Military Social Work: Opportunities and Challenges for Social Work Education

Abstract

Military social work is a specialized field of practice spanning the micro-macro continuum and requiring advanced social work knowledge and skills. The complex behavioral health problems and service needs of Iraq and Afghanistan veterans highlight the need for highly trained social work professionals who can provide militarily-relevant and culturally-responsive evidence-informed services. Responding to the military behavioral health workforce and service needs of recently returned veterans presents both opportunities and challenges for military social work education. This article discusses the rationale for a military social work specialization, the need for military social work education, and opportunities and challenges for social work education. An integrated model of intellectual capital is proposed to guide strategic planning for future military social work education.

Over a decade of war in Iraq and Afghanistan has raised concerns about the behavioral health problems and treatment needs of Operations Enduring Freedom, Iraqi Freedom, and New Dawn (OEF/OIF/OND) veterans. This “Long War” characterized by a high operations tempo, a dynamic battlefield, multiple deployments, short dwell times, and an unprecedented utilization of women, National Guard, and Reserve forces has resulted in unique individual, family, organizational, and community stressors, as well as co-occurring behavioral, psychological, and physical conditions among recently returned veterans—many who experienced intense combat and remain in military service (Armed Forces Health Surveillance Center, 2013; C. W. Hoge et al., 2004; C. W. Hoge et al., 2008; C. W. Hoge, Terhakopian, Castro, Messer, & Engel, 2007; Seal, Shi, Cohen, & et al., 2012; Tanielian & Jaycox, 2008). Posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI) are signature injuries of these wars and often co-occur with chronic pain, substance use, depression, and physical injuries (Afari et al., 2009; Grieger et al., 2006; C. W. Hoge et al., 2004; C. W. Hoge et al., 2008; Larson, Wooten, Adams, & Merrick, 2012). Consequently, OEF/OIF/OND veterans have complex physical and behavioral health problems and treatment needs requiring multidisciplinary case management, care coordination, and evidence-informed interventions.

Behavioral health problems among military personnel have been linked to individual and family psychosocial difficulties and decreased military readiness. Among OEF/OIF/OND veterans, behavioral health problems have been associated with suicide, absenteeism, reduced work productivity, risky behaviors, interpersonal violence, child maltreatment, marital discord, criminal activity and separation from military service (Hawkins, 2009; C. W. Hoge, Auchterlonie, & Milliken, 2006; Newby et al., 2005; Rentz et al., 2007). A greater than 90% survival rate for serious injuries among OEF/OIF/OND veterans (Holcomb, Stansbury, Champion, Wade, & Bellamy, 2006) has resulted in post-deployment physical and psychological injuries that have transformed the lives of these veterans, their families, and communities. Consequently, various psychosocial, rehabilitation, and behavioral health services as well as skilled multidisciplinary service providers are needed to assist OEF/OIF/OND veterans and their families with post-deployment reintegration and disability accommodation.

Although post-deployment health problems have received significant attention, the majority of deployed military personnel are resilient to deployment stressors or have low levels of posttraumatic stress symptoms that resolve over time (Bonanno et al., 2012; Meredith et al., 2011; Olatunji, Armstrong, Fan, & Zhao, 2014; Pietrzak et al., 2010; Pietrzak, Johnson, Goldstein, Malley, & Southwick, 2009; Wooten, 2012). Resilience among military service members and their families is associated with increased military readiness, and thus, a number of military organizations and programs have been developed to increase pre-deployment and post-deployment resilience (Bowles & Bates, 2010; Casey, 2011; U. S. Department of Defense, 2011b). Therefore, providing resilience-enhancing and behavioral health services to OEF/OIF/OND veterans is a priority and significant public health focus for the Department of Defense (DoD) and Department of Veteran Affairs (VA) organizations and systems of care.

Unlike previous wars, the DoD and VA have coordinated responses to the behavioral health needs of OEF/OIF/OND veterans and their families that include new and reformed health, disability, and social policies (U. S. Department of Veterans Affairs & U. S. Department of Defense, 2009, 2010, 2013; U. S. Government Accountability Office, 2012; U.S. Department of the Army, 2009b); enhanced comprehensive health surveillance including pre-deployment and post-deployment assessments (Hartman, Wolfson, & Yevich, 2004; U. S. Department of Defense, 2011a); seamless patient-centered care (U. S. Government Accountability Office, 2006a); multidisciplinary care coordination (U. S. Department of Defense, 2009); and pre-deployment and post-deployment resiliency programs for service members and their families (Casey, 2011; Murphy & Fairbank, 2013; U. S. Department of Defense, 2011b). These policies and programs provide service members and their families with strengths-based prevention; screening, brief intervention, and referral to treatment (SBIRT); and multidisciplinary service options involving collaborations among military, veteran, and community agencies (Beardslee et al., 2013; Beardslee et al., 2011; Gibbs & Olmsted, 2011; Larson et al., 2012; Lester et al., 2011). Within DoD, VA, and community agencies, social workers have critical roles in behavioral health service provision to OEF/OIF/OND veterans and their families, and thus, need evidence-informed training and education about how to most effectively perform assessments and implement evidence-based interventions that are militarily relevant. Focusing on Iraq and Afghanistan veterans who remain in military service after their deployments and later transition to veteran status, this article discusses the rationale for a military social work specialization, the need for military social work education, and opportunities and challenges for social work education. An integrated model of intellectual capital is proposed to guide strategic planning for future military social work education.

WHY A MILITARY SOCIAL WORK SPECIALIZATION?

Military social work is a specialized practice area that differs from generalized practice with civilians in that military personnel, veterans, and their families live, work, and receive health care and social benefits in a hierarchical, sociopolitical environment within a structured military organization. The complexity of the military context is broad and varied. Broad in that there are five branches of military service with distinct, but sometimes overlapping missions (e.g., national security) that selectively recruit healthy, young adults who are systematically indoctrinated and socialized into military organizational culture during basic training (Ramsberger, Wooten, & Rumsey, 2012). Varied in that military personnel, veterans, and their families have different affiliations (e.g., Active, Guard, Reserve, retired, discharged) with military and veteran organizations that determine their entitlements to means-tested benefits and services. For instance, active duty service members are entitled to free military health care and upon retirement are entitled to veterans’ health benefits and services. National Guard and Reservists, on the other hand, are not entitled to free military health care unless they are injured while on military duty, activated for active duty, or mobilized for a military operation. National Guard and Reservists may qualify for veterans’ health benefits if they have deployed in support of a combat operation—designating them a combat veteran.

Military service and deployments also result in occupational hazards that can expose military personnel and their families to individual, family, and environmental stressors that may differ from civilian populations. Military service is characterized by frequent relocations, putting mission first over family responsibilities, high work demands, and potentially traumatic events (e.g., military sexual trauma, gender and racial discrimination, training accidents). Military deployments can result in combat exposures, serious injuries, risk for substance use, mental and physical health problems, war-related traumatic events (C. W. Hoge et al., 2004; Jacobson et al., 2008; Milliken, Auchterlonie, & Hoge, 2007), as well as the disruption of established family roles, responsibilities, and dynamics.

Summarily, what makes military social work a specialized field of practice are the high work performance, personal demands, standards order and discipline, occupational hazards, and organizational culture and climate that distinguish military service from civilian occupations. Additionally, the DoD has multiple conflicting roles in the lives of service members and their families that includes employer, health care provider, and provider of food, clothing, housing, and subsistence. Furthermore, military occupational hazards in voluntary or conscripted service to one’s country could result in knowingly sacrificing one’s life for love of country and/or comrades. Military members are also held to high standards of order and discipline, and make national and international sociopolitical statements by merely wearing a U. S. military uniform. Social workers practicing with military and veteran populations need to be aware of these military organizational and cultural differences, how they influence access and adherence to care, and care coordination between military, veteran, and civilian organizations. Considering the complexity of military organizations, occupational hazards associated with military service, and the impact of military-related stressors on individuals and families, a systematic and coordinated method for increasing the behavioral health workforce trained in military social work is needed. Formalized military social work coursework, certificates, and specializations can provide a structured educational context in which to educate and train future military social work practitioners. A rationale for this pedagogical advancement is explained below.

THE NEED FOR MILITARY SOCIAL WORK EDUCATION

Recent reports (Institute of Medicine, 2012; National Association of State Alcohol and Drug Abuse Directors, 2009; U. S. Government Accountability Office, 2006b) indicate that substance abuse is a public health crisis within the DoD and that there is a critical need for more licensed behavioral health professionals to treat military service members, veterans, and their families. Prior research (Cukor, Spitalnick, Difede, Rizzo, & Rothbaum, 2009; Lester et al., 2011; Monson, Fredman, & Taft, 2011; Murphy & Fairbank, 2013) has also identified multiple evidence-informed interventions for military and veteran populations which facilitates effective treatment referral and intervention. However, the knowledge needed for effective military social work practice is complex, multidimensional, and spans the micro-macro continuum. Most evident for social work professionals may be the comprehensive and multidisciplinary programming implemented by the DoD and VA in response to the resiliency and behavioral health care needs of recently returned veterans. Select DoD and VA programming include the Yellow Ribbon Program (U. S. Department of Defense, 2011b), Warrior Resiliency Program (Bowles & Bates, 2010), and the VA Office of Seamless Transition (U. S. Government Accountability Office, 2006a).

Micro military social work

Effective micro practice in the military context requires social work professionals to understand military culture and subcultures (e.g., Special Forces, pilots, infantry), the life-stage and developmental influences of basic and advanced military training; the multidimensionality of vulnerability, risk, and resilience associated with military service and deployments; how pre-military experiences impact military and deployment-related outcomes; empirical evidence regarding the behavioral manifestations, comorbidities, and evidence-based treatments for combat-related PTSD compared to PTSD in civilians (Blount, Cigrang, Foa, Ford, & Peterson, 2014; Chaison, Dunn, & Teng, 2010; Harb, Thompson, Ross, & Cook, 2012; Stander, Thomsen, & Highfill-McRoy, 2014); and unique barriers to care related to stigma and potential negative military career implications (Ben-Zeev, Corrigan, Britt, & Langford, 2012; Dickstein, Vogt, Handa, & Litz, 2010; Greene-Shortridge, Britt, & Castro, 2007; Kim, Thomas, Wilk, Castro, & Hoge, 2010). Military indoctrination, socialization, training, and unit cohesion influences on vulnerability, risk, and resilience are also essential. When working with military populations, social workers need to understand how physical symptoms and psychiatric diagnoses may affect military career progression, security clearances, military medical reviews, fitness-for-duty evaluations, disability ratings and compensation, and separation from military service. Knowledge and training in evidence-based interventions for individuals diagnosed with PTSD, mood, and other anxiety disorders is also required. It is also vital that military social workers understand the resiliency-enhancing aspects of the military lifestyle and how these strengths play a role in treatment planning, adherence, and outcomes.

Mezzo military social work

Mezzo practice in a military context involves understanding the individual service member as a part of a family system and military unit in military organizations, the transactions between those systems, and deference to military missions over the needs of the family system, which may significantly differ from work-family conflicts in civilian families and employment settings (See Wooten, 2013). Military family practice also involves understanding the impact of military organizations and military service obligations on family systems, subsystems, and non-military members within those systems. Assessment of the influence of the military context on the developmental milestones and life stressors of military children and adolescents is also critical. Intervening with military units involves understanding unit readiness, cohesion, and camaraderie; recent deployments and combat exposures; collective experiences of war-related trauma; the individual and group dynamics between leadership and subordinates; and unit climate regarding gender, diversity, stigma, same-sex partners, immigration status, and military families. Evidence-based family and unit-level interventions are also important for maintaining family and unit cohesion, post-deployment reintegration, and resilience to military, deployment, and life stressors.

Macro military social work

At the macro level, social workers practicing in a military context must effectively assess, advocate, and intervene on behalf of military personnel and their families within a highly structured, hierarchical organization that employs, sustains (e.g., provides housing, healthcare), and trains warfighters. Military rank defines socioeconomic status and upward mobility in the military, and social workers must understand how “rank rules” by influencing the social status and behaviors of military personnel and their families on military installations, in government and community agencies, and in the larger military and sociopolitical context. Military organizational culture and climate factors are associated with psychological and social stigma regarding help-seeking behaviors (Britt, Greene-Shortridge, & Castro, 2007) and understanding how the military context impacts military and veteran health system help-seeking is critical for effective outreach, advocacy, and service provision. To be change agents in the military context, social workers new to military social work practice need advanced training and education to better understand the provision of evidence-informed services and evidence-based interventions to individuals, groups, families, and communities affiliated with military and veteran organizations and how access and barriers to care, care coordination, and quality of care are influenced by defense and social policymaking within multiple government, civilian, and military organizations and systems of care.

Guidelines for military social work

The Council on Social Work Education (CSWE, 2010) and the National Association of Social Workers (NASW, 2012) outlined advanced practice behaviors and standards of care, respectively, for effective military social work practice. Both provide a foundation for the development of innovative pedagogical and field placement models to: (1) educate a behavioral health workforce trained in military social work practice and (2) integrate evidence-informed interdisciplinary practice models into military social work education. CSWE and NASW guidelines also inform the operationalization of military-related foundation and advanced knowledge for military social work curriculum development and continuing education programs. In this discussion, foundation knowledge in military social work refers to the cultural, organizational, and contextual knowledge social workers need to understand and intervene in the social environment in which military members and their families live, work, and receive services; and the sociopolitical climate and mandates that influence help-seeking behaviors, access and barriers to care, and benefits and services offered by military and veteran systems of care. Advanced knowledge refers to the practice knowledge and expertise informing the development of clinical practice behaviors needed to provide evidence-informed assessments and interventions most effective for military-related problems, deployment stressors, posttraumatic stress reactions, post-deployment reintegration, and resilience.

Operationalizing foundation and advanced military social work knowledge and skills builds upon CSWE and NASW guidelines by identifying specific knowledge, skills, and personal characteristics (i.e., attitudes, values, and traits; Marrelli, Tondora, & Hoge, 2005) that facilitate the acquisition of militarily-relevant, culturally-responsive practice behaviors and adherence to evidence-informed standards of care. Broad categories of foundation military social work knowledge include an understanding of military and veteran cultures, the military deployment cycle, potential ethical dilemmas, the application of theories and conceptual frameworks to the military context, and DoD and VA policies. Broad categories of advanced practice knowledge include the ability to assess vulnerability, risk, resilience, coping strategies, and social support in the military context; applying knowledge of differential clinical presentations and behavioral manifestations in military populations; and evidence-based interventions to effectively intervene at the individual, family, community, and organizational levels to address military service and deployment-related health problems. Additional advanced practice knowledge includes the ability to respond verbally and in writing to Congressional, governmental (e.g., Governmental Accountability Office, DoD Inspector General), and military leadership inquiries regarding the care and well-being of military personnel, veterans, and their families; and the ability to select and modify clinical and preventive interventions for effective military social work practice. Table 1 lists select foundation and advanced military social work knowledge and skills to facilitate competency modeling for military social work practice (See M. A. Hoge, Tondora, & Marrelli, 2005; Marrelli et al., 2005).

Table 1.

Foundation and Advanced Practice Knowledge for Military Social Work Education

FOUNDATION KNOWLEDGE	ADVANCED PRACTICE KNOWLEDGE
Similarities and differences among military service organizations (Army, Navy, Air Force, Marines, Coast Guard), military service components (i.e., Active, Guard, Reserves), military culture, role of veteran service organizations (e.g., Veterans of Foreign Wars, American Legion, Order of the Purple Heart)	Appropriate use of interview and self-report measures for PTSD, depressive symptoms, major depressive disorder, TBI, substance use disorders, sleep problems; suicide, domestic violence, parental stress, and child maltreatment risk in military personnel, veterans, and their families
Social workers’ roles within DoD and VA systems of care, and community organizations serving military personnel, veterans, and their families; Role of military and VA chaplains in addressing war trauma, military-related moral conflicts, survivor’s guilt, and grief	DSM-V diagnostic criteria and differential diagnoses for PTSD, major depressive disorder, substance use disorders, generalized anxiety disorder, panic disorder, obsessive compulsive disorder, adjustment disorder (and applicable specifiers)
Special populations (Special Forces, pilots, dual military families) and vulnerable groups in military service; Race/ethnicity, class, gender disparities, sexual orientation, and immigration status during military service; Disability, rehabilitative and special needs in military families	Sequential, concurrent, and integrated empirically supported treatments for comorbid PTSD, major depressive disorder, substance use disorder, other anxiety disorders, behavioral (suicidal ideation, domestic violence, child maltreatment) and psychosocial (marital, family, occupational) problems
Ability to describe the military deployment cycle; military service, deployment, and combat stressors; pre-deployment and post-deployment health assessments; post-deployment reintegration	Familiarization with the differential effectiveness of empirically supported treatments for combat-related disorders, and conditions associated with military service, deployments, and military sexual trauma
Knowledge of the historical perspectives on war trauma, combat stress, posttraumatic stress reactions, and posttraumatic stress disorder diagnosis	Specialized training in psychosocial and vocational rehabilitation, cognitive behavioral treatment, cognitive processing therapy, and prolonged exposure
Vulnerability, risk, resilience, and protective factors associated with military service and deployments	SBIRT in DoD and VA health care systems, substance abuse prevention and Family Advocacy programs
Physical and mental health conditions and functional impairment associated with deployment stressors and combat exposures	Familiarization with the neuropsychology and psychopharmacology for deployment and combat-related disorders
Military and deployment experiences and risk factors for National Guard, Reservists, and their families; Role of the Directors of Psychological Health in the National Guard/Reserves and Family Advocacy, Victim Advocate, and New Parent Support Programs	Familiarization with screening, early identification, and risk assessment for suicide, prescription drug misuse, alcohol abuse, child maltreatment, domestic violence, and risky behaviors in military personnel, veterans, and their families
Knowledge of the similarities and differences between the DoD Military Health System, the Veterans Health Administration, Veterans Benefits Administration, Vet Centers, and Community-Based Outpatient Clinics	Familiarization with the role of social workers in the integration of behavioral health models into DoD and VA Primary Care Clinics; interdisciplinary care coordination, illness management and recovery
Coordinated efforts between DoD and VA systems of care regarding barriers and access to care, continuity of care, care coordination, Seamless Transition	Familiarization with substance abuse prevention, screening, and treatment programs within DoD organizations and VA health care systems
Familiarization with DoD and VA outreach programs; Veterans courts; Yellow Ribbon Program, Substance Abuse Prevention, Suicide Prevention, and Family Advocacy programs; DoD and military-connected schools in local and regional service provision areas	Familiarization with the multidisciplinary treatment of polytrauma, amputations, PTSD, burns, and other blast-related injuries at VA Polytrauma Rehabilitation Centers, the Integrated Disability Evaluation System, Office of Warrior Care Policy
Prevalence, nature, and course of the signature post-deployment diagnoses (PTSD, TBI, SA) and the application of theoretical and conceptual models to understand these phenomena in the military context	Knowledge of and specialized training in empirically supported biobehavioral and sleep medicine, innovations in telemedicine, complementary and alternative medicine, biofeedback for military members
Familiarization with the DoD Health Surveillance Program and collaborative DoD and VA programs and policies responding to deployment, combat trauma, and environmental exposures (e.g., Agent Orange, contaminated water, pesticides, burn pits)	Familiarization with DoD/VA Clinical Practice Guidelines for PTSD, substance use disorders, suicide, tobacco use, major depressive disorder, chronic pain management; DoD, GAO, CRS, RAND, and military reports on the needs of war veterans
Similarities and differences between contemporary war cohorts; men and women who experience military sexual trauma	Familiarization with school-based interventions for military children & families in DoD and military-connected schools

Note: DoD = Department of Defense. VA = Department of Veteran Affairs. PTSD = posttraumatic stress disorder. TBI = traumatic brain injury. SA = substance abuse. GAO = Government Accountability Office. CRS = Congressional Research Service. SBIRT = screening, brief intervention, and referral to treatment.

OPPORTUNITIES FOR SOCIAL WORK EDUCATION

In addition to a behavioral health workforce shortage, significant military health care and occupational burdens are associated with the physical and psychological injuries of the Iraq and Afghanistan wars (Armed Forces Health Surveillance Center, 2013; C. W. Hoge et al., 2005). The social work profession and schools of social work are well suited to educate and train skilled, culturally-responsive behavioral health providers to address this workforce shortage and increase the organizational and service provision capacity of civilian and military-connected agencies needed to adequately respond to the behavioral health care needs of OEF/OIF/OND veterans. Given the VA is the largest employer of masters-level social workers (NASW, 2012), there is a wealth of institutional knowledge available to educate and train future military social workers and establish a pipeline of highly skilled military social work professionals. Current social work educators and field instructors can be instrumental in training current and future social work professionals to be leaders in military, community, mental health, and substance abuse programs at multiple levels of military social work practice. They can also train social work professionals in strengths-based approaches and resiliency-enhancing interventions that will improve the coping capacity and coping self-efficacy of military personnel, veterans, and their families.

To advance the social work profession’s leadership potential, numerous schools of social work have developed military social work certificate programs, specializations, and courses. The University of Southern California is a trailblazer in the development of military social work practice guidelines, pedagogical models, virtual reality training, and the Center for Innovations in Research on Veterans and Military Families. The University of Texas at Arlington has developed innovative field education and psychosocial rehabilitation models to assist student veterans with post-deployment reintegration, higher education goals, and training for new careers, as well as a military certificate program. Recently, Boston University and West Virginia University received Health Resources and Services Administration funding for behavioral health workforce capacity building and both programs include military-specific training for social work students and professionals. The University of Missouri and the University of South Carolina both have developed military social work certificate programs as well as university-military partnerships. For example, the Vice President of Research at the University of South Carolina was instrumental in negotiating a University of South Carolina-Fort Jackson Partnership that resulted in a university-military forum and the signing of a memorandum of understanding to facilitate education, research, scientific innovation, interdisciplinary collaborations, student internships and service learning. In collaboration with the Military Family Research Institute at Purdue University and the South Carolina National Guard, the University of South Carolina College of Social Work received a Wounded Warrior Project grant to implement the Star Behavioral Health Providers’ Training Program to provide free behavioral health training to civilian behavioral health providers to serve military and veteran populations in South Carolina. These are all noteworthy endeavors, but more is needed. The breadth and depth of the social work profession’s ability to serve the military community and develop a skilled military behavioral health workforce is underdeveloped and unrealized. Opportunities and strategies to provide military social work education and training to social work students and professionals are outlined below.

Graduate social work education

The critical need for a skilled military behavioral health workforce presents unique opportunities for graduate social work education. Social work students in masters of social work programs as well as those in the masters of public health dual degree program can be trained to engage in military behavioral health outreach, health education and promotion, psychoeducation to destigmatize help-seeking among military and veteran populations, and to implement preventive public health strategies that facilitate the early identification and referral of military members with behavior health problems. Understanding the principles of population health applied by DoD and VA in comprehensive health surveillance, post-deployment health promotion, disease prevention, interdisciplinary care coordination, and the continuum of care from the DoD to the VA health care system (Reisinger, Hunt, Burgo-Black, & Agarwal, 2012) are also critical for effective military social work practice.

Masters of social work students who are also pursuing master of divinity degrees can be assigned to military or veteran field placements that include rotations with military chaplains, which facilitates interdisciplinary collaborations between social workers and chaplains to address combat trauma, war-related killing, survivor’s guilt, complicated grief, and moral injury using a biopsychosocial spiritual approach (For more information, see Besterman-Dahan, Gibbons, Barnett, & Hickling, 2012; Cardona, 2000; Greene, Galambos, & Lee, 2003; Litz et al., 2009; Sanders, 1994; Waynick et al., 2006). Social work students with field placements at military treatment facilities, TRICARE-approved contracted agencies, VA medical centers, Vet Centers, and community-based outpatient clinics (CBOCs) can also be provided specialized training to administer reliable and valid measures of behavioral health, such as the Clinician Administered PTSD Scale (Weathers, Keane, & Davidson, 2001), Primary Care-PTSD Screen (Bliese et al., 2008), Patient Health Questionnaire-9 (Kroenke & Spitzer, 2002), Pittsburg Sleep Quality Index (Carpenter & Andrykowski, 1998), Alcohol Use Disorders Identification Test (Allen, Litten, Fertig, & Babor, 1997), Prescription Drug Use Questionnaire (Compton, Wu, Schieffer, Pham, & Naliboff, 2008), Connor-Davidson Resilience Scale (Connor & Davidson, 2003), and Drug Abuse Screening Test (Yudko, Lozhkina, & Fouts, 2007) to screen for PTSD, depression, sleep problems, prescription drug misuse (e.g., opioids, psychotropics), resilience, alcohol and other drug abuse to facilitate early intervention among vulnerable groups (e.g., severely injured, polytrauma) as well as those engaging in high risk behaviors (i.e., drinking and driving, suicidal ideation, criminal behavior). Training and certification (as applicable) in evidence-based treatments for PTSD such as cognitive processing, prolonged exposure, and eye movement desensitization and processing therapies (See Moore & Penk, 2011; Alan L Peterson, Luethcke, Borah, Borah, & Young-McCaughan, 2011) are also vital for advanced graduate-level social work students and professionals.

Doctoral social work education can be instrumental in training social work researchers and educators to develop evidence to inform the translation of military research to military social work policy and practice. Social work educators and researchers can be vital in developing innovative psychoeducational and outreach strategies that are symptom-focused, rather than disease-focused, and have the goals of normalizing help-seeking and reducing stigma. Training doctoral students to conduct military research is also essential to developing a militarily-relevant knowledge base for future military social work education and practice. Military and veteran research training supports the development of a skilled behavioral health workforce, and gives the social work profession influence in military and veteran social and health policymaking, advocacy, and implementation. For example, using DoD Military Health System, deployment, and post-deployment data, Larson, Mohr, Adams, Wooten, and Williams (2014) examined the extent to which the DoD post-deployment health surveillance program identifies and refers at-risk drinkers for additional assessment and found that interviewing providers under-identified alcohol problems during post-deployment health assessments. These findings identified missed opportunities to improve post-deployment health outcomes and has implications for screening and early identification of at-risk drinking within the DoD post-deployment health surveillance program. Wooten et al. (2013) found that Army women were substantially less likely than Army men to receive substance use treatment the year before deployment which has implications for pre-deployment health assessments and the Army’s Substance Abuse Program (U.S. Department of the Army, 2009a). Evidence-based knowledge and program evaluation can also be instrumental in informing initiatives championed by military leadership, health policymakers, and veteran organizations, such as the Wounded Warrior Program (Hudak, Morrison, Carstensen, Rice, & Jurgersen, 2009), RESPECT-Mil (Engel et al., 2008), and Comprehensive Soldier Fitness (Casey, 2011). Current military researchers and social work administrators can also play vital roles in the translation of military social work research to defense health and social policies by establishing and promoting pre-doctoral and post-doctoral military research training opportunities, which can increase the social work profession’s research infrastructure and impact on evidence-based policymaking. Without a cadre of military social work researchers, we forfeit valuable opportunities to develop discipline-specific knowledge and the ability to acquire research funding needed to develop, implement, and evaluate behavioral health inventions and policies relevant to military personnel, veterans, their families and communities.

Continuing social work education

Opportunities to develop military-related continuing social work education throughout the United States abound. Continuing education opportunities for licensed social work professionals promote lifelong learning and can take the form of workshops or advanced practice certificate programs offered by accredited schools of social work, professional education programs, or community, social work, military, and veteran organizations. Military-related continuing education will allow experienced social work professionals to retrain, retool, and adapt their clinical skills to serve a new client population and recent social work graduates can obtain specialized knowledge and skills to prepare them for future military social work practice.

Increasing the military behavioral health workforce capacity with experienced, licensed social workers also facilitates professional leadership in military-related service provision in civilian, military, and veteran organizations. For example, social workers currently working in children and youth service organizations can receive military-related continuing education training to better assess and identify military youth who experience psychosocial and psychological problems associated with parental deployment, prolonged separations, frequent family transitions, life stressors, and coping with developmental milestones in the military context. Experience in child mental health can also be useful in conducting reception behavioral health assessments in military basic training programs to facilitate the early identification of military recruits who have psychological symptoms, undiagnosed psychiatric problems, and extreme or chronic stress reactions to the demands of military training.

Social workers in private practice can become approved to provide TRICARE-contracted services so they can be a resource for community-based military behavioral health care, which is especially needed for National Guard and Reserve members and their families who may not reside in close proximity to the VA or TRICARE-approved health care facilities. Public health social workers can be trained to provide preventive strategies and psychoeducation for military leaders, spouses, and family members about the physical health effects (e.g., hypertension, cardiovascular disease) associated with posttraumatic stress symptoms (See Boyko et al., 2013; Granado et al., 2009). Insomnia, obstructive sleep apnea, chronic pain, and prescription drug abuse co-occur with PTSD and TBI, and have the potential to exacerbate posttraumatic stress symptoms and negatively impact work productivity, marital and family relationships (Gironda, Clark, Massengale, & Walker, 2006; LeardMann et al., 2009; Morasco & Dobscha, 2008; Seal et al., 2012; Wallace et al., 2011). We also need social workers to take a strengths-based practice approach to identify military personnel and veterans who have thrived despite chronic stressors.

Social workers, who are often a point of entry for BSIRT, are ideally situated to screen for chronic co-morbid conditions that can complicate behavioral health care and negatively impact treatment outcomes if left untreated. Practitioners trained in motivational interviewing can play a critical role in addressing the mismatch between the early identification of behavioral health problems during post-deployment health assessments and behavioral health referral, help-seeking, and service utilization within DoD and VA health care systems (See Larson et al., 2014). Social workers trained in substance abuse assessment, suicide prevention, and crisis intervention can be instrumental in providing services in veterans’ courts, military suicide prevention programs, postvention, and family support groups. Finally, newly trained military social work professionals licensed at the independent level can become a new pool of field instructors to supervise and train social work students in military social work.

Considering the need to increase outreach and access to care among military personnel and veterans, opportunities exist to educate and train social work professionals and students in telehealth applications, hosting secure symptom-based or client-specific blogs and chat rooms, and other innovative health informatics, such as the Care Coordination Home Telehealth Program and My HealtheVet personal health record portal (Darkins et al., 2008; Hogan, Wakefield, Nazi, Houston, & Weaver, 2011), found successful for outreach and treatment engagement among veterans. Multiple social media and remote communications technologies may also prove effective for practice and research among recently returned veterans who utilize these technologies in their military occupations and to maintain contact with family members during prolonged separations (Matthews-Juarez, Juarez, & Faulkner, 2013; Wooten et al., 2014).

CHALLENGES FOR THE SOCIAL WORK PROFESSION

Despite numerous opportunities for social work educators and professionals, working within DoD and VA organizations and with individuals and families in a military context poses several challenges, including secondary trauma, compassion fatigue, conflicting values and ethics, and ethics stress (See Wooten, Kim, & Fakunmoju, 2011 for more information on occupational stress in social work practice). Secondary trauma and compassion fatigue can result from listening to traumatic events when treating military personnel using prolonged exposure (A. L. Peterson, Foa, & Riggs, 2011) and cognitive processing therapies (Williams, Galovski, Kattar, & Resick, 2011). Conflicting values and ethics can result when service members show a significant decrease in PTSD symptoms, but treatment progress results in a perceived threat to disability compensation or malingering. Ethics stress may be experienced when working in Family Advocacy Programs with military spouses and youth who experience domestic violence and child maltreatment, and social workers must (1) fulfill command notification requirements regarding investigative and treatment progress, (2) identify a service member as a treatment failure, or (3) make a PTSD or other psychiatric diagnosis that results in reclassification to a different military occupation, or perceived or actual denial of a coveted military assignment, training program, or promotion. It is also important for social workers to understand the organizational and social work practice-oriented differences in working for DoD and VA-affiliated agencies, as well as potential ethical dilemmas posed by mission and command-driven organizations (i.e., DoD) compared to the VA in which access to health services and benefits are based on a means-tested, priority system.

To facilitate ethical decision making in military social work practice, Daley (2013) provides an overview of ethical decision making models that address dual loyalties, confidentiality, and hierarchy and power dynamics in the military context. Military social work education requires teaching ethical decision making within a structured, hierarchical organizational culture in which being deemed non-compliant or a treatment failure is potentially career ending for service members and life-altering for military children and families. More stress prevention interventions, wellness and self-care programs for social workers are also needed so the profession can lead by example men and women of the armed forces who seek solace in the midst of nightmares, flashbacks, marital and family discord, unemployment, moral conflicts, and memories of war trauma and atrocities.

All Iraq and Afghanistan veterans are eligible for DoD or VA health care for service-connected injuries or problems after returning from deployments. One challenge for military social workers providing services to Iraq and Afghanistan veterans are those who choose not to seek care within DoD or VA systems of care. Military personnel may refuse to use these services for various reasons, such as stigma, military career implications, or personal choice. Although military personnel earned these benefits as a result of military service, military social workers must consider the unique aspects of help-seeking in the military context as well as their right to self-determination.

An additional challenge for the social work profession is the instructional design by which military social work education will be taught and disseminated within schools of social work and to the professional community, and whether there will be a preferred method by which military social work education will be integrated into social work curricula. Depending upon local professional and community needs, some schools of social work may choose to integrate military social work education material within existing courses whereas other schools of social work located within large military and veteran communities may establish military social work courses, specializations, and/or certificate programs. To inform decision making, a local needs assessment involving military and civilian organizations, community stakeholders, alumni, and social work professionals may be required for schools of social work to determine the most effective instructional design and pedagogy.

RELEVANCE TO FUTURE MILITARY SOCIAL WORK EDUCATION

Because social workers have served military veterans since World War I and the VA is the largest employer of masters-level social workers (Harris, 2000; National Association of Social Workers, 2012), the social work profession has viable leadership potential in building intellectual capital in military social work. Recently, a wealth of evidence (Coll, Weiss, & Yarvis, 2011; Rubin, 2012; Rubin, Weiss, & Coll, 2013; Savitsky, Illingworth, & DuLaney, 2009) has emerged from the social work research and practice community regarding the need for a highly trained, culturally-responsive military behavioral health workforce and evidence-informed practice models to guide effective military social work practice. But how does the social work profession become a leader in developing a highly trained military behavioral health workforce? How will the wealth of military-related intervention research (Benish, Imel, & Wampold, 2008; Foa & Meadows, 1997; A. L. Peterson et al., 2011; Schnurr et al., 2007) and conceptual models (Adler & Castro, 2013; DeVoe & Ross, 2012; Esposito-Smythers et al., 2011; Huebner, Mancini, Bowen, & Orthner, 2009; Paley, Lester, & Mogil, 2013; Wooten, 2013) on assessing, understanding, and treating PTSD, TBI, substance abuse, and post-deployment reintegration difficulties be translated into relevant military social work education?

Considering the breadth and depth of knowledge required for effective military social work practice, a systematic approach to advancing military social work with collaboration among social work educators, practitioners, and researchers is needed to move beyond the identification of advanced practice behaviors and standards of care to an actionable strategic plan involving the development and implementation of pedagogical innovations, evidence-informed instructional design, knowledge generation, and translation of military research into military social work policy and practice—nationally and internationally. In military social work, this strategic plan must be militarily-relevant taking into consideration military downsizing [i.e., base realignment and closure (BRAC)], troop reduction in Iraq and Afghanistan, the dynamic sociopolitical climate of the United States armed forces, and national security threats and needs.

To realize the social work profession’s leadership potential in military social work, an integrated model of intellectual capital (Khalique, Shaari, & Hassan, 2011) is proposed as a framework to guide strategic planning that promotes lifelong learning, the development of innovative pedagogical models, and, considering the wealth of military prevention and intervention science, the translation of military research to military social work education and practice. This framework also supports a systematic approach to program evaluation, workforce capacity building and assessment, and evaluating the profession’s effectiveness in addressing the needs of diverse, resilient, and vulnerable populations within military organizations that may be overshadowed by a primary focus on military service and deployment-related stressors.

According to Khalique et al. (2011), components of an integrated model of intellectual capital for knowledge-intensive organizations (e.g., schools of social work, institutions of higher education) include human, customer, structural, social, technological, and spiritual capital. In military social work, increasing human capital involves the development of militarily-relevant practice skills, evidence-informed military social work education, innovation, and solution-focused problem solving. Customer capital development involves assessing the satisfaction and loyalty of students, faculty, and alumni with military social work educational opportunities, as well as networking with current and former students, alumni, field instructors, faculty, community leaders, and military stakeholders to determine their needs and potential contributions to military social work education advancement. Structural capital involves the development of military social work leadership; research, field education, program evaluation, and practitioner databases; infrastructure (i.e., research centers, training programs); program plans, educational policies, process and governance manuals that can be replicated and shared across higher education, nonprofit, military and veteran organizations. Social capital involves military social work resources accumulated by a network of intraorganizational relationships that may result from professional collaborations, geographical and subject matter expert networks, professional organizations, military-community and military-university collaborations. Technological capital involves military social work research, development, and knowledge dissemination; acquisition of internal and external funding for research, education, and practice programs; access to and integration of information technology and innovation in military social work education and practice; development and adaptation of evidence-informed conceptual and treatment models; translation of military research to practice; and the protection of intellectual property. The development of spiritual capital involves the identification and assessment of militarily-relevant ethical decision making models and ethical practice behaviors, and social work leadership engaging military chaplains, community religious leaders, and faith-based organizations in the response to the spiritual and behavioral health care needs of military personnel, veterans, their families and communities.

Professional infrastructure to develop intellectual capital in military social work

The infrastructure proposed to develop intellectual property in military social work is a Military Social Work Advisory Council that would be responsible for development, implementation, and oversight of a strategic plan for military social work education and advising professional social work organizations (e.g., CSWE, NASW, IFSW) in the development of military social work education strategies within the scope of their missions while avoiding duplication of effort. Primary goals of the advisory council would be to: (1) provide subject matter expertise about military social work practice and education, and (2) organize collaborative efforts among professional social work organizations for military social work professional development. The advisory council would also have a dissemination role to officially communicate with the social work profession by authoring reports on its endeavors; development, modification, and implementation of a military social work strategic plan and military social work programs established by professional social work organizations it advises in support of the development of intellectual capital in military social work education. Considering that the provision of behavioral health services to military and veteran populations is an enduring need and the time need to launch this effort, the Military Social Work Advisory Council would be a standing work group with 3–5 year terms for the initial members to allow continuity of institutional knowledge as members rotate off the council. Subsequent members would serve for 3-year terms. Each professional social work organization and institutions of higher learning that choose to participate in the development of intellectual property in military social work education would be able to nominate subject matter experts for the advisory council based on the expertise they think would assist them in meeting their goals related to this endeavor. Criteria for advisory council membership and additional council responsibilities would be established by input from a broad spectrum of social work professionals, military and community stakeholders.

CONCLUSION

Considering the multitude of opportunities available to move military social work beyond its current state, a comprehensive strategic plan guided by an integrated model of intellectual capital is an excellent way to ensure the social work profession continues its tradition of service to our nation’s warriors. This special issue on military social work education provides exemplars of military social work curriculum development, program development and evaluation, and evidence-based services that can guide the social work profession in becoming a leader in training a highly skilled behavioral health workforce that engages in advocacy for and treatment of military families. Our quest for excellence and leadership in military behavioral health service provision and military social work education includes challenges in the development and implementation of innovative pedagogical methods, student veteran education and supportive programs, and field placement and continuing education models that assist social workers to be all they can be in support of the strong, the few, and the proud men and women of the United States armed forces in their recovery from war trauma and their search to find peace despite experiences of combat, atrocities, and terrorism.