Motivational Interviewing and Addictions: Collaboration, Not Confrontation

November/December 2015 Issue

Motivational Interviewing and Addictions: Collaboration, Not Confrontation
By Christina Reardon, MSW, LSW
Social Work Today
Vol. 15 No. 6 P. 22

Though it has its critics, motivational interviewing has proven effective with clients capable of engaging with clinicians who operate from a strengths-based perspective, tapping into internal wisdom and resources, rather than viewing the client as someone with deficits that need to be "fixed."

Ambivalence about change is part of the human experience. You want to exercise more, but you'd rather watch your favorite TV show than go to the gym. You want to lose weight, but the sweets displayed in the window of the neighborhood bakery look so good.

Substance abusers face ambivalence, too. On one hand, they see how addiction has damaged their health, their families, their careers. On the other hand, they don't want to give up that pill, that drink, that high.

Many clinicians trying to help clients resolve this ambivalence turn to advice giving in an effort to persuade the user to give up drugs or alcohol. These helpers are often surprised when their efforts backfire, and the client continues to use.

Motivational interviewing (MI) provides an alternative to this destructive cycle of confrontation and resistance. MI is built on the premise that the clinician is not there to force clients to change but instead should facilitate the capacity clients already have within themselves to change. Although now used in fields as diverse as health care, education, and criminal justice, MI's roots are in addiction, and clinicians working with substance abusers from all walks of life are increasingly using the approach.

"[MI] gets clients thinking on a different level because they're the ones making the decisions," says Daryl Cioffi, MEd, CAGS, LMHC, co-owner of Polaris Counseling & Consulting in Rhode Island. "You get people to tap into their own power. You're just there to help them along the way."

MI: An Overview
William R. Miller, PhD, a professor of psychology and psychiatry at the University of New Mexico, originally outlined MI in the early 1980s. Miller and psychologist Stephen Rollnick, PhD, have further developed and refined the concepts of MI in subsequent editions of their book,Motivational Interviewing: Helping People Change (2013).

MI is not a therapy itself, but a conversational style or way of being that a clinician uses when interacting with clients. The approach is focused on conversations around change, primarily those involving ambivalence when clients are going back and forth about making changes.

Underpinning MI is the idea that people tend to rebel when they feel that they are being forced to choose a certain course of action in resolving ambivalence. Unfortunately, this urge to pressure people to make the "right" decision about change—what Miller and Rollnick call the "righting reflex"—is prevalent among many well-intentioned helpers, including those working in professional settings.

Miller and Rollnick argue that people are more likely to change when hearing themselves speak about the reasons to change and how that change might be accomplished. MI is designed to gently guide clients toward focusing on that change talk—statements that promote change—and away from sustain talk—statements that promote the status quo. Clinicians create an environment that fosters change talk by embodying Miller and Rollnick's "spirit of MI," which includes the following elements:

• Partnership: The clinician and client collaborate in the journey toward change. The clinician's role is to listen to and support the client, not to tell the client what to do.

• Acceptance: The clinician accepts what the client brings to the partnership. This acceptance involves respecting the client's inherent worth, practicing empathy with the client, supporting the client's autonomy, and affirming the client's strengths.

• Compassion: The clinician commits to promoting the client's welfare and best interests.

• Evocation: The clinician operates from a strengths-based perspective and helps the client tap into internal wisdom and resources instead of seeing the client as someone with deficits that need to be "fixed."

Practicing in the spirit of MI involves more than an intellectual belief that these elements are important for a good therapeutic relationship. Clinicians must put these elements into action during interactions with clients, says Paul Burke, MA, RSW, team leader at Paul Burke Training & Consulting Group, which provides MI training throughout Canada. "It's a set of interviewing habits you have to get into," he says.

In addition to the four elements of the spirit of MI, the following four processes that emerge in MI (Miller & Rollnick): engagement (building rapport, developing a therapeutic alliance); focusing (seeking clarity in the direction of the change discussion and change goals); evoking (guiding clients to voice arguments that support change); and planning (committing to change and discussing how to pursue change). Each process builds the foundation for subsequent processes. The five key communication skills used by clinicians during these processes are asking open-ended questions, affirming, reflecting, summarizing, and providing information and advice with permission (Miller & Rollnick).

MI and Addiction
Miller began to develop MI after beginning to question the confrontational style of addiction treatment that was in vogue during the late 20th century. Using the confrontational style, clinicians would yell at, argue with, denounce, humiliate, and otherwise verbally abuse clients in an effort to break through their denial (White & Miller, 2007).

Miller observed that confrontation tended to lead to a vicious cycle (Miller & Rollnick). The confrontation made clients defensive. Clinicians interpreted this defensiveness as resistance, which convinced them that they had to confront even more. MI offered a new way to approach clients in a much more collaborative, nonjudgmental way.

MI has been used in a variety of interventions addressing issues such as alcoholism, heavy drinking, drinking and driving, smoking, marijuana use, and cocaine use. Evidence suggests that MI can be useful in helping people change problematic behaviors related to substance use and abuse. Studies that point to MI as a promising practice in the addictions field include the following:

• A review of four meta-analyses by Lundahl and Burke (2009) found that MI was significantly more effective than no treatment and generally as effective as other approaches for treating substance abuse to increasing client engagement in treatment.

• Smokers in Spain who were randomly assigned to MI were more likely to have remained abstinent from smoking after six and 12 months than those assigned to an intervention where they received antismoking advice (Soria, Legido, Escolano, Yeste, & Montoya, 2006). The authors surmised that participants in the group receiving advice might have perceived such advice as preaching and thus engaged in contrarian behavior.

• A study of 423 substance users entering outpatient treatment in five community-based settings in Oregon, Virginia, and New York showed better treatment retention rates for clients randomly assigned an intake that integrated MI techniques vs. a standard intake. The MI-adapted intake, however, did not lead to any difference in substance-use outcomes at 28-day or 84-day follow-ups (Carroll et al., 2006).

• Problem drinkers randomly assigned to directive-confrontational counseling showed significantly more resistance than those assigned to client-centered counseling. The resistance predicted poorer outcomes at 12-month follow up (Miller, Benefield, & Tonigan, 1993).

Both MI and motivational enhancement therapy (an adaptation of MI) appear on the Substance Abuse and Mental Health Services Administration's National Registry of Evidence-based Programs and Practices (NREPP). Information about additional research on these interventions can be found on NREPP's website (www.nrepp.samhsa.gov).

MI is especially useful in working with clients struggling with addiction because these clients tend to be incredibly ambivalent about their substance use, says James M. Walsh, PhD, LPCMH, BACC, a pastoral counselor in Delaware and a former program assistant in the MS in Clinical Mental Health Counseling program at Wilmington University. Walsh says MI also can be used to help clients move to a place where they are willing to explore painful experiences or situations that have contributed to their substance abuse.

MI is not intended to replace other therapeutic approaches, such as cognitive behavioral therapy, but instead can be used as a tool within other approaches to resolve ambivalence whenever it arises. "The integration of [MI] into my practice is seamless," Walsh says. "It's something that I may work on with a person a minute here and there, or it may take up most of a session."

Burke first learned about MI in 1993 when he was in the addictions field and attended a training conducted by Rollnick, MI's codeveloper. Burke says he was immediately struck at how nonconfrontational and respectful the approach was—leading to a much more positive and engaging experience for clients.

Maryellen Evers, LCSW, CAADC, who has a private practice at Ronald J. Refice & Associates in Pennsylvania, has noticed that MI works particularly well in helping her forge therapeutic alliances with adolescent clients. Adolescents who come into therapy expecting to be lectured like they have by their parents or other adult authority figures are pleasantly surprised when they are trusted to make their own decisions. In addition, Evers says, MI engages clients who are not ready for complete abstinence from substances because by putting clients in control of their decisions, MI leaves open harm reduction or moderation as options.

Perhaps the most surprising thing about MI is not the impact it has on clients struggling with substance use but the impact it has on clinicians. Behavioral health professionals discussing MI repeatedly use words like "enjoyable," "energized," "easy," and "enthusiastic" to describe their experiences practicing MI.

MI releases the clinician from having to struggle with clients to get them to make changes in their lives, says Brian Hurley, MD, MBA, an addiction psychiatrist and Robert Wood Johnson Foundation clinical scholar at UCLA. "I found MI to be transformative in my practice. It's made my practice fun because I am working with patients on goals they define rather than those I define."

These benefits do not have to be limited to clinicians. At Hazelden Betty Ford Foundation's facilities in the Tribeca and Chelsea neighborhoods of New York City, even nonclinical staff receives training about MI so the approach is infused into all the services clients encounter. "[MI] is used from the start, from the moment that someone participates in an assessment," says Barbara Kistenmacher, PhD, executive director of Hazelden Betty Ford Foundation's New York campus. "It's woven into everything we do."

Easier Said Than Done 
Despite its many benefits, MI is not a panacea. There are certain situations in which its use with substance users may be ineffective or even counterproductive, says Amber Madden, MA, LPCA, of Madden Wellness Counseling in Kentucky. For example, Madden says MI might not be initially appropriate with clients in crisis because these clients need to resolve the crisis first before engaging in conversations about change.

Another red flag with MI is if clients are already committed to change and confident about making it, says Sarah A. Suzuki, LCSW, CADC, of Chicago Compass Counseling. In that case, discussing ambivalence may stymie clients' progress.

MI has acquired a certain cachet as it has become more well-known and popular, with more and more behavioral health professionals claiming that they practice MI or in the MI style. But many of these practitioners—both in addictions and in other fields—have misconceptions about MI. One of these misperceptions, Burke says, is that MI is the same as motivational speaking—a kind of pep talk that gets people pumped up and enthusiastic.

Another misperception centers on how MI can be learned. Miller and Rollnick, for example, express their dismay about some clinicians' perceptions of MI as being a simple set of verbal tricks that can be taught to staff during the lunch hour. In fact, it takes a lot of time and hard work to master the approach, Cioffi says. "You're not just going to be able to watch a YouTube video and learn it," she says.

Cioffi and several other addiction treatment professionals offered the following advice to clinicians who want to become proficient in MI:

• Learn about MI. Reading about MI, looking at articles, and watching videos are among the many activities addictions professionals can engage in to learn about the method of MI and the concepts behind it.

• Learn how to do MI. Taking the leap from knowing MI to doing it requires intensive training, preferably training that includes role plays, teach-backs, and other opportunities to demonstrate MI skills. The Motivational Interviewing Network of Trainers is a good way to find out about upcoming trainings (www.motivationalinterviewing.org). Try to bring at least one other person with you to trainings so you can continue to practice together and provide feedback to one another once the training is over.

• Do MI. Practicing MI is key to becoming skilled at it. Get clinical supervision from someone who is well-experienced in MI. Record your sessions and use a coding tool to assess the quality of and the fidelity to the MI approach.

Practicing MI is essential to getting to a point where MI comes naturally when interacting with clients, Suzuki says. She likens the process to learning how to play the piano. Listening to music and reading books about the piano are only going to get you so far; it takes practice to truly become prepared to perform.

Mastering MI may be harder than some clinicians think it will be because practicing the radical acceptance MI requires is difficult, and it can be easy to slide back into directing, advice-giving behavior, Walsh says. It may be especially challenging for clinicians working in addictions, Hurley adds, because of addiction treatment's long history of confrontation. "Sometimes people have a fair amount of unlearning to do of well-worn patterns that are not compatible with [MI]," Hurley says.

Just as MI practitioners must practice patience with and acceptance of their clients, they also must be patient with and accepting of themselves as they try to use MI, Suzuki says. "It's OK to make mistakes; even the most experienced practitioners aren't perfect," she says. "The only way I can do it is to keep practicing. It becomes more fun and easier and more fulfilling the more you do it."

— Christina Reardon, MSW, LSW, is a freelance writer based in Harrisburg, PA, and a contributing editor at Social Work Today.

References
Carroll, K.M., Ball, S.A., Nich, C., Martino, S., Frankforter, T.L., Farentinos, C., et al. (2006). Motivational interviewing to improve treatment engagement and outcome in individuals seeking treatment for substance abuse: A multisite effectiveness study. Drug and Alcohol Dependence, 81(3), 301-312.

Lundahl, B., & Burke, B.L. (2009). The effectiveness and applicability of motivational interviewing: A practice-friendly review of four meta-analyses. Journal of Clinical Psychology, 65(11), 1232-1245.

Miller, W.R., Benefield, R.G., & Tonigan, J.S. (1993). Enhancing motivation for change in problem drinking: A controlled comparison of two therapist styles. Journal of Consulting and Clinical Psychology, 6(3), 455-461.

Miller, W.R., & Rollnick, S. (2013). Motivational interviewing: Helping people change. 3rd ed. New York, NY: The Guilford Press.

Soria, R., Legido, A., Escolano, C., Yeste, A.L., & Montoya, J. (2006). A randomised controlled trial of motivational interviewing for smoking cessation. British Journal of General Practice, 56(531), 768-774.

White, W.L., & Miller, W.R. (2007). The use of confrontation in addiction treatment: History, science and time for change. Counselor, 8(4), 12-13.

Substance Abuse and Intervention at Colleges and Universities

May/June 2016 Issue

Addictions Advisor: Substance Use and Intervention at Colleges and Universities
By Liza Greville, MA, LCSW
Social Work Today
Vol. 16 No. 3 P. 30

For many young adults, "the college experience" entails varying realms of experience with alcohol or other substances, and national statistics show variations over time in categories of use. Colleges and universities continually reinvent and reinvest in strategies to deal with the seemingly intractable problems associated with substance abuse.

Alcohol Use and Intervention
As in the general population, alcohol is the most widely accessible and abused substance among college students. According to the National Institute on Alcohol Abuse and Alcoholism College Drinking fact sheet, almost 60% of college students ages 18 to 22 drank alcohol in the past month, and almost two out of three of them engaged in binge drinking during the same time frame (2015).

Researchers estimate that the following happen each year:
• About 1,825 college students between the ages of 18 and 24 die from alcohol-related unintentional injuries, including motor vehicle crashes.
• About 696,000 students between the ages of 18 and 24 are assaulted by another student who has been drinking.
• About 97,000 students between the ages of 18 and 24 report experiencing alcohol-related sexual assault or acquaintance rape.
• About 1 in 4 college students report academic consequences from drinking, including missing class, falling behind in class, doing poorly on exams or papers, and receiving lower grades overall.

Patrick Gilligan, LISW, director of counseling services at Kenyon College in Gambier, Ohio, notes that "Since research indicates that most students start using alcohol in the first year of college, colleges find themselves in the unique position of helping students with an introduction to responsible alcohol use without sanctioning it" (as the majority of undergraduates are under the legal drinking age of 21).

To that end, he states that Kenyon takes an aggressive approach to delivering education through relationships. Among several programs, Kenyon has 150 students (10% of the student body) who are trained as peer educators and understand the resources for substance use treatment on campus. "Research shows us that students are more likely to divulge their problems to other students," Gilligan says. "Therefore, we work very closely with these groups to convey that issues that affect college students are real, invariable, and can be made better with support."

Michael Durham, LSW, LICDC, substance abuse counselor at Kenyon, explains the college's Good Samaritan policy. This policy allows a student (or peer) to call the campus safety service to respond to and assess a student when there is concern that the student may be at risk of alcohol poisoning, acute intoxication from another substance, or other imminent harm. Students acting under the Good Samaritan policy are not subject to disciplinary action, and Durham meets with any student who uses this service for an individual session. This policy exemplifies the delicate balance of prioritizing safety without condoning dangerous binge drinking, which Durham believes is the most critical challenge facing colleges related to substance abuse.

Other Substance Use
The Monitoring the Future (MTF) survey, conducted by researchers at the University of Michigan with funding from the National Institute on Drug Abuse, has been monitoring trends on college campuses for 30 years. The most recent survey, released in 2014, shows the following (Wadley, 2014):
• Illicit drug use has been rising since 2006, when 34% of college students indicated some illicit drug use in the past year. In 2013, that rate was up to 39%; this is attributable to a rising proportion using marijuana.
• Marijuana is the most widely used illicit drug, with daily or near-daily use (defined as 20 or more occasions of use in the past 30 days) rising from 3.5% in 2007 to 5.1% in 2013.
• Nonmedical use of Adderall ranks second among the illicit drugs being used in college, with 11% of college students indicating some use of Adderall without medical supervision in the prior 12 months.
• The next most frequently used drugs are ecstasy (5.3% in the past 12 months of college in 2013), hallucinogens (5%), and narcotics other than heroin, such as Vicodin and Oxycontin (5.4%).

To put the increase in marijuana use in perspective, Lloyd Johnston, principal investigator of the MTF study, notes, "This is the highest rate of daily use observed among college students since 1981—one-third of a century ago. In other words, one of every 20 college students was smoking pot on a daily or near-daily basis in 2013, including one in every 11 males and one in every 34 females" (Wadley).

Mary-Jeanne Raleigh, PhD, director of counseling and testing services at the University of North Carolina at Pembroke (UNCP) and past president of the American College CounselingAssociation, sees reflections of the growing cultural acceptance of marijuana in students' perceptions. "Marijuana is so ubiquitous, students often don't consider it a drug, and rather they see it as a medicinal product," she says. Durham adds that it is incumbent on the clinician to be well versed in the current research and literature on marijuana in order to provide accurateeducation as well as maintain credibility with students.

The Addictions Recovery Model
Depending on the institution, the variety of offenses related to underage drinking and associated behavioral problems, as well as the offenses related to possession of illicit substances, may be handled as violations of a student code of conduct (thus invoking sanctions through an internal judicial affairs process) or alternatively through a legal process. Both are primarily punitive systems.

Raleigh believes colleges have an opportunity to broaden intervention strategies while still holding students accountable for their actions. "Addiction patterns solidify in early adulthood, around ages 18, 19, 20, when students are often away from home for the first time and protective factors in their lives are shifting. Instead of dealing with substance use issues primarily as violations of the student code of conduct or through the legal system, I think colleges would serve students well to incorporate an addictions recovery model into the conduct process."

Research published in Alcoholism: Clinical and Experimental Research supports this approach. In sum, researchers surveyed how campus and local security responded to serious, less serious, and underage alcohol-related incidents both on and off campus. According to an article summarizing the findings, "It was also not typical for these students to be referred to a campus health center to be evaluated for a possible alcohol problem. Rather, students were usually referred for discipline or sanctions to other university officials" (Swartz, 2014).

Raleigh describes the "Be Brave" Recovery Community model at UNCP, which is part of a growing trend at colleges and universities across the country, notably in the University of Texas system. Transforming Youth Recovery, a nonprofit created by the Stacie Mathewson Foundation, accelerates this trend by providing an asset-based model as the basis for building collegiate recovery capacity, as well as grants to institutions to aid in the start-up costs. UNCP is a grantee of Transforming Youth Recovery.

Transforming Youth Recovery
While recovery programming varies across institutions, common components include a licensed alcohol and other drug specialist in the counseling service offering individual and group therapy, peer-facilitated recovery groups, social activities, and housing, as well as an emphasis on service projects. Beyond "substance-free" events, members of recovery communities monitor one another for signs of relapse and mentor each other as they actively confront the challenges of maintaining sobriety in a collegiate environment.

According to Raleigh, "We've spent a lot of money (in higher education) on prevention over the years, and the large-scale efficacy of our prevention work is just not there. Of course, we continue our prevention efforts, but at UNCP, we are not putting all our eggs in the prevention basket. We are expanding our treatment and recovery programs."

Given the complex problems associated with the pervasive use of alcohol, marijuana, and other drugs among young adults, colleges and universities are bound to grapple with best practices in helping students cope with the harmful effects. Multipronged approaches including prevention interventions and treatment resources, as well as effective support for college students in recovery, are integral to a broadening access to a successful college experience for more students.

 — Liza Greville, MA, LCSW, is in full-time clinical practice and a contributor to Social Work Today.

References 
National Institute on Alcohol Abuse and Alcoholism, National Institute of Health. (2015). College drinking. Retrieved fromhttp://pubs.niaaa.nih.gov/publications/CollegeFactSheet/CollegeFactSheet.pdf.

Swartz, J. (2014, July 21). Colleges can be doing more to combat drinking culture, study says.USA TODAY College website. Retrieved from http://college.usatoday.com/2014/07/21/colleges-can-be-doing-more-to-combat-drinking-culture-study-says/.

Wadley, J. (2014, September 8). College students' use of marijuana on the rise, some drugs declining. University of Michigan website. Retrieved fromhttp://ns.umich.edu/new/releases/22362-college-students-use-of-marijuana-on-the-rise-some-drugs-declining.
 

Mental Health Monitor: Promoting Prevention

May/June 2016 Issue

Mental Health Monitor: Promoting Prevention
By Sue Coyle, MSW
Social Work Today
Vol. 16 No. 3 P. 8

In social work, we react to problems by treating them. Treatment has, in many ways, become the focus of much social work. Clinicians and researchers often try to determine how best to address present and past issues. They look at what is and don't look often enough at what will be.

"In general, that's a challenge in the United States," says Jordan DeVylder, PhD, an assistant professor at the University of Maryland School of Social Work. "It is a part of our culture, of how we view health. We are very focused on the idea that you have an issue and then you treat it."

However, that idea leaves out a crucial aspect of social work: prevention. Preventive care can promote physical, mental, and behavioral health. It can save lives and money, but for that to happen, it must first be more prominent part of social workers' training.

"We have to train the workforce to be involved in prevention," says J. David Hawkins, PhD, an endowed professor of prevention at the University of Washington School of Social Work. "We train people to intervene where kids are already enmeshed in problems. That's important. But we also have to provide preventive interventions."

In an attempt to do that and to better highlight the evidence supporting preventive action, "ensuring the healthy development of all youth" has been identified as one of the American Academy of Social Work & Social Welfare's Grand Challenges for Social Work. The Coalition for the Promotion of Behavioral Health has deemed "unleashing the power of prevention" as having the greatest potential to achieve the grand challenge.

Grand Challenges 
What does that mean?

"The Grand Challenges for Social Work Initiative is intended to increase the impact of social work by strengthening the underlying science behind what we do and, in so doing, to make broad and deep measurable changes in society over the next decade. To do so, we will take advantage of the fundamental truth of social work that social relationships and social organizations are among the most influential forces in human experience," explains Richard Barth, PhD, MSW, dean of the University of Maryland School of Social Work and president of the American Academy of Social Work and Social Welfare (AASWSW).

Sarah Butts, MSW, assistant to the president at AASWSW, further explains that the grand challenges model is based on those from other fields, such as engineering. For social work, "The 12 grand challenges and supporting papers emerged from input from the field," says Butts, who staffs the grand challenges initiative and coordinates the work nationally.

"To develop the grand challenges, the AASWSW solicited ideas, including two calls for concept papers and additional outreach to fill gaps. The most promising concepts were selected, papers were further developed, and a list of 12 grand challenges emerged," she says.

The goal of ensuring healthy development for all youth emerged. The key to that challenge? Prevention.

Prevention 
"What's really exciting in the area of youth development is the progress that's been made in our ability to actually prevent behavioral health problems," Hawkins says. "We've learned that there are common risk and protective factors that can predict [behavioral health problems]. And we've also learned that you can change those things and actually prevent behavioral health problems from developing."

Prevention can begin as early as gestation. "[Prevention services] can start during the second trimester of pregnancy," Hawkins says. "There are programs like Nurse-Family Partnership that start when [for example] a pregnant teenage girl who doesn't have a partner or other supports is visited at home by a nurse. Preventive interventions across development through adolescence have been tested and found effective. They work."

DeVylder is currently taking part in research that examines whether schizophrenia and other psychotic disorders can be prevented.

"There is a lot of work being done in hospitals and university-based specialty clinics," DeVylder says. "We work with a very small group of individuals who are adolescents or young adults and are experiencing hallucinations and delusions, though not to the same level of intensity [as an adult with a diagnosis of a psychotic disorder]. These youth are help seeking and, based on the criteria, they're identified as being at high risk for progression to a psychotic disorder.

"It does seem possible to actually prevent the initial onset [of the disorder], based on the evidence we have so far. Psychotherapy, maintaining family supports, maintaining social supports, staying in school, staying in work, maintaining housing, and harm reduction to substance use are a lot of the things that are working for this group," he says.

While the work DeVylder is a part of is still in the early stages of development, Hawkins notes that there are more than 60 evidence-based interventions on Blueprints for Healthy Youth Development, a site aimed at providing a registry of tested and effective programs to be used with families, in schools, and in communities, and these programs are ready to be implemented.

What's more, they work and they save lives and money—music to every social worker's ears. "One of our strong arguments is that preventive interventions not only work but they're [also] more cost-effective," says Jeff Jenson, PhD, the Philip D. and Eleanor G. Winn professor for children and youth at risk at the University of Denver. Together, Jenson and Hawkins were a part of the team that authored "Unleashing the Power of Prevention." Jenson and Hawkins note that mental and behavioral health problems cost the United States approximately $247 billion per year. "If we could reduce those problems by even 20%, as we believe is possible, think of the savings to society," Hawkins says.

"The majority of people in the United States don't realize that prevention is effective. They are not aware of the large number of tested and effective programs that exist for children and families," Jenson says. "We think it's important to shift the paradigm in a way that acknowledges the importance of prevention in our society. Along with that, we think it is key that we fund more programs that offer preventive interventions for young people and families."

Pushing for Prevention 
But why should social workers lead the way in prevention? Why should they shift the paradigm?

"Social workers are trained in fundamental ways to assess problems, assess clients, assess a variety of situations," Jenson says. "Social workers have a presence in so many different ways and are very well positioned to contribute more to prevention practice.

"If we think back to the roots of social work, in the early days," Jenson continues, "it was all about building relationships, understanding community needs—trying to prevent these problems."

In order to do that, social workers need to get involved in the push for prevention. "One way to get involved is to join our coalition," says Jenson, referencing The Coalition for the Promotion of Behavioral Health, which was created to further the prevention work of the grand challenge and comprises social workers and allied colleagues throughout the country. "Our coalition includes task forces that have been established to raise awareness about the effectiveness of prevention, assist states and communities who are interested in increasing preventive interventions, and train students to become skilled in prevention practice and policy," Jenson says.

Involvement in the coalition can and will lead to a sharing of ideas and practices surrounding prevention. "One of the things that I'm hoping is that faculty in schools of social work and other disciplines will offer courses on prevention," Hawkins says. "Kim Bender [an associate professor at the University of Denver] and Valerie Shapiro [an assistant professor at the University of California, Berkeley] are collecting curricula that people are using. If someone wanted to teach a course on prevention, he/she could get in touch with them. They can get you curricula to help you get started.

"If you're integrating something on prevention into a course now," he adds, "share that with us."

For those in the field, Hawkins encourages the use of Blueprints for Healthy Youth Development initiative at the University of Colorado Boulder. "Look at the programs that are on the Blueprints website," he says. "Ask, 'Which of those can I add to my bag of tricks?' If we're successful, it's going to be really important that people have the skills to be able to lead prevention work. Be prepared to do preventive interventions in your community and get the word out about these programs and their effectiveness.

"We have to create demand on the part of the public to say we want to prevent these problems," Hawkins continues. "We don't want to wait until kids get kicked out of schools. We need to have preventive interventions that are effective." We have to, as Hawkins and Jenson denote in the title of their paper, unleash the power of prevention.

For more information on the American Academy of Social Work and Social Welfare and the 12 Grand Challenges for Social Work, visit grandchallengesforsocialwork.org. For more information on evidence-based preventive models/programs, visit www.blueprintsprograms.com.

— Sue Coyle, MSW, is a freelance writer and social worker in the Philadelphia suburbs

Children of People With Serious Mental Illness

May/June 2016 Issue

Children of People With Serious Mental Illness
By Kate Jackson
Social Work Today
Vol. 16 No. 3 P. 24

Many of these children are resilient; others face problems that persist into adulthood, but resources are available for intervention and support.

According to the National Institute for Mental Health, 9.8 million Americans aged 18 or older, or 4.2% of the adult population, are living with a serious mental illness such as schizophrenia, bipolar disorder, or major depressive disorder. Other mental illnesses that may affect parenting and child welfare include obsessive-compulsive, paranoid, psychotic, panic, and posttraumatic stress disorders.

Because two-thirds of females and one-half of men afflicted with serious mental illnesses are likely to be parents, "There's a significant number of individuals with some level of emotional distress who are raising children," says Joanne Nicholson, PhD, a professor of psychiatry at Dartmouth Psychiatric Research Center in The Geisel School of Medicine at Dartmouth University. These parents may bequeath to their children a legacy of physical, emotional, or social impairment or dysfunction that may manifest in feelings of guilt or low self-esteem, instability, and difficulties with employment, socialization, interpersonal relationships, and parenting their own children. Many children of parents with serious mental illnesses are resilient and will not experience these challenges. But for those who do, the problems may persist into adulthood and, without acknowledgement or attention, may have the power to negatively affect many aspects of their lives.

This lingering impact on some of the adult children of people with serious mental illnesses, experts say, has been widely overlooked. A significant portion of individuals with such illnesses and the problems experienced by their offspring often go unrecognized, in part because only a small percentage of the population with these illnesses receive services, and of those who do, a significant percentage are probably not questioned about their parenting status, Nicholson says. Thus, both the children and the parents tend to be underserved.

These issues may be compounded and exacerbated by other factors within the family. "It's important to understand the context of families where one or both parents has a mental illness," says Barbara J. Friesen, PhD, a research professor at the Regional Research Institute for Human Services at the School of Social Work at Portland State University. "These families are often characterized by poverty, may consist of single-parent households, and/or be challenged by conflict and disrupted parental relationships. These contextual factors may be related directly or indirectly to parents' symptoms and/or behavior."

All children are not equally affected. "Some are born more vulnerable than others and some have vulnerabilities that are conveyed by bad economic climate, poor housing climate, many social and environmental conditions, and unsafe neighborhoods," Nicholson says. "There are a lot of factors that contribute to how well people do in general, and having a parent with a mental illness is just another domain of vulnerability," she says.

Wide-Ranging Repercussions 
According to Friesen, the research literature identifies many challenges for the adult children of people with serious mental illnesses. "The older literature focused almost exclusively on problems and was not strengths-based. Older studies looked at rates of mental health and behavior problems and substance abuse, as well as issues such as 'parentification'—role reversal, where children become caregivers of their ill parents. Data sources were usually secondary, not gathered from the adult children themselves, but rather based on agency and clinical records or on studies using service providers as sources. These data, therefore, were biased in the sense that they did not include adult children who had not sought treatment. Major problems identified were higher rates of depression and other mental health problems, higher rates of substance abuse, social adjustment issues, and increased suicide risk in children whose parents committed suicide."

More recent studies, Friesen says, explore the issues directly with the now-adult offspring of people with mental illness. She points, for example, to researchers who synthesized seven qualitative studies using data garnered directly from adult children, identifying 26 key issues sorted into four categories: family relationships, relationships with others outside the family, the emotional repercussions of the parents' illness on the child, and issues related to the illness itself and the associated stigma (Murphy, Peters, Jackson, & Wilkes, 2011). Among the common themes identified by the researchers were the following:
• difficult and confusing parental relationships;
• feelings of abandonment;
• "parentification," or the need to take on the parenting role;
• feelings of isolation;
• lack of understanding and support from nonrelatives;
• difficulty trusting others;
• inability to maintain relationships;
• grief;
• low self-esteem; and
• depression.

In addition to these issues, resentment commonly arises among the adult children of people with serious mental illnesses, triggered, Sherman says, by the parents' resistance or failure to get help, their noncompliance with treatment, and the burden of caregiving. "As the offspring have their own families, they often continue to dedicate a lot of time to caregiving, which can be logistical, such as taking the parent to doctor appointments or attending to financial, emotional, and legal issues," says Michelle Sherman, PhD, an associate professor at the University of Minnesota Medical School and coauthor of I'm Not Alone: A Teen's Guide to Living with a Parent Who Has a Mental Illness. Also contributing to the pressures of caregiving is the fact that individuals with serious mental illnesses experience a higher than average rate of other medical conditions.

Furthermore, many offspring are troubled by concerns for their own children. "They may be afraid that their children will develop serious mental illnesses as well," says Sherman, who adds that the research is clear that offspring are at an elevated risk.

Whether these problems persist throughout life, Nicholson says, depends on a number of variables. "The impact of a parent's illness on a child or young adult varies depending on the nature and severity of the adult's illness; the extent to which the family has stability, resources, and support; and the extent to which the child or adult has internal resources and supports themselves are all factors that go into the equation of how well a person will do," she explains.

Interventions
Interventions provided in childhood may prevent some, but not all, of the difficulties experienced by the now-adult children of people with serious mental illnesses, Sherman says. "There are a number of promising interventions and a few that have a solid research base," Friesen says. "Interventions range from services such as care coordination to family-based interventions and clinical interventions with adolescents, and families also benefit from practical support, such as income assistance, housekeeping, transportation, and recreation. There are some nice cognitive behavioral prevention programs with some follow-up data showing positive outcomes for youth and decreased rates of depression among kids," she adds, pointing, for example, to the work of William Beardslee, MD, at Harvard University.

Falling Through the Cracks 
Also contributing to lack of services for both parents and children is the remaining stigma surrounding mental health issues. But even when stigma is overcome and helpful interventions exist, many offspring never are able to take advantage of services when they are children or later in life. "These are kids whose issues often do fall through the cracks," Nicholson says. "The first problem is that their parents' problems go unrecognized, so their needs also go unrecognized."

Chief among the obstacles to obtaining care for the adult offspring, Friesen says, may be a "general lack of information and understanding that many people with serious mental illness are parents."

And the flip side of that, Sherman says, is that offspring of parents with serious mental illness, regardless of age, often feel invisible. "They're often ignored and no one asks about the impact of their parent's mental illness on them."

Friesen says, "Lack of funding, proven programs, public and policy-maker understanding, and appropriate professional training, and poor coordination between adult and child mental health services," also contribute. Medicaid funding, she continues, "tends to pay only for services for individuals, not for families, although that is slowly changing."

Sherman adds, the "continued division of funding streams and care for adults and kids" is also a factor.

"The way funding streams are organized around identified parents, the medical model of treatment requires that there be an identified parent with a medically necessary condition to justify payment and reimbursement," Nicholson says. While some of the offspring do have diagnosable mental conditions themselves, many do not. "So unless you're a person whose condition has been identified by a credentialed provider and deemed medically necessary by the rubrics and treatment algorithms that are applied, then there are lots of cracks," Nicholson says.
In addition to lack of programs, lack of access to treatment, and financial barriers is lack of awareness by clinicians of the availability and helpfulness of those services that do exist, Sherman says. And even when children do get treatment, she says, "this doesn't ensure the parent will get or stay in treatment, so the burden can continue."

"Parents often are afflicted by many types of illnesses, and we have huge mega-marathons for breast cancer, for example, and lots of awareness of other kinds of conditions," Nicholson says, "but less support for mental health."

On the positive side, Friesen says, there have been some strides forward. She points to "better research information about effective interventions, some decreased stigma about depression, more studies that directly ask children about their lives, and a move toward broader, more holistic interventions in addition to narrowly focused clinical studies," though she adds that the latter are important, too.

The Research Needs
The major limitations to the research, Friesen says, are the use of "second-hand information, only looking at clinical populations, and a general narrow vision of the problems and solutions." Obstacles, she adds, include a lack of specific funding and interested researchers. Program evaluation or effectiveness studies, she says, can't be done when there are no programs. "Reforms are needed to improve coordination between adult and child mental health services. Researchers in other areas in adult mental health—for example, supported employment, case coordination, medication management—could include parenting issues as part of studies," Friesen says. "There's also much to learn from studies of effectiveness of early intervention, either done by professional mental health workers, allied professionals, or in settings such as Head Start and day care."

Social Workers Can Help 
"The good news is that there are lots of opportunities to provide resources and support, so if you don't catch a child, you catch them when they're older," at the individual, family, or communities level, Nicholson says.

It's a ripe field for social workers, Friesen says, "especially since they take a strengths-based biopsychosocial approach and are more likely than others to focus on the whole person and the whole family."

Experts point to the important role social workers have in advocating for and participating in much-needed policy research. "It's a great fit because social workers are trained to think systemically. They embrace and understand the complexity of community and family life and appreciate the context in which people are living their lives, so their training is consistent with the right kind of approach for teasing apart complex sets of relationships, Nicholson says.

Friesen advises interested social workers to become familiar with the recent literature, "especially that coming out of countries where there's more research and more services addressing these issues, such as Australia, Norway, Sweden, and The Netherlands," and to attend conferences addressing the subject.

"Australia and the United Kingdom are far ahead of the United States of America," Sherman says, "and have many great programs and free resources."

Nicholson agrees that other countries and cultures are ahead of the United States in addressing this issue. "In Norway, Finland, and Sweden," for example, she says, "if a parent is diagnosed with a serious physical or mental illness, providers are obligated to inform their children and provide support."

Sherman and Friesen both direct social workers to the website of Children of Parents with Mental Illness in Australia (www.copmi.net.au), which highlights relevant activities, studies, and services. "Take a sabbatical to Australia," Friesen says, "and get involved." Sherman also suggests that social workers become familiar with the Daughters & Sons Initiative (www.dandsinitiative.org/index.php), which has good information about workshops, online podcasts, and more. Memoirs by offspring, she adds, such as Daughters of Madness: Growing Up and Older with a Mentally Ill Mother, by Susan L. Nathiel, PhD, can also help social workers and others understand the experience of living with a parent with mental illness. Others include Growing Up with a Schizophrenic Mother, by Margaret J. Brown, and The Memory Palace: A Memoir, by Mira Bartok.

"This is a massively understudied area and is most deserving of funding, resources, and research. I think we can collaborate with and learn from colleagues in the United Kingdom who are doing this work," Sherman says. "We need to improve our understanding of changing experiences and the needs of adult offspring over time, available resources, and what could be helpful to support them. Sadly, just as their experiences and needs are typically neglected in childhood, they can become even more neglected in adulthood. The potential to empower offspring may benefit not only them and their ill parents but also potentially support their own children/families," Sherman says.

— Kate Jackson is an editor and freelance writer based in Milford, PA, and a frequent contributor to Social Work Today.

Reference
Murphy, G., Peters, K., Jackson, D., & Wilkes, L. (2011). A qualitative meta-synthesis of adult children of parents with a mental illness. Journal of Clinical Nursing, 20(23-24), 3430-3442

PTSD in Today’s War Veterans: The Road to Recovery

July/Aug 2007

PTSD in Today’s War Veterans: The Road to Recovery
By Richard Currey, PA-C
Social Work Today
Vol. 7 No. 4 P. 13

A stunning public health issue of PTSD in today's war veterans is imminent. Mental health professionals must prepare for the tough road ahead.

When former Army National Guard Captain Jullian Goodrum first began experiencing the symptoms of posttraumatic stress disorder (PTSD), he was confused. “I had no idea what was going on. It was as if someone had slipped some sort of bizarre drug into my coffee.” The Knoxville, TN, native found himself haunted by grotesque nightmares and agonizing daytime anxiety. As Goodrum’s symptoms progressed from intermittent and annoying to constant and disabling, he experienced a persistent fatigue and malaise that progressed to a paralyzing depression.

It would ultimately be a civilian psychiatrist who diagnosed Goodrum’s PTSD, underscoring the military’s reticence about combat-related stress and its psychic fallout. Although never an official stance, the Pentagon’s hesitancy to confront and accept what is, in fact, a ubiquitous aspect of combat has been long-standing and detrimental to the health and stability of thousands of service members.

But the times—and both Pentagon and U.S. Department of Veterans Affairs (VA) policies—may be changing. Military doctors and combat medics are better educated about the early triggers for PTSD. Combat stress teams—usually medics with additional training in counseling and psychological assessment—now serve on the ground with combat units. A unique pilot program at Walter Reed Army Medical Center has utilized the skills of social workers in pioneering “whole person” post-deployment care for service members struggling with PTSD and other impacts of war. The VA’s National Center for Post Traumatic Stress Disorder has developed an Iraq War Clinician Guide, now in its second edition. And the VA’s Seamless Transition of Returning Service Members initiative is up and running.

“Seamless Transition is a special program created by the VA and designed to specifically address the needs of veterans who have served in Iraq and Afghanistan,” explains Richard H. Selig, PhD, LSCSW, LCMFT. Selig is program manager and coordinator of the Trauma & Transition Resource Program for the VA’s Eastern Kansas Health Care System, which includes two major VA medical centers in Leavenworth and Topeka, KS. The goal of Seamless Transition, described in Congressional testimony by Robert H. Roswell, MD, under secretary for health for the VA, is straightforward: Deliver the highest level of care in a timely manner.

The challenge imbedded in that 10-word mission statement lies in the execution. PTSD, with its many associated issues, impacts families and communities and is predicted by many to soon be overwhelming.

Old Problem, New Name
The diagnostic category now known as PTSD—309.81 in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition—is, of course, a malady as old as war itself and variable as every war’s political era and the unique geography of combat, be it desert, jungle, or city streets. PTSD has gone by many names through the years, from battle fatigue, shell shock, combat exhaustion, acute situation reaction, and even, in World War I, the clanks. Wherever there has been war, there has been individual psychological devastation and the formidable challenges of recovery. And it is here, in the landscape of recovery, that caregivers work to understand the precarious balance between memory and psyche. For clinical social workers, in particular, there is a point in the near future when combat-related stress disorders will touch virtually every facility, institution, hospital, and private practice in America.

The general principles—and devastating outcomes—of PTSD are well-known to most social workers. PTSD has become something of a household term in the last decade, and whether related to combat, an accident, or some other trauma, the results are similar: anxiety, hypervigilance, and impulsive, sometimes violent, behavior undercut by depression, substance abuse, chronic unemployment, emotional numbness, homelessness, and suicide. Recent research points to more than emotional distress at the core of the phenomena, as biochemical pathways are increasingly implicated in the behavioral changes that PTSD generates. As mounting research and collective clinical experience confirms that PTSD is not simply an affliction of battered and limping psyches but a neurological disease as well, the coming national burden of combat-related PTSD was clarified, ironically, by the Army itself.

Looking at mental health problems in veterans of Iraq and Afghanistan, Army psychiatrist Charles Hoge, MD, and his colleagues at the Walter Reed Army Institute of Research published in 2004 what is now regarded as a landmark study (Hoge, C.W., Castro, C.A., Messer, S.C., et al. [2004]. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med, 351 (1): 13-22).

The Hoge study noted that more than 80% of soldiers and Marines had experienced at least one firefight, with survey respondents reporting “a very high level of combat experiences, with more than 90% reporting being shot at, a high percentage reporting handling dead bodies, knowing someone who was injured or killed, or killing an enemy combatant.” As many as one in six surveyed after returning from Iraq suffered major depression, generalized anxiety, or met formal diagnostic criteria for PTSD.

These observations reflect a combat force exposed to multiple stressors that could far exceed anything seen in recent conflicts. This guarantees a generation of veterans whose psychological needs will trump anything the nation’s healthcare providers have faced in the past. With other subsequent data accruing, it is now generally understood that a stunning public health issue of PTSD is in the offing. As if that were not disturbing enough, the bad news, in the opinion of Matthew Friedman, MD, PhD, director of the VA’s National Center for Post Traumatic Stress Disorder, is that “the [Hoge] study underestimated the prevalence of what we are going to see down the road.”

The Hoge study received widespread media attention, rare for a scholarly article published in a journal devoted to research and clinical medicine. But the study spoke to something else—a national concern that transcends statistics about a particular group of combat soldiers. These soldiers, much like those of the Vietnam era, are fighting an increasingly unpopular war. Among the many lessons of Vietnam, one appears to have stayed with us: A war may lose political support, but we cannot abandon that war’s veterans. The emerging challenge for caregivers is recognizing the clinical variations of PTSD, knowing how to address the needs of the veterans of Iraq and Afghanistan, and becoming familiar with resources and programs. As the nation’s eyes and hearts turn toward our veterans, these demands will be particularly felt among clinical social workers, who will inevitably see and manage a significant percentage of postdeployment and veteran cases.

A Devastating Detour
Goodrum enlisted in the Navy and served aboard a ship during the first Gulf War. After leaving the Navy to attend college, he realized he missed the order and structure of military life. With an undergraduate degree completed, he returned to uniform, this time as an Army National Guard officer.

“I looked forward to a career,” he says. “I had every reason to think this is where I could make my best contribution in life.” As a platoon commander in Iraq in 2003, Goodrum led security forces tasked with protecting convoys along unprotected (and often unmapped) highways in the interior of Iraq. Despite desert standoffs with insurgents, frequent mechanical breakdowns in hostile territory, attacks on his convoy, and motivating an underequipped, frightened, and stressed-out platoon, Goodrum aimed to do his job, complete his tour, move on to another assignment, and carry on with his career.

It was not to be. Goodrum returned to the United States on other military duties but says he soon found himself in trouble. “I was coming apart at the seams. There were the dreams, the edginess, the constant sense that I had something to fear—as if something or somebody that meant me harm was just around the corner. My mind was no longer my mind. I was going over a cliff,” he explains.

There had been a time, however, that Goodrum remembered seeing himself as invincible, at least psychologically. This attitude is not unusual; indeed, it is virtually a requirement of military service. Many young soldiers imagine that the rigors of battle will be tough but tolerable. They believe—and the military has traditionally institutionalized this belief—that only “weaker” comrades will succumb to some form of PTSD.

This attitude toward the psychological impact of combat hearkens back to an earlier time, exemplified by a notorious episode in World War II when Gen George S. Patton publicly derided—and slapped—a soldier suffering from what we now know was PTSD. Although Patton was compelled to apologize, his apology was more a public relations maneuver than a reflection of official policy. And while neither the Pentagon nor VA have ever formally repudiated PTSD or officially refused to treat affected veterans, an informal perception has long held sway that PTSD is a failing among an unstable few “bad apples.”

Many veterans—Goodrum among them—are eager to correct this misconception. And one way to do so, Goodrum believes, is providing more training, education, and professional support for social workers, psychologists, and psychiatrists throughout the military and VA systems. “First, we need to understand that PTSD can happen to anybody. Second, it’s more common than we think. Consider my case: I was turned away by the Army’s medical system. Turned away or ignored. All the while, my PTSD was brewing unchecked. I’m sure my situation is not all that unique, which suggests a broken system that dishonors all Americans, not just those of us who happened to serve. And, I say, if it’s broke, let’s fix it,” he says.

This is precisely what’s happening at the VA, illustrated in the work of Selig, program manager for, in military parlance, OIF (Operation Iraqi Freedom) and OEF (Operation Enduring Freedom) services. “I oversee all Seamless Transition activities,” Selig says, “along with coordination of care and services for all OIF/OEF service members and veterans treated at our facilities.”

In that role, Selig also oversees a range of clinical interventions for reservists and National Guard veterans. “By virtue of a special memorandum of understanding between the VA and the Kansas Army National Guard, we provide interventions and care along a continuum from predeployment, deployment, and postdeployment. While we certainly treat PTSD and related disorders, the emphasis of this program is to begin to intervene with the soldier and family before deployment in order to provide training in the skills and techniques necessary to improve emotional resiliency and strength. We want to improve personal resources in an attempt to help reduce or mitigate the effects of stress—before a soldier ever goes into action.”

Predeployment counseling is, in itself, innovative, but there is another new and complicating element in this war. “The ‘signature’ injury of this war,” says Selig, “is traumatic brain injury (TBI).” This injury results from a kind of mega-concussion, commonly seen in survivors of explosions. TBI-affected individuals can be as debilitated as stroke survivors and must relearn walking, speaking, and simple motor skills. Veterans with concurrent TBI and PTSD are increasingly common, compounding the complexity of care and long-term alternatives. Recognizing that most wounded veterans will not return from the front with only PTSD, “the VA has established a Polytrauma System of Care in order to specifically address issues related to lasting injuries due to polytrauma and TBI,” according to Selig. “The VA polytrauma system is organized around an interdisciplinary model of care delivery. Specialists from several medical and rehabilitation disciplines work together to develop an integrated treatment plan for each veteran.”

Selig says the VA is improving coordination of care for polytrauma veterans with concurrent PTSD by assigning a social work case manager to every patient treated at the polytrauma centers. This case manager coordinates the continuum of care; acts as a point of contact for emerging medical, psychosocial, or rehabilitation problems; and provides psychosocial support and education. “This is all augmented via a new telehealth network that links facilities and ensures that polytrauma and TBI expertise are available throughout the entire system of care,” Selig says.

“In regard to PTSD alone, the VA has over 200 specialized hospital-based PTSD programs,” Selig says. “Here at the Eastern Kansas Health Care System, we have both an inpatient and outpatient PTSD unit in addition to our specialized treatment program designed for reservists and National Guard personnel. And the VA has mandated additional funds, resources, and staff to meet the growing mental health needs of OIF/OEF veterans. Twenty-three new community vet centers have been added to the VA system, and every new enrolling veteran is screened for PTSD as well as TBI.”

Selig agrees that the number of vets in need of mental health services (or related assistance) will rise. “As the incidence of multiple deployments becomes increasingly common,” he says, “soldiers are subjected to longer and multiple tours of duty and are clearly at risk for higher incidences of stress-related disorders.”

But Selig also emphasizes that with help, time, and an organized care management system, most vets confronting PTSD or polytrauma can recover. Goodrum confirms that, one year or more from being “essentially a madman,” he is working his way back home in both body and spirit, relocating heart and soul. If the road has been treacherous, he sees new hope and possibility in the days ahead.

When social workers find themselves working with combat veterans, Selig emphasizes that essential knowledge of and treatment skills in PTSD, as well as TBI, are critical. “But beyond that,” he says, “I would draw on our profession’s history and tradition of assessing and interfacing with an individual in the context of systems—the structure of a person’s life and interactions at familial, community, and organizational levels.” Selig says that combining all these ways that ensure a complete and comprehensive view of an individual is what social workers do, and the multifaceted effects of PTSD are arenas where the skills of social workers are particularly appropriate.

Selig says, “Combat not only affects an individual; it affects everything in that person’s life, everybody they know, everybody that cares about them. Effective treatment and transition from these experiences will require the full and complete understanding of combat and its sequelae.”

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

What To Look For and How to Help
Fred Bush, LMSW, is the returning veteran behavioral care coordinator at the Syracuse (NY) Veterans Affairs (VA) Medical Center. “Combat stress is as much a community problem as it is an individual issue,” Bush says. “Social workers inside the VA system are passionate about getting the word out about combat-related polytrauma. If we fail to educate providers and raise awareness about this issue, the burden on social service agencies and individual caregivers will be shocking.” Bush offers several key points for social workers who are or will soon encounter combat veterans in their practices, including the following:

• Readjustment issues are expected, but if they persist, returning soldiers should seek help from a mental health professional.

• Acute behavioral changes such as excessive drinking, social isolation, or elevated levels of anxiety signal a need for intervention.

• Soldiers returning from combat tend to sleep lightly for some time, but continued problems sleeping or repeated bad dreams are signs that help is needed.

• Marital readjustment periods after being in a war zone are common. Returning spouses should feel needed and useful and reclaim responsibilities they used to perform, even if the spouse who stayed home has been doing them.

• Returning soldiers need at least one person to talk to about their experiences. Family and friends should make it clear, without excessive nudging or pressure, that they are available and willing to listen. Some soldiers will think they should not share accounts of dangerous or disturbing situations they faced, fearing such stories will unnecessarily disturb friends or family members. It is important to share these stories with the right person and reach out for support.

• Returning soldiers may have been near explosions and may have undiagnosed brain injuries. Unusual, erratic, unexpected, or “out-of-character” behavior could be a red flag indicating a need for intervention.

• Even if you disagree with the politics surrounding the war, be sensitive when talking to returning vets. A “thanks for your service” goes a long way.

For more information about readjustment issues faced by returning soldiers or to find out how to get help, call the Veterans Administration’s TelCare information line at 888-838-7890.

— RC