releasing two special journal editions on social work in Health and Social Work and Children and Schools, in collaboration with Joining Forces, is preparing a five-course continuing education module expected to be rolled out this spring, along with its professional credentials which, Clark says, “will showcase in-depth knowledge, proven work experience, leadership capacity, competence, and dedication in this field of practice at the baccalaureate, advanced, or clinical level.”

“We’ve already seen growth in educational programs and initiatives that focus on social work with service members, veterans, and their families,” Hoffler says. In addition to seminars, symposiums, and conferences on the topic, numerous schools of social work, she observes, already have added courses, certificates, and entire tracks to their programs on social work within this population.

At the forefront of this effort is Anthony Hassan, EdD, MSW, a clinical associate professor and director of the University of Southern California’s (USC) Center for Innovation and Research on Veterans and Military Families in Los Angeles and a retired Air Force officer who served during Operation Iraqi Freedom on the first Air Force combat stress control and prevention team embedded in an Army unit.

With Marilyn Flynn, PhD, MSW, dean of the USC School of Social Work, Hassan helped jump-start the educational movement and drum the message that the social work profession needs to lead the way. The result of his efforts, USC’s subconcentration in military social work, is a three-course sequence for MSW students, including a two-day seminar on military culture along with two courses on military clinical practice with service members, veterans, and military families, and a two-semester internship in a military-impacted organization or an organization that cares for, or plans to care for, veterans, service members, and reservists or National Guard members. In addition to the campus-based program, USC offers military social work education to more than 300 of the 1,800 graduate students in more than 43 states through its virtual academic program.

Hassan credits not only Flynn and the support of the Department of Defense (DoD) but also the Council on Social Work Education (CSWE), which he says “was amazing in its willingness to step up and allow me to lead 40 colleagues across the professions, in and out of uniform, to develop the first set of competencies—CSWE Advanced Military Social Work Practice Guidelines—a document I believe has helped frame course curricula and training for many schools of social work and continuing education.”

Beder, another pioneer in designing military social work curricula and editor of Advances in Social Work Practice With the Military, developed a fascination with military issues after being emotionally blindsided by James Gandolfini’s documentary film Alive Day Memories: Home From Iraq. It spurred a fever of research that turned into what she describes as a major area of study. “I had to learn what it means to be in the military culture.”

She researched, published, presented, and became increasingly passionate about sharing her newfound yet hard-won knowledge with other social workers, developing the course “Social Work Practice With the Military,” which she’s been teaching for several years at Yeshiva University’s Wurzweiler School of Social Work. There, she oversees a certificate program launched this year that requires MSW students to take four courses related to the military as well as perform field work that serves the military for a hands-on component.

Military curricula are proliferating, with programs at institutions such as the Catholic University of America in Washington, DC, Boston College, and SUNY Empire State College. The emergence of these and other military social work programs begs the question of whether all social workers need training in military issues or merely those planning to specialize in working with this client population.

“We believe that all social workers, not just those who work at the VA or within the DoD, but clinical social workers, policy practitioners, educators, researchers, and direct practitioners at homeless shelters, domestic violence agencies, or substance abuse organizations, etc., need to have access to basic information so that when they do work with a military-connected family, they will have the tools and knowledge to inform their practice,” Hoffler says.

“It would be impossible to require every social worker to take one credit hour of CEU on military issues,” Hassan says. “But for anyone in the community serving men and women in uniform, Guard, and Reservists coming into their program settings, it is simply ethical for them to have at minimum a military culture continuing education course. That’s a start.”

A Culture Clash
This issue of military culture is a bone of contention among some practitioners. A precept of social work is to meet clients where they are. But there’s a belief among many well versed in the military experience that it’s difficult to meet clients where they are if you don’t truly know where they’ve been. However, not everyone agrees.

Hassan has often discussed military culture with highly experienced social workers who say, “I don’t need to know the culture of all the people I work with, but I’m able to meet my clients where they’re at when they come in the door.” Hassan, however, is doubtful that social workers can make the therapeutic alliance strong without knowledge of the unique challenges and the aspects of military culture such as “their sacrifices, the seen and unseen war injuries” that affect the way veterans may perceive and respond to interventions.

“The majority of our providers have no idea about the uniqueness of military culture,” Hassan says. “Military personnel are trained to go to war; they’re placed in austere and dangerous environments that others probably will never understand; and their families are also serving and impacted by extended separations, anxiety, and fear of loss.”

 “The military extracts a huge allegiance from those who join, and it’s not just conceptual—it’s literal,” Beder notes. “Some of the difficulties that occur when one returns revolve around this schism—these dual loyalties to one’s ‘brothers’ and to one’s family. That becomes very problematic and creates tremendous difficulties upon returning home. There are approaches to care that have to be understood, but even more elemental is understanding what the military experience has extracted from, or given to, someone.”

“Serving in a combat zone multiple times and engaging the enemy multiple times affects how you see the world,” Hassan says. “Even for those of us that never shot at the enemy, we return home viewing our environment through a different lens. This readjustment may be short-lived or it can last a lifetime. We can sometimes feel isolated in a community that doesn’t understand our experiences. That’s why I feel it’s important for behavioral health professionals, at a minimum, to understand military culture, to understand the different military occupations, rank, branches of service, the deployment cycle, the uniform code of military justice, the warrior ethos, and the perceived stigma associated with seeing a mental health professional. All of these cultural factors impinge on our ability to connect with our military and veteran clients.”

Judith Rubin, MSS, LCSW, a mental health specialist and readjustment specialist at the VA’s Community Based Outpatient Clinic in San Bruno, CA, takes a different stance. Rubin encourages social workers to learn as much as possible—to read widely, observe, ask questions, and volunteer to work with veterans wherever they are—yet doesn’t necessarily endorse the need for formal training in military culture. “I don’t put the onus on the schools,” she explains. “Most of the students I’ve worked with are familiar with the lens of cultural competence. They have often triumphed over enormous adversity and can viscerally understand the complexity of PTSD. The military culture is just another culture.”

“It’s nuanced,” Armstrong says. “Yes, it’s important to educate social workers about military culture but, like anything, just being educated in something gets you about five feet of the way there.”

Schools, he suggests, are doing their part. The other part is up to the individual. “It’s important to educate yourself, read, take in information about what the experience must be like, but more important to be curious about the client’s experience of their situations, to say ‘I didn’t serve. I don’t know about this experience. Tell me what you think I need to know so I can be as helpful as possible.’”

In the end, he says, “It’s being humble and curious and ultimately providing that safe holding environment for the patient so they feel you get them, so they can feel safe enough to begin to tell you more about who they are.”

Moving Forward
Armstrong praises NASW, schools, and organizations that are stepping up and underscores the need for this call to action to resonate with all social work professionals. “We have more than 2 million men and women who served in Iraq or Afghanistan, and you’ll be working with them whether you end up serving at a VA or veterans readjustment counseling center or in any other setting. There’s no way around it.”

“Social workers have been serving veterans since 1926, when the first social work program was established in the Veterans Bureau,” Clark notes. “We must continue, as a profession, to lead this response. It’s important to create a flexible social service system that is prepared to respond to their ongoing needs. This means reaching out to and training all social workers as well as determining ways to institutionalize the services that we provide. Attention to this population cannot be fleeting, and social workers must lead the way in the consistency and competence with which we approach military clients.”

“The call to action is now,” Hassan says. “Our profession has and will continue to step up.”

— Kate Jackson is an editor and freelance writer based in Milford, PA. She has written for Social Work Today on topics such as grief and loss, mental health, compassion fatigue, and the emotional aspects of illness.

For More Information
• Council on Social Work Education Advanced Military Social Work Practice Guidelines (www.cswe.org/File.aspx?id=42466)

• Joining Forces (www.whitehouse.gov/joiningforces)

• NASW Standards for Social Work Practice With Service Members, Veterans, and Their Families (free at www.socialworkers.org/practice/military/documents/MilitaryStandards2012.pdf or for purchase at http://naswpress.org/publications/standards/service-members-veterans.html)