Assignment 2- w3 - ADV Clinical Studies

NATIONAL HEALTH LINE

Bringing It All Back Home: Social Work and the Challenge of Returning Veterans

Darrell P. Wheeler and Martha Bragin

Tiie system of care for psychological health that has

evolved over recent decades is imtijficicnt to meet the

needs of today's jarntedlforces and their beneficiaries,

and will not be sufficient to meet their needs in the

future.. .As in the civilian sector, military mental healtb

practices tend to emphasize identification and treat-

ment ofspedjk disorders over preventing and treating

illness, enhancin'^ co{m^ and maximizing resilience.

(Department ot Defense [DOD] Task Force on Mental Health, 2007, pp. ESl-2)

T he June 2007 DOD Task Force on Mental Health report cited here suggests the cur- rent .system of care is inadequate and unable

to meet the needs ot veterans now and into the iu- ture.Tbis is so, not only because of a lack of human power, but also because of the underlying theoreti- cal and methodological assumptions on which the system is based.The report states emphatically that the current system is not succeeding in providing successful care for those affected by the current Iraq war or in building resilience among the soldien and their families as a whole.This report challenges the way that health and mental health care in the United States has been provided, not only to veterans and their families, but also to all of those affected by exposure to violence.

In recent years, social workers, and otbers working in the formal health and mental health sector, have been required to apply a medical model that treats psychosocial issues as though they were diseases, to be managed through "dosed" therapies designed to reduce symptoms. This medical model is different from the biopsychosocial framework on which social work practice is built and the strengths perspec- tive, which places each person as the subject rather than tbe object of his or her ovm life (Robbins, Chatteijee, & Canda, 2006). Therefore, the DOD critiques of the model of care for serving mental health needs of soldiers, veterans, and their families present social work with an important opportunity.

if not an obligation. Namely, to bring its methods of inquiry to bear on the problems of reintegmting war veterans into society, as well as understanding and mitigating the effects of exposure to violence on soldiers and civilians alike.

The need to build resilience and promote effec- tive reintegration processes for acdve-duty soldiers, veterans,and their families is not a problem for prac- titioners alone. It is an issue that requires stringent intellectual inquiry to locate, test, and provide more successful models of intervention, and in so doing, shed light on the contemporary discourse regarding trauma and recovery, violence, and transformation.

The task force report (DOD, 2007) provides a detailed account of the scope of the current problem facing the Departments of Defense and Veterans Affairs. According to the report, which uses data from the Post-Deployment Healtb Reassessment administered to service members from 90 to 120 days after returning from deployment,

• 38 percent of soldiers and 31 percent of Ma- rines report psychological symptoins.

• 49 percent of returning National (iuard members report psychological symptoms.

" Hundreds of children have experienced the deployment of one or both parents.

• Psychological concerns among family niem- ben have yet to be quantified.

The report emphasizes the prevalence of co- occurring diagnoses, most frequently posttraumatic stress disorder (PTSD) and traumatic brain injury, sometimes complicated by pbysical injury and dis- ability.The report states that such a range of injuries require a seamless continuum of biopsychosocial care (DOD, 2007) that is unavailable in the current system.

One issue raised by the report is the emerging public health problem presented by a cohort of men and women returning from repeated deployments

CCC Code: 0560-7283/07 13.00 ©2007 National Association of Social Workers 297

with untreated mental health and neuropsycho- logical issues. Of greater concern is the loss to the nation of the enormous leadership potential that this returning cohort represents. Viewed through a strengths perspective lens (Scurfield, 2006), these men and women represent essential resources to address current and emerging social, economic, and developmental problems here at home.

A BRIEF HISTORY Some history is useful to help us understand how work involving emotional and physical difficulties resulting from the effects of external real-world stressors was ceded to the medical model.

The diagnosis of PTSD formally entered the nomenclature in 1980. before the development of this diagnosis, survivors of extremely violent events, including war veterans, were considered to have a character defect if they reacted with symptomatic behavior to the violence they had experienced (Horowitz, 1986). The new diagnostic category emphasized that strong responses after experienc- ing violent events were normal reactions to events beyond the capacity for the mind to endure them (van der Kolk & McFarlane, 1996).

The new diagnosis, and the understanding that came with it, led the way for war veterans to receive the benefits they deserved and the treatment they needed (Peterson, Prout, & Schwarz, 1991). With many veterans seeking treatment, scholars and cli- nicians from all health-serving disciplines invested in research to understand the causes and treatment of the newly defmed disorder. Researchers soon discovered that symptoms suffered by survivors vary, not by the nature of the survivor's history, but by the severity and duration of their exposure to violent events (Hovens, Falger. Op den Veld, & Shouten, 1992). Furthermore, researchers learned that many veterans, who did not appear affected immediately after the events, became symptom- atic much later, especially if they did not receive timely treatment (Horowitz, 1986; van der Kolk & McFarlane, 1996).

However, despite the extensive research sur- rounding the medical treatment of PTSD in recent years, successful treatment for the majority of those diagnosed with the disorder appeared elusive. In 1982, army psychiatrist James Titchener noted that the majority of veterans entering treatment for PTSD became worse, not better, over time (Titchener, 1982). By 1998, the phenomenon of

posttraumatic decline was firmly established in the literature and practitioners were seeking to explain the phenomenon (Inderbitzin & Levy, 1998). Garbarino's (1998) hypothesis that "trauma is for- ever," drew attention to the fact that the treatment protocols being used simply did not work with many people, like veterans, exposed to severe and repeated trauma. His explanation was widely cited by practitioners and experts.

In the wake of these therapeutic limitations and emerging data, social work has joined other disciplines in turning its attention to studies to identify factors that make it possible for some people exposed to extreme violence to withstand the stress. Commonly referred to as "resilience" perspectives, these approaches seek to identify the factors that mitigate extreme risk, and under which circumstances they work most effectively (Fraser, 2004).

INTERNATIONAL CRITICISMS OF THE MEDICAL MOOEL OF PTSD TREATMENT At the same time, the international community, including many social workers and anthropolo- gists, saw grave limitations and misuses of the new diagnostic label (13arton & Mutiti, 1998; Becker, 1995; Bragin. 2004, 2005; Honwana, 1998.1999). Noting that many of those who had been ex- posed to violence, particularly war, often suffered psychological symptoms after the fighting was over. New questions emerged regarding whether a phenomenon so ubiquitous should be treated individually, as a disorder, or whether it did not speak more to a need for broader social integration. Barton and Mutiti and Honwana (1999) noted that African societies had traditional mechanisms for cleansing those who had participated in war before their return to the community. Other studies found that such ceremonial solutions were located in several cultures, including Native American, African American, and Southeast Asian cultures in the United States. Initial longitudinal studies have shown promising outcomes for interventions that combine these ceremonies with opportunities for excombatants to act collectively to benefit the community, while also receiving economic and educational benefits availabte to civilians (Boothby, Crawford, & Halperin. 2006; WiUiamson. 2006). These programs recast the excombatants. and other survivors of war, as contributors capable of using the combined group energy of combat as a posi-

298 Health &SocialWork VOLUME 32, NUMBER 4 NOVEMBER 2007

tivc force to be used in the interest of change. The programs job was not to treat individual trauma, but to assist excombatants in making this shift back into their communities as productive contributors. These approaches follow a community-based risk and resilience model (Fraser, 2{H)4),They are also culturally competent, a critical requirement of social work practice.

The international approach to psychosocial reintegration is resonant with the one used to re- integrate members of the U.S. armed forces after World War 11. The troops came bome together, typically on boats, giving them the opportunity to maintain bonds and prepare for the return to a world tbat was radically different from tbe one tbey had experienced in war. Whereas the GI bill provided extensive educational opportunities, "other government programs provided assistance with employment, home mortgages and health care, Tbese programs were immensely successful, contributing to a sustained period of extraordinary econoniic growth and innovation driven by wbat bas become known as this country's'Greatest Gen- eration'" (Hartwig, 2006, p. 3).

THE CHALLENGE FOR SOCIAL WORK Social work can no longer cede veterans' reinte- gration or the care of clients experiencing violent life events (that is, trauma) to a medical model tbat pathologizes survivors and has been unable to provide comprehensive, seamless, and effective treatment (DOD, 2007). Instead, it is time for so- cial work to bring its methods of inquiry to bear on tbe development of and advocacy for cultur- ally informed, strengths-based, biopsychosocial ap- proaches to work with veterans and otbers affected by violence. Such approaches, coordinated with public healtb care systems, would maximize oppor- tunities for veterans and otber survivors of violence to emerge as contributing members and leaders in their communities, while still being provided with the continuum of care needed.

To make this coordinated system of care a reality, the social work profession should

• develop a social work task force to support research on reintegration approaches tbat nuiximize tbe contribution of veterans and tbeir families, and look toward the implica- tions of this work for all those experiencing violence

• initiate and support research into the cultural resources of tbe diverse communities that can be used to reintegrate excombatants

• use existing social work organizations to advocate for pubhc health and social work partnerships to address the needs of returning veterans through tbe creation of compre- hensive reintegration programs open to all members of tbe armed services, the national guard, and tbeir families, between and after deployment

• develop and test specific measures to support those soldiers adected by a combination of PTSD and traumatic brain injury, who need more tban a public bealtb program can pro- vide, and ensure tbat tbis researcb is rooted in a culturally competent and comprehensive framework (tbat is, biopsychosocial).

The DOD Task Force report, indicating the in- ability of the existing systems to provide adequate care for veterans and tbeir families, makes it clear that it is time to bring social work knowledge and methods back home to the care and treatment of America's veterans. The question for social work is whether we are prepared to mobilize and stand bebind our professioTia! skills to meet tbe needs of tbis growing cadre of veterans, excombatants, their families, and others affected by trauma and violence.

REFERENCES Barton.T,,tf>. Muiiti.A. (1998). Nurr/icm Uganda psycho-

social needs assessment report. Kampala: UNICEF. Becker,D. (1995).The deficiency of the concept of post-

traumatic strew disorder when dealing with victims of human rights vioUtinns. In R. Kleber, C. Figiey, & B.Gersons (Eds.), lieyond trauma: Societal and cultural dynamics (pp. 99-114), NewYork; Plenum l'rcss.

Boochby, N., Cra\vford,J. & Halperin,J. (2006), Mozambique child soiditT lit'e outcome study: Lessons learned in rehabilitation and reintej^ra- tion efforts. Global Public Heaitb, 1 (I). 1744-1692, Retrieved September 06, 2IK)7, from http;//www. informaworld.com/l I), 1 (180/1744U)9OS(t()324347

Bragin. M. (2004), Baseline information and recommenda- tions: Responding to the psychosocial nt-eds of ex-comhat- ants and war affected communities in post-conjlici l.iheria. Monrovia: ('ARE Internatioiul and USAlD,

Bragin, M. (2005). 'lite tiger r.* our guest: Helping children to grow up in lime of war and afteru'ards.VwnnA: C'ARE Osterreich,

Department of Defense Task Force on Mental Health. (2007). An achia'able vision: Report of the Department of Defense'lask Force on Mental Health. Falls C~hurch,VA: Defense Health Board.

Fraser, M . W (Ed.). (2004), Ri.<k and resilience in childhood: An ecological perspective (2nd ed.). Washington, D C ; NASW Press.

WHEELER AND BRAGEN / Brinpng It AU Back Home: Social Work and tht Chatknge ofRetumingVeterans 299

Garbarino,J. (1998,July-August). Raising children in a socially toxic environment. Child Care Information Exchange, 122, 8-1(1.12.

H j r t w i g , R . (2{)()6). H^ienjobtiiiy comes marchitiji home: Injured veterans returning from mir present unique challenga for insurers. Retrieved July 10,2007,&Dm http;//server. iii.org/yy_obj_data/binary/773496_l_0/Veterans_ WC.pdf

H o n w a n a , A . (1998). Ohisiakala ondalo yokalye: Let us Hght ij new fire: Local hiowlcd^^e iii the post-war heatinj^ and re- integrmion ofutiT-ajfecied fhiiiircn in Angola. R i c h m o n d , VA and Luanda; Christian Children's Fund.

Honwana.A. (1999). Challenging Western concepts in trauma dnd healing. Track Two: Culture and Confict, 8(\). 1. Retrieved September 7. 2007, from http:// ccrweb.ccr.uct.ac.za/archive/Cwo/8_l/p30_ c ol 1 f c ti ve_b ody. h t ml

Horowitz, M. (1986), Stress response syndromes. Northvale, NJ:J,ison Aronson.

HovensJ., Falger, H, O p den Veld, W., 6c Shouten, E. (1992). Occurrence of current post traumatic stress disorder among Dutch World War II resistance veterans ac- cording to the SCID.Ji'tinw/ of Anxiety Disorder, 6, 147-157.

Inderbitzin, L., & Levy, S.T. (1998), Repetition compulsion revisited: Implications for technique. Psychoanalytic Quarterly. 67, 32-53.

Peterson, C . Prout, M., & Schwarz, R. (1991).Theoretical perspectives, [n Post-trauma tic stress disorder: A clinician s guide. NewYork: Plenum Press.

Robbins, S. P., Chatteijee. P, & Canda. E. R. (2006). Contemporary human behavior theory:A aiticalperspective

for social work. Boston; Pearson/Allyn & Bacon, Scurfteld, R. (2006). War trauma: Lessons unlearned from

Vietnam to Iraq.Vol. 3 of aVietnam trilogy. New York: Agora.

Titchener.J. (1982). Post-traumatic decline:A consequence of unresolved destructive drives. In C. Figley (Ed.). Trauma and its wake, vol. II (pp. 5-19). NewYork; Brunner/Mazel,

van der Kolk, B.,& McParlane.A. (1996),Trauma and its challenge to society. In B. van der Kolk, A. McFarlane, & L.Weisaeth (Eds.). Trdunmtic stn:>;s:TIn' effects of oveni'helmiiig experience on mind, body, and society (pp. 24-45). NewYork: Guilford Press.

Williamson,J, (2006),The disarmament, demobilization and reinlegration of child soldiers: Social and psycho- logical transformation in Sierra Leone, Inlcrrention: 77w' Ittternatiomil Jounial of Mental Health, ['sychosodal IVork and Coumelling in Areas of Armed CotiflicI, 4, 185-205.

Darrel! P. Wlieeler, PhD, MPH, is associate professor and associate dean for research. School of Social Work, Hunter Col-

lege, City University of NewYork, 129 East 79th Street, New

York, NY 10021; e-mail: du'[email protected]. Martha Bragin, PhD, LCSH^ is associate professor. School of Social Work, CUNY, Hunter College, NewYork.

Social Work Speaks SEVENTH EDITION

N A S W Policy Statements 2006-2009

• Unabridged collection of policy statements adopted by the NASW Delegate Assembly in 2005

• Collective thinking of thousands of experienced social work practitioners from all fields of practice

• 22 new statements addressing current issues such as affirmative action, child abuse and neglect, disasters, end-of-life care, HIV and AIDS, people with disabilities, and others

• User-friendly volume organized alphabetically and by topic area for easy refetence

• First rate social policy text for policymakers, educators, students, and individuals

ISBN:O-S71O1-37O-3. Item #3703. February 2006. $45.99 To order this resource and others, please visit us at www.naswpress.org or call 8000-227-3590

Please refrr to code APSW06

NASW PRESS

300 Health & Social Work VOLUME 32, NUMBER 4 NOVEMBER 2007