Nov/Dec 2007

Surviving Professional Stress in a Military Setting
By Richard Currey, PA-C
Social Work Today
Vol. 7 No. 6 P. 24

Caring for those wounded in war takes its toll on professionals. Read how social workers are balancing self care with caring for others.

Jackie Whitehouse, LCSW, has been a social worker for many years. “I’ve worked a lot of tough jobs—jails, crisis services, mental health walk-in, alcoholism, detox. But Walter Reed [Army Medical Center] is different from anything I’ve done before. Casualties of war are different, their families are different, and I think wounded soldiers and veterans touch a social worker differently. This has certainly been true for me.

“One thing I learned within the first few months of working here is that I had to figure something out or I wasn’t going to make it,” she adds. “This is a constant challenge at Walter Reed. We’re always looking for new and better ways to manage ourselves, because if you’re not taking care of yourself, you’re not doing anything for your clients and their families.”

At Walter Reed, the Army’s flagship hospital in Washington, DC, the corridors are filled with wounded soldiers in various stages of recovery moving by in wheelchairs or on stretchers, walkers, crutches, or canes. This is the face of a new generation of veterans whose service has been celebrated while the war they have fought has fueled intense and increasing national scrutiny. Two earlier articles in this series looked at the startling rates of posttraumatic stress disorder (PTSD) we will see in the next few years and the isolation many vets are experiencing as they seek out desperately needed clinical and counseling services.

But what about the professionals who care for these wounded warriors? What does an overwhelming tide of PTSD, traumatic brain injury (TBI), and the psychosocial ricochet of war-related distress mean in the lives of the professionals who are now or will soon care for these veterans? Social workers stand at the forefront of this group, operating in roles ranging from direct counseling and family therapy to assistance with virtually every aspect of living, including getting to doctors’ appointments or the grocery store.

According to Whitehouse and two of her colleagues at Walter Reed, sometimes one must hit all the marks, such as one-on-one counseling; calming a jittery young military wife; running interference with a soldier’s doctors, nurses, or case managers; or helping a soldier simply find the bus stop.

“The impact of PTSD is going to be a huge burden as vets return to their lives and jobs. But they’re returning as changed people. They’re going to behave differently and, perhaps, in difficult or unexpected ways,” says Cheryl Zook, LISW.

Like Whitehouse, Zook is a member of the inpatient social work staff at Walter Reed, those social workers charged with seeing and helping soldiers who have just arrived at the massive hospital complex. “There is a sense of marginalization among some of these soldiers,” Zook says. “The military is going to war, but the rest of the country is going to the mall. This is something we social workers here at Walter Reed deal with every day. We’re never sure these men and women will be effectively or sufficiently honored down the line, so we want to be sure we honor them by doing the best we can for them while they’re here with us.”

In doing so, however, Zook acknowledges that any social worker in this situation must have a well-developed sense of self and some “personal techniques for centering yourself and getting through the rough patches.”

Increasing Stress
As early as one year after the Iraq War’s start in 2003, United Press International reported that at least “10% of soldiers … evacuated to the [Landstuhl Army Hospital] in Germany were sent for mental problems.” Since then Time, Newsweek, U.S. News & World Report, Rolling Stone, and several major newspapers have all had feature stories about mental health issues among soldiers and Marines returning from Middle Eastern combat zones.

If psychological distress is a signature injury of time spent in Iraq and Afghanistan, it typically occurs in the context of other wounds—TBI (seen in up to 60% of combat-injured vets), the amputation of one or more limbs, gunshot wounds with extensive organ damage, and bones shattered beyond recognition. Social workers who care for returning service members are encountering cases that redefine the medical term comorbidity, where PTSD is simply one of several interacting conditions in a matrix of medical concerns and complex social and physical needs.

“America will have to adjust to a group of veterans who are in the process of surviving traumatic events,” says Judi Dekle, LCSE, chief of behavioral medicine at Walter Reed and supervisor of inpatient social services. “These vets are not going to look like people we’re used to looking at. They’re going to have different needs. America has not yet faced this issue, but it’s on the way. I think we’re in for a fundamental cultural shift as many more of our Iraq and Afghanistan vets come home and reenter society.”

Dekle supervises 15 inpatient social workers at Walter Reed, part of an overall staff of nearly 30 social workers at the high-profile Army hospital. Beyond Reed, social workers already play critical roles in the care of veterans throughout the armed forces and Department of Veterans Affairs, as well as in community-based programs and private practice. Dekle notes that personal and professional challenges will continue to mount for all social workers assisting active duty military personnel and veterans, as available resources likely diminish in the face of increased demand. Expanding caseloads, organizational and system delays, and a challenging client population will all contribute to rising stress levels for social workers.

Organizational Support
“You have to know your own capacities and what you’re suited for,” says Zook. “But even if you bring a lot of self-awareness to the table, you still need to be able to protect yourself against the stresses in this kind of social work.”

Zook describes an event that occurred early in her career when she joined the social work staff at an Army base in Germany shortly after an air show disaster. “I was seeing some of the first responders, and I quickly realized I didn’t have the personal tools to manage some of the pain and inner turmoil I was hearing from my clients. I started looking for a personal technique to help me keep my balance.”

It is no different today at Walter Reed, according to Zook. If anything, she says, the need has never been greater to facilitate one’s own psychological survival as a social worker. Zook cites unwavering support from her supervisor, colleagues, and other hospital managers as a key stress reducer. “The minute you start to feel isolated in a work situation, you’re in trouble. That’s not the case here at Reed. There’s always another person to talk to, consult with, or just offer another perspective on an issue or a client,” she says.

Whitehouse concurs: “It sounds a little obvious maybe, but organizational support is critical in helping us stay on track and intact.” Whitehouse notes that organizational support can mean anything from formal continuing education to a regular lunch with colleagues or a few words exchanged with a supervisor in the course of a busy day.

Within the concept of organizational support is how social workers engage the larger healthcare team at Walter Reed, according to Dekle. “We reach out, explain, help, collaborate. We’re willing to partner. Our staff do a terrific job of letting the larger team know what we can do for them. And in many small and large ways, this reduces stress for all of us, as well as the other professionals we work with,” she says.

Whatever Works
The critically overburdened social worker has been discussed and studied since the mid-1970s when the term burnout first entered the lexicon. Since that time, other concepts have gained in popularity, including compassion fatigue, secondary trauma, and vicarious trauma.

“We can’t be afraid of letting service members talk about their combat experiences and how they got injured,” Zook says. “These experiences were, of course, very traumatic and very frightening, and some of those elements—the fear and apprehension—will rub off on a social worker.”

Zook notes that she is a particularly visual person, at risk of visualizing a client’s traumatic memories as they are shared. Dating back to her work with first responders at the air show disaster, she understood that allowing traumatic experiences to manifest visually or pictorially in her imagination was personally stressful and reduced her therapeutic effectiveness.

“Visualizing a client’s experiences, which I’m prone to do, places me so close to the trauma that I lose my objectivity as a therapist,” she says. “I work at not picturing a client’s story in my own imagination. I stay in the moment, stay with the client, but I do not attempt to relive their experience with them.”

Zook says she had to get past the notion that not visualizing a client’s experiences meant she was somehow less of a therapist. “When a soldier shares a difficult memory, my job is to be there, be focused and present, but not to be inside that memory with them. I respect them more by retaining my objectivity and my capacity to help and assess. After all, that’s what they need and why they’re with us,” she says.

Whitehouse and Dekle agree that avoiding compassion fatigue and secondary or vicarious trauma—through whatever personal technique or method—is critical to remaining professionally effective.

“The first thing I do when I get to work in the morning is to plan my day,” Whitehouse says. “Now, mind you, the days here at Walter Reed never go according to plan. Everything changes, sometimes in the space of minutes. I know that, of course, but the morning planning process is, for me, a ritual that I use to center myself. It anchors me and helps me move calmly into the day’s work.”

Whitehouse shares a story about her first days as a social worker at Walter Reed. “When I first came to Reed, I had a one-hour morning commute. I’d listen to the news about casualties in Iraq on my way to work,” she says. “If I heard there were three deaths, it usually meant we had 12 casualties coming. It’s usually like that—3 to 1 or 4 to 1. As I listened to the news, I could literally feel my own anxiety rising about what I was going to see in the course of the day, and I’d hit my desk bubbling over with stress before I’d done anything or seen even a single client. I knew I would be short-lived on this job if I didn’t master my mornings.”

Whitehouse says she instituted a few simple rules. “Some were easy,” she says, laughing. “Like no news! I switched to music I enjoyed and that was relaxing. And I made sure I planned my day and assigned myself a few key objectives that would make the day, for me, a success. This very simple ritual has gone a long way to helping me destress and stay alert and effective.”

Whitehouse describes how she manages to greet a soldier’s anxiety and fears without also being swallowed by those feelings. “It’s an interesting question,” she says, “and one that I’ve thought a lot about over my career. If we put up some sort of shell to protect ourselves, we lose our empathy and, with that, our usefulness. After all, this work is all about touch and connection. On the other hand, we have to stay whole while not compromising our capacity to connect.”

Whitehouse comes back to what she calls “the basics”—simple and straightforward techniques that reduce stress and keep her centered. “A lot of survival as a social worker is, in the end, common sense, like not listening to news reports about casualties in Iraq. Another important piece of advice I’d offer is go home on time. Don’t linger at work worrying about what didn’t get done or how you might have done something differently. Call it a day. You’ll be back tomorrow.”

All social workers, in Whitehouse’s view, must be vigilant about burnout and fatigue. “I think we all came into this work to get some gratification in helping others. We don’t see much success with clients in the environments many of us work in. Look at the burnout rate among child welfare social workers. I came out of substance abuse treatment, and we had terrible success rates no matter what we did. So, early on, in order to stay in the field and stay vital, I had to readjust my personal expectations about what was reasonable. The great thing here at Reed is that we see a lot of successes. These young soldiers do get better, and we have the privilege of helping them transition back to duty or out of the service.”

The process and implications of trauma, says Zook, has often been likened to a rock thrown into the water that creates ripples. “That’s what we see here—every soldier’s story ripples from them and out to their families, their friends, and to their caregivers. You can’t do this work effectively and not be part of that. So it’s critical that social workers learn to care for themselves.”

Staying Effective
As much as, if not more than, psychologists or psychiatrists, social workers operate at a kind of emotional ground zero in many therapeutic relationships. But if a social worker’s own foundation erodes under the stress of these interactions, it can become difficult—if not impossible—to continue to function at the complex level required in working with military service members, veterans, and their families.

For Zook, Whitehouse, and Dekle, the rigors of social work at Walter Reed are balanced by professional relationships, supervisory support, and client successes. But all three women acknowledge the critical need to develop and use techniques of self-preservation and renewal, from Zook’s capacity to “be here now” without getting lost inside a client’s experiences to Whitehouse’s morning ritual of day planning and “bullet points” for achievement to Dekle’s commitment to addressing collective job stress through collaboration, support, education, and outreach.

“I love my work,” Zook says. “I’m very proud of what we do here at Walter Reed. But there’s no doubt that social workers who care for service members and vets must come to work each day and continue to make a difference while also managing their own needs for self-renewal.”

— Richard Currey, PA-C, is based in the Washington, DC, area where he currently works with several agencies within the National Institutes of Health as a writer and consultant.

Seven Survival Tips
• Avoid professional isolation. Feeling alone in the midst of clients’ traumas and problems is the road to burnout.

- Recommendation: Stay connected with colleagues and supervisors. Share the issues and concerns that come with each day. Enjoy collaboration and cooperation.

• Pursue professional education that expands and supports your clinical effectiveness. Learning or reviewing a therapeutic process or strategy in the structured environment of a classroom with other clinicians can function as a stress reducer.

- Recommendation: Never be “too busy” to find time for participation in continuing education and other meetings that enhance and facilitate your knowledge.

• Beware of trauma’s “ripple effect.” Clinical effectiveness does not mean joining a client in their pain, fear, and anxiety. Sharing too deeply or too intimately reduces a social worker’s objectivity and usefulness.

- Recommendation: Stay focused and in the moment but avoid intense visualizations or reimagining of a client’s traumatic memories.

• Keep professional expectations reasonable. Imagining yourself as a failure can be professionally disabling and personally toxic. Excellence in social work is client-dependent and context-driven as opposed to a fixed point that can be achieved and maintained in every case or situation.

- Recommendation: Work with colleagues and supervisors to identify reasonable expectations for success, celebrate those successes, and avoid self-blame or discouragement.

• Use “ritual” to anchor or launch a work day. A few personal minutes each morning centers your sensibilities and grounds you for the demands of the day.

- Recommendation: Find your own ritual activity. Possibilities include writing a day plan with three to five specific objectives; 10 minutes of meditation or breathing exercises before leaving the car in the morning; or structuring time to enjoy the first cup of tea or coffee quietly at your desk before the day begins.

• Keep work at work. Avoid the continuing stress of staying long after quitting time (as your energy drops) or trying to “catch up” with tasks that can wait for the next day.

- Recommendation: Go home on time, and once you’re home, try to avoid excessive talk with family or friends about work.

• Maintain a healthy and centered self. All the classic advice about a balanced diet, regular exercise, and taking pleasure in family and personal relationships pertains here.

- Recommendation: Find some unexpected (for you) activities and do them. If you’ve put off a weekend outing, get it on your schedule. If you’ve always wanted to see a major league baseball game, buy the tickets. If you want to learn to rumba, sign up for classes. New and different often equals energizing and restorative.

— RC