Military combat has always taken a toll on service members. Being vigilant, stoic and protective of fellow soldiers are invaluable, life-saving traits during war. But the stress of remaining on high alert has physiological and psychological effects that can make life outside of combat difficult for those returning and challenging for their families.

Service members returning from combat in Iraq and Afghanistan, however, have the advantage of a system tuned in to their needs for readjusting to civilian life, one in which social workers are at the forefront.

New dynamics. Service members who have been deployed in Operation Enduring Freedom (OEF) in Afghanistan and Operation Iraqi Freedom (OIF) are facing unique experiences.

"The nature of this war is vastly different from other wars," said Rick Selig, a social worker working for the Department of Veterans Affairs (VA) as the program coordinator of the OIF/OEF Trauma and Transition Resource Program in Topeka. (Selig was recently featured in a print advertisement that is part of NASW's National Social Work Public Education Campaign.)

"There is a need for the clinical social worker out there to be very careful about equating what we know from our work with Vietnam veterans to this population," Selig said.

"First of all, the demographics are markedly different," he explained. "Nearly 60 to 70 percent are married, and I think upwards of 12 to 15 percent are married to another service person. The service personnel is more varied in age and in gender."

Selig also pointed out that more than 40 percent of the ground troops are National Guard and Reserve members. "These folks are, in the true sense of the word, civilian warriors," Selig said.

And, he said, many of the service members in Iraq and Afghanistan have been deployed multiple times, which can create additional stress. "When National Guard folks come back, they've been back maybe six or eight months or a year and they haven't worked through the transition from the first deployment, they go back. This is unprecedented in our history."

Social worker Hilda Heady noted that in these wars, a high number of rural service members and women have been exposed to combat. Heady is the associate vice president for rural health at the Robert C. Byrd Health Sciences Center at West Virginia University and a former president of the National Rural Health Association.

Heady estimated that by 2012, 15 percent of veterans in the United States will be female, many of them African American. "We know the military has a disproportionate representation of minorities and a disproportionate representation of rural people," she said. "Whatever issues we need to be concerned about for minorities and women who are rural are exacerbated" among veterans.

Effects of combat. "You can't be in a war zone and expect not to be affected," said Kristin Day, deputy director of social work services for the VA. "Coming home, all the things you've done [during combat] are not going to be working well for you. Driving fast, which can be life-saving in Baghdad, is treacherous here at home.

"If you're struggling, having trouble sleeping — those are normal responses to trauma," Day said.

Selig explained that the nature of the combat in Iraq is different. "It's almost exclusively city war fighting. . . . Your enemy is fighting a very unconventional type of warfare, which makes it hard to do an adequate job of fighting yourself.

"That contributes to the escalation of the situational stress states because the typical deployed soldier never gets a reprieve. . . . The human body is remarkably resilient and adept at handling short-term crises and traumatic experiences. It isn't very good at handling that in an unremitting, chronic environment," he said.

In his work, "we place great emphasis on trying to reframe [reactions when returning from combat] as a normative response to high stress and a chronic stress state," Selig said. "It isn't a sign of weakness; it's a function of being in a chronic stress state."

There are also significant physical effects of these wars that social workers should be aware of, Selig added. "Because of the up-armored vehicles and the ceramic vests and the 90-pound armor these guys wear, more are surviving with their injuries," he explained.

Because of the higher survival, "the percentage of those returning with severe injuries such as traumatic brain injury, amputations and burns has skyrocketed," he said. "Social workers are going to have to be prepared to work with people who have those traumatic brain injuries and burns."

A proactive approach to help. While the combat new veterans have faced is different from previous wars, their experiences upon returning are also different.

"Society is embracing the women and men returning, and their families, in a very different way than we did with Vietnam veterans," Heady said. "The way Vietnam veterans were treated has complicated things every time they go in to try to get services. . . . It's very different with this current war."

Jill Manske, director of social work services at the VA, explained that the VA is working to ensure that veterans are informed about services that are available. "Rather than sitting back passively, we're being proactive in going to them."

Manske said that in August 2003, a VA social worker was assigned to Walter Reed Army Medical Hospital. Initially, she said, the medical staff was not sure why the social worker was there. But, Manske said, "it soon became clear that what the social worker was doing was really valuable."

Soon, a second VA social worker was assigned to Walter Reed, and currently social workers are on the staff at nine major military hospitals. These staffers talk with service members and their families about VA health care services, help with discharge planning and assist with transfers to rehabilitation and treatment centers.

The VA also has social workers placed in its Vet Centers, which provide readjustment counseling and outreach services to all veterans and their families at no cost. These social work services are part of the VA's Seamless Transition Program, which is designed to help returning service members quickly access the services and programs they need.

The VA has also worked to ensure that its staff has up-to-date and accurate information about the services available to veterans. To this end, the department has produced several videos and has offered satellite broadcasts to its staff to provide training for employees about the experiences and needs of returning service members.

Selig said his work with veterans in his VA Medical Center is centered around the experiences they faced in combat and the military training they received. He uses a variety of techniques, including cognitive behavioral therapy, marital and family therapy, as well as a heart-rate variability therapy that helps people control their heart rhythms and anxiety.

The Walter Reed Army Institute of Research Land Combat Study Team has developed a program for the military called Battlemind Training. The training is intended to help soldiers and their leaders develop skills and mind-sets that will prepare them for battle.

The Battlemind Training skills are "extremely useful and absolutely necessary for survival in harm's way and combat," Selig said. "But to bring those sorts of skills back and continue to use them at home isn't healthy. Things like aggressive driving: Over in the 'sandbox' you drive fast, you alter your pattern, you're hyper-vigilant for anything in the road or at the side."

But, he pointed out, "being hyper-vigilant at home to that degree is going to create some difficulty."

Selig's program uses Battlemind Training to frame some of the experiences that returning service members may be facing in which combat-ready behavior must be changed. For example, while "controlling your emotions during combat is critical for mission success and quickly becomes second nature," at home "you may be seen as detached and uncaring. . . . Displaying emotions is not unmilitary and does not mean you are weak."

The social worker's role. Social workers should become aware of the impact of combat on veterans. Day and Manske said that because traumatic brain injury is so pervasive, it is important to ensure that providers are aware of symptoms.

"A lot of time it is misdiagnosed as a mental health problem," Manske said. "The lack of impulse control and other symptoms might be confused with a psychiatric disorder. . . . We want to train social workers to screen out the [service members] who have a head injury and send them for neurological testing."

For social workers not working directly with the VA, Day recommended being aware of the impact that combat can have not only on returned service members but also on their families. "Ask if somebody is a veteran or somebody in their family is a veteran," she said.

Manske also pointed out that social workers should be mindful of the number of returning service members who are women. Social workers "need to ask men and women, not only did you serve, but did you have a close family member who did."

Manske and Day also recommended that social workers familiarize themselves with the health care services the VA can offer service members. "If they know where points of care are and have contact with social workers, they can make referrals or consult" with VA staff members, Manske said.

"The trend for social workers [will be] to do more proactive education and intervention," Selig said. "There is a lot of room for post-deployment growth where you continue to talk about and address ways families and soldiers can make that transition back and grow from that experience.

"Social workers are in a position, because of our training and frame of reference, to be there at the cutting edge of offering services that are truly holistic and growth-producing for the soldiers and their families," Selig said.

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