Thursday, July 7, 2011

Cultural Considerations in Military Social Work: Interview with Dr. Anthony Hassan

[Episode 69] Today's Social Work Podcast, Episode 69 – Cultural Considerations in Military Social Work, is the second in a two-part series with Anthony Hassan on Military Social Work. In Part I, Anthony and I spoke about The Training and Education of Military Social Workers.

Any discussion of culture and culturally relevant practice begins with the idea that we are all cultural beings. We see the world differently depending on which culturally-informed lenses we have on. In the United States, where military service is not a requirement, being in the military offers a unique set of lenses.  I got a glimpse of the very practical, day-to-day implications of seeing the world through military lenses when I asked today's guest what I thought was a very straightforward question – a question I ask all my guests before the interview starts – "what do you want me to call you?"

Jonathan Singer:
I didn't actually ask you – what do you want me to call you? Do you want me to call you Anthony? Dr. Hassan?... 
Anthony Hassan: Oh, please, Anthony. Surely not Major Hassan. You know I'm still in my own transition. It is interesting. It has been a year and a half now. I still reach to put on my hat. If my hair is blowing in the wind, it is like, "why is that happening? Oh – you don't have your hat on." So I go to reach for a hat. Or, just the other day I was like, "my goodness my left arm is tired from carrying this brief case." But I wouldn't put it in my right hand. I'm thinking, "why aren't you putting it in your right hand, Anthony?" Well, because I've always had to keep my right hand free to salute.  
Jonathan Singer: Oh... 
Anthony Hassan: And you know, believe it or not, this morning I walked out of my house, it was a little breezy – I feel it in my hair, and I thought instantly, "where is your cover? where is your hat?" It is still a transition that we all have to make. And so when I jokingly said, "don't call me Major Hassan" it is because, you know, sometime I still talk as if I'm still in the service. And I talk about people I talk with every day as "civilians." It is a transition. And here I am, you know moving from one career to the next, pretty seamless, everything is going ok. Just imagine what it must be like to leave service, young, without a job, without any skills, having been to war twice, and maybe having a wife and a three year old daughter. You're all of the sudden in Los Angeles again where you grew up. What is that going to be like? That's all I want social workers to try to understand. How can we help this family, this individual, navigate this transition?
So, how can we help? The Council on Social Work Education's Military Social Work task force, chaired by Anthony Hassan, provides some guidance on the knowledge, values and skills that all military social workers should have. Here's their statement on educational policy 2.1.4 - engaging diversity and difference in practice
"Advanced practitioners in military social work understand there are many subgroups and subcultures in the military and veterans' communities. Interventions and personal reactions differ over time with changes in social policy and diversity among individuals. Advanced practitioners in military social work understand the power and authority structure within the military (as part of the culture) and the impact this structure can have on the lives of service members and their families. They recognize the impact of intersectionality of various diversity factors (e.g., in-rank structure [hierarchy]; military occupational specialty statuses; racial status; gender; service cultures and practices; "family" composition and definition; sexual orientation; age; disability; life stage; culture and ethnicity; spirituality; and citizenship status) on direct practice. They understand the differences in factors that motivate people to enter, serve, separate from, and transition into the VA system of care.
CSWE identified the following practice behaviors:
  • Advanced practitioners in military social work manage potential conflicts between diverse identities within and among individuals and the military and veterans' organizations;
  • manage potential conflicts between personal feelings/expression and collective/ institutional responsibility;
  • recognize the potential risk and protective factors among diverse populations and communities that may be the result of military service; and
  • communicate with a culturally responsive approach that includes service members with varying statuses such as active duty/retired, guard/ reserves, and combat/garrison." (CSWE, 2010, pp. 7 -8). 

In today's interview, Anthony and I talked about the similarities and differences between military and non-military social work; is it necessary for social workers to have military experience in order to be effective doing military social work?;  what are some mistakes that civilians make when working with people in the military?; What are the treatment needs of community dwelling veterans? How the wars in Iraq and Afghanistan have advanced our understanding of and treatments for PTSD and other disorders. Anthony ended our conversation emphasizing that when we think of community dwelling veterans we should remember their strengths as well as their needs.


A couple of notes about this interview. I invited fans of the Social Work Podcast Facebook page to submit questions for Anthony. The response was fantastic. There were over 20 questions, most of which I couldn't ask. But those that were suggested on Facebook I identified as such. So, thank you to everyone who posted questions – you'll recognize your contribution. And I'll definitely be asking folks to submit questions for future podcasts. Finally, as with all my remote interviews, this one was done using Skype. Anthony was in Los Angeles and I was 3,000 miles away in Philadelphia. And now, without further ado, on to Episode 69 of the Social Work Podcast: Cultural Considerations in Military Social Work: And Interview with Dr. Anthony Hassan.

Download MP3 [31:35]





Bio

Anthony Hassan, is a retired Air Force officer with 25 years of experience in military social work. He served during Operation Iraqi Freedom in 2004 on the first-ever Air Force combat stress control and prevention team embedded with an Army unit. He led the largest military substance abuse and family advocacy programs in the Pacific which were recognized as benchmark programs and training sites for all other Pacific bases. He chaired the committee responsible for creating the Council on Social Work Education's model for advanced social work practice in military social work (CSWE, 2010) which I quoted a few minutes ago. And, if those bona fides aren't enough, he is currently the director of the Center for Innovation and Research on Veterans and Military Families at the University of Southern California's School of Social Work.


TRANSCRIPT

Jonathan Singer:  You know based on your experience, what's one of the differences between your non-military social work and the military social work that you’ve done?

Anthony Hassan:  Yeah.  For me really there is no difference in the social work that I’m doing.  It's just with a different population and I think that’s how I try to see this work.  It's not that we need to change everything about us.  I think social workers have the perfect skill set period.  I even feel that way for social work and leadership.  I believe we have the right skills set to be great leaders in organizations as well but my point I guess is that social work is perfectly situated and suited to work with the veteran population, service member and their family population.  But I think like any culture in order to be culturally responsive, you need to be fully aware of the challenges and the values the way of doing things, rituals, traditions and this culture just like in any other culture, this culture being the military culture.

Jonathan Singer:  So, what are some of the values and rituals and traditions that you think are kind of essential for people to know about?

Anthony Hassan:  It starts just by knowing who they are and a little bit about that there are cultures within and there are cultures among the military. And to make an assumption that all military are the same or stereotyping surely isn't what we would want or need to work with this population. You need, you know, to be aware of ethical issues that, you know, come up in terms of: their need to come to get help or desire for help; how that might conflict with your own issues of confidentiality; the legal parameters of working a with a service member who is under a different set of laws and regulations; the policies that affect, you know, delivering service to service men and women; advocating for them and knowing who they advocate to or with; understanding some of their issues as it relates to going to get mental health; realizing that they value things that maybe aren't valued by civilians if you would - the idea of cohesion and teamwork and duty and honor and loyalty and respect and courage, self-sacrifice.

I mean, these things will get in the way of an individual seeking help for sure. But to understand that, and to be able to engage them in a conversation, and to get to know them and to share with them your understanding or lack thereof is important. To recognize “should I call them a sergeant or should I call them John?”  You know, how do I even interact with someone who wears the uniform? So just understanding the power and authority and structure within the military. 

There's a number of things, I mean, I – you know, I could sit here and list off I mean just the fact that even though on a difference between army and navy, air force and marines.  Calling a marine a soldier is not something you probably want to do and calling a soldier a marine - just simple things like that that - can derail the interaction. And the therapeutic relationship is probably the most important thing and we need to establish that right away.

I always tell folks, “if you don’t establish a relationship with any of your clients, they're not coming back.”  But even more so I think with military who already are concerned about going to seek help, have issues in their own mind about what this can do to their career if they get help. Just learning or having lived to be stoic and courageous to go get help may be seen as a weakness.  So, how do you work with that?  How do you at least share with the service member that you really do understand their concerns and their challenges and, you know… A host of other things, like your rank.  I mean, do you know the rank?  Do you know the difference between an officer and a non-commissioned officer?  Do you understand, you know, a senior NCO versus a junior NCO, gender and issues of culture in the military itself?  What is family?  Sexual orientation?  Don’t ask, don’t tell?  I mean, I could go on and on and on.

Jonathan Singer:  You know, one of the questions that was posted on Facebook for this interview that I think fits our conversation right now is, “is it necessary for social workers to have military experience in order to be effective doing military social work?”

Anthony Hassan:  That’s a great question.  No, you don’t need military experience to be an effective social worker working with service members, veterans and their families.  I don’t believe that you need military experience.  I think what makes a uniformed social worker, what makes it easier for them to practice is that they have instant credibility because they wear the uniform and because they live the lifestyle. But when I think of the work we're doing here and the work that we need to continue to do is to increase the workforce capacity is to really work with those in the community - those social workers and behavioral health providers in the community who do not have experience working with this population, have never worn the uniform and that is where the majority of folks are going to get their care. We know about 70% of the servicemen and women who return will get care in our community.  So, if we had to depend on someone who had worn the uniform then I think we will be in trouble.  So, no, you do not have to have it. 

Now, surely for me, you know, there's an instant bond.  There's an instant understanding between me and any service member who’s ever wore the uniform or is wearing it.  They know I've been deployed to the war.  They know I have served in uniform.  They know I’m a retired officer.  There's an instant bond.  There's a brotherhood or sisterhood that makes my life easy if I wanted to go back to clinical work and work just with this population will be very easy.  I talk like them.  I walk like them.  I think like them.  I use acronyms and that makes my life or would make my job much easier. But no, it's not necessary.

But I do would believe what's necessary just like with any population that we work with is we need to understand them.  We need not to stereotype them and we need to dispel myths and we really need to understand the social cultural factors involved in providing care.  We need to know how to advocate for them, understanding what their service needs are, where they can get help, who can help them.  So, again, being a good broker of service as a good advocate is key in providing this care. But, I think someone who takes the time out to understand the culture, to learn about the culture, to understand what it takes to engage and connect will be very effective.

It's unfortunate, though, that in my time that I have sent service members downtown,  meaning off-post or to an off-base to a civilian provider, unfortunately, my experience shows me eight out of 10 times - and I’m not exaggerating - the service member would come back and say, “you know, I would rather wait in your long line in your clinic on base than to go back to the civilian provider because they just don’t understand me.” What does it mean when they say “they just don’t understand me”?  Maybe it is that they don’t and they said some things that offended this individual or maybe it's just that individual doesn’t feel comfortable with them.  But we're trying to make sure that that first engagement is a good one.

Jonathan Singer:  I want to follow up on what you just said about, you know, maybe that civilian doesn’t understand you.  What are some other classic mistakes that a civilian social worker might make when working with somebody in the military?

Anthony Hassan:  And, again, I don’t know all those ins and outs but I have had many, you know, exchanges with servicemen and women and I think a lot of it has to do with this person didn’t show much interest in them in what they do, Like well, “what do you do in the military?  Have you been deployed?  What was that like?  How long were you gone?  What's your job?  What do you do?”  And sometimes I think when we see patients, and this is from my own clinical experience, we read the demographics sheet, we do the – look at the intake sheet and we just go right into business and because we kind of think we understand the context because they're, you know, coming in with a problem that appears to be, you know, typical problem or whatever, maybe we just kind of cut corners and I think that might be the difference here is that you really have to show some interest and some awareness or even lack of knowledge about military.

Jonathan Singer:  I think that’s a great point just in terms of being culturally sensitive or culturally, you know, relevant with any client.  I can see how asking questions about “what your experience was like? Provide me a context for your problems” would be essential in establishing that rapport and developing that therapeutic alliance or engagement with somebody in the military especially if you don’t have military experience.

Anthony Hassan:  Absolutely you know and I’m thinking as you were talking about the community-dwelling veteran, that’s the term that I've taken out of the new report from the RAND – the new RAND Report on the New York State Veterans - and that’s exactly the focus that I have is on the community-dwelling veterans.  So, you have a veteran who is now coming to your community mental health center or your private practice office, you may want to know about their status.  Are they in the reserves?  Are they in the national guard?  Are they just separated from military?  Have they been separated for six years already?  Have they been separated from military because of medical condition? And, I know, a lot of providers that I know, a lot of civilian social workers are saying, “Anthony, we do that with all of our patients and we need understand context and we ask all of those questions.” And I agree with you.

You know this practice of social work is no different with this population but, again, understanding the power of stigma in this population, understanding this culture, understanding where they're coming from, understanding that maybe they’ve been to war two and three times, realizing that in the military it’s a microcosm of society but it's a very close system and being in the military things are taken care of for you.  You know all the agencies on the post and you know exactly what they're there for.  Coming out here for example in Los Angeles has a very intimidating adjustment or adding to that is you’ve been to war twice.  You’ve been away from your family or your community for two or three years.  All of a sudden you're out of the military, you know, you're out here and you look left and you look right and nothing looks familiar and nothing sounds familiar, you're having a hard time finding employment. You’ve joined the military from a civilian community where your education was marginal at best and now you're back into this community.  You don’t have a job.  You really – you may not have any new skills other than maybe an infantry man or artillery man in some cases.  You probably aren't prepared to go to college but you have this GI bill that everybody says you should use.  You might have a wife and two children by now. And wow!  So, I think that the provider really just needs to understand this individual under new and unique needs and maybe not make assumptions that they're just another client coming in for marital counseling or another depressed client.  And I think as you said, sometimes in the business we have large caseloads and we get used to a routine and all I’m saying is if you have a veteran in your waiting room, think about how you might need to interact with that individual, the things that you may need to engage them with initially in the conversation.

Jonathan Singer:  So, yeah, so clearly, you know, understanding the context, “who is this person and where are they coming from?” Because their issues aren't coming out of nowhere.  They're coming from somewhere so where is that and what can I do to understand that.  And then there's the other side which is even if I understand this person, that’s not going to help them unless I know how to treat the problem unless I know how to be effective in addressing their issues. I know the classic diagnosis that everybody talks about is PTSD. So one of the questions from Facebook was actually from a social worker in Israel who has military experience and he wrote, “Wars usually advanced technology and treatments, did the wars in both Iraq and Afghanistan advanced the course of PTSD treatment in the U.S. military?  What are the current guidelines for the treatment of PTSD in the military?” I was wondering if you could answer that sort of is there anything you need to know about PTSD as a diagnosis with folks in the military that might be different from PTSD in non-military populations?

Anthony Hassan:  Yeah.  First I’d like to say, you know, I’m not an expert in PTSD but as the person who asked the question is actually right on target when you think about what has the advancements that we have now or an awareness that we brought to the posttraumatic stress disorder.  We have seen in a lot of the research and a lot of researches being conducted about what are those evidence-based interventions that have shown to be the most effective in working with this population and the VA and the Department of Defense have adopted a few approaches in too in particular one is called Prolonged Exposure Therapy and the other one is Cognitive Processing Therapy. Those two are the evidence-based interventions that have now received a lot more attention and study and so that those are the ones they recommended to work with veterans both in the VA and in the Department of Defense.

So, I think that this war has brought a lot of awareness and researchers have paid a lot of attention to what is it that works best and what is it that works best with this military population.  Now, there are a number of other therapies out there, you know, cognitive behavioral therapy, problem solving, EMDR. And there's actually some folks, a partner of ours in research named Skip Rizzo, Dr. Rizzo who’s using virtual reality to immerse an individual back into that environment to help them process the traumatic event and his small studies have shown that virtual reality technology is actually helping veterans recover or to manage posttraumatic stress disorder.  So, yes, the war and the attention of the war and all of the challenges faced by veterans particularly with those who come back with posttraumatic stress disorder has moved this field forward.

But I also noticed that it's also allowed the Korean war veteran, the Vietnam veteran and even World War II veteran to finally be able to talk about and label or name what they’ve been going through and to feel okay about getting help. And that’s amazing.  I've talked to some World War II veterans in particular Vietnam veterans who are now finally coming forward and saying you know what, I know what's wrong with me now and I’m okay and I can go get help.  That is just amazing to me.  So, yes, the war has helped increase awareness for posttraumatic stress disorder.  It has helped us identify evidence-based interventions.  We're focused on what works and what doesn’t work.  We support the things that work.  We're training on those evidence-based interventions so that people are using state-of-the-art current evidence informed treatments. Unfortunately not enough are. The research has shown us that many providers who are providing care and not providing evidence-based care.  So, I think we're moving in the right direction and of course, yeah, it took a war to do this. 

As for someone who may have experienced posttraumatic stress disorder as a civilian from a tragic event versus a combat soldier, I’d say to me and I’m not an expert in PTSD but I think the difference is that many times our servicemen and women are exposed to more than one event, multiple events over multiple months and even multiple tours of combat which would seem to exacerbate the first event, you know, so subsequent events over and over again surely I think would make it more challenging to treat someone who’s experienced war for two and three tours.

Jonathan Singer:  And I would also imagine that if, for example, you have a child who’s repeatedly sexually assaulted, that’s something that society does not condone.  There's no expectation that that should happen.  There's no normalization of that but if you are on a tour of duty, you have all these sort of multiple traumas... Well, it's just part of your job.  I mean, that’s what you do, right.  It's awful and of course, you know, we wish it didn’t happen but that’s just the way it is.  And so I think there's probably a social context that would distinguish those types of traumas to repeated traumatic events that might occur outside of a war situation.

Anthony Hassan:  Absolutely.  Yeah as we're talking about posttraumatic stress disorder, you did mention and I want to mention that what's more prevalent in the returning veterans is, you know, those adjustment disorders, those major depression, substance use, intimate partner violence, you know, work-related stressors.  I mean, those are the things that I want to emphasize that are probably going to be coming into mental health clinics.  Those are the challenges I think they're going to see more often.  Yes, there are many servicemen and women who experience posttraumatic stress disorder but I don’t want us to get just focused on the disorder.  I would like to talk about, you know, posttraumatic stress that the effects on the family, the secondary trauma on spouses and children where spouses can't sleep, you know, their days turn into nights.

It's tough for everyone and I think we tend to just think about posttraumatic stress disorder on TBI, traumatic brain injury as the signature injuries that require the most attention but I would have to tell you that my experiences tell me what we're really going to see are people who are having hard times.  We've seen this with increased suicides, divorces, unemployment, economic challenges and I think social work is again, if we understand the services and the agencies available to those servicemen and women, we can help advocate for them on the ground. 

I know we've spent a lot of time talking about posttraumatic stress disorder and a lot of the research that comes out is in PTSD and TBI but I really think we need to look at those microtransition moments, those moments when a service member comes back home. What happens in that first day, that first week?  What happens during the first month?  What happens in the three-month, six-month, at one year mark?  When are they most challenged?  What's really happening?  How are they strained?  What kind of family relationships are they dealing with?  Are they dealing with unemployment?  This is why I think social work is the right profession to work with veterans and military families because of our understanding of that total person. 

And I also need to mention that we again focus on pathologizing and we focus on the problems but let's remember 80% of servicemen and women return home and do just great.  Actually some of them are probably more resilient and more determined than ever.  When we think of a service member, we shouldn’t just rush to think of PTSD or TBI or someone who’s angry and ready to, you know, shoot up a building.  I think we need to think about someone who is strong and who’s committed and who served and who has experienced things well we maybe never will experience but has come out of it strong or more capable than ever, is a good citizen, would be someone we wanted to hire at our workplace, a leader.  So, I just throw that out there just because I feel that I had to get on soapbox to remind us that yes, people are going to come back and yes they're going to have challenges but there are many servicemen and women who do just fine.

Jonathan Singer:  I’m so glad that you mentioned that because, you know, the news doesn’t cover the successful vets, the vet that comes back and is doing great things. And what's true is that people don’t go to social workers when things are going well.  You know so that said, your point, you know, is really well taken.  Military social workers need to think about working with vets and their families not just in terms of pathology but also in terms of, you know, adjustment and successful transition.  And you used the term, I can't remember what it is, but it really spoke to this idea that, you know, a large focus of military social work is working in the community.

Anthony Hassan:  No, I think that’s what I want to focus on.  I want everyone to think about is that what I call the “community-dwelling veterans.”  The military as Admiral Mullen will tell you in many of his speeches, he says: Look the military does a great job of taking care of the service member and their family when they have the uniform on.  We do a good job if they have some kind of service-connected disability because they'll go the VA (many of them won't even though they do but let's just say they can go to the VA).  All veterans who separate from the service are left to fend for themselves and that is why I’m committed to training and educating the next generation of therapists and social workers and the current ones to really understand this population because that’s where they're going to be.  That’s where they need the most help. They're no longer in the military and so that is why I focus on what we call the community-dwelling veteran, as the RAND report has labeled this population, which is about 70 to 80% of the people you're going to see in your clinic are going to be those who’ve separated or who are on the reserves and national guard and who are now living out here and trying to navigate this new life.  So, transitions yes are very important.

Jonathan Singer:  You know, Anthony, I want to thank you so much for spending the time with us today and talking with us about military social work.

Anthony Hassan:  Thank you so much for the opportunity.  It was my pleasure and again this is my commitment.  So, anything I can do to help now and in the future, please don’t hesitate to call upon me.

--End--


Resources and references

Council on Social Work Education. (2010). Advance Practice Behaviors for Military Social Work Practice. Alexandria, VA: Author. http://www.cswe.org/File.aspx?id=42466

Department of Defense Task Force on Mental Health (2007). An Achievable Vision: Report of the Department of Defense Task Force on Mental Health. Falls Church, VA: Author. http://www.health.mil/dhb/mhtf/MHTF-Report-Final.pdf

Furlow, B. (2011, June 25). Primary care settings front line in battle against military children's psychosocial issues. The Clinical Advisor. Retrieved from http://www.clinicaladvisor.com/primary-care-settings-front-line-in-battle-against-military-childrens-psychosocial-issues/article/206111/

Hall, L. K. (2008). Counseling military families. New York, NY; Taylor and Francis.

Halpern, S. (2008, May 19) Virtual Iraq: Using simulation to treat a new generation of traumatized veterans. The New Yorker. Retrieved from http://www.newyorker.com/reporting/2008/05/19/080519fa_fact_halpern?currentPage=all

Hoge, C.W. & Castro, C.A. (2005). Impact of combat duty in Iraq and Afghanistan on the mental health of U.S. soldiers: Findings from the Walter Reed Army Institute of Research land combat study. In Strategies to Maintain Combat Readiness during Extended Deployments - A Human Systems Approach (pp. 11-1 – 11-6). Meeting Proceedings RTO-MP-HFM-124, Paper 11.Neuilly-sur-Seine, France: RTO. Available from: http://www.rto.nato.int/abstracts.asp.

Institute of Medicine. (2010). Preliminary Assessment of Readjustment Needs of Veterans, Service Members, and Their Families.Washington, DC: Author. http://www.iom.edu/Reports/2010/Returning-Home-from-Iraq-and-Afghanistan-Preliminary-Assessment.aspx

Institute of Medicine. (2010). Provision of Mental Health Counseling Services under TRICARE.Washington, DC: Author. http://www.iom.edu/Reports/2010/Provision-of-Mental-Health-Counseling-Services-Under-TRICARE.aspx

National Military Family Association. We serve, too: A Toolkit about Military Teens. Alexandria, VA: Author. Retrieved from http://www.militaryfamily.org/assets/pdf/Teen-Toolkit-PDF-FINAL.pdf

Rizzo, A., Reger, G., Gahm, G., Difede, J., & Rothbaum, B. O. (2009). Virtual reality exposure therapy for combat-related PTSD. In P. J.Shiromani, T. M.Keane, & J. E.LeDoux (Eds.), Post-traumatic stress disorder: Basic science and clinical practice. Totowa, NJ: Humana Press.

Schell, T. L., Tanielian, T., Farmer, C.M., Jaycox, L. H., Marshall, G.N., Vaughan, C. H., & Wrenn, G. A. (2011). Needs Assessment of New York State Veterans: Final Report to the New York State Health Foundation. Santa Monica, CA: RAND Corporation. http://www.rand.org/pubs/technical_reports/TR920.

Tanielian, T. & Jaycox, L.H. (Eds.). (2008). Invisible wounds of war: psychological and cognitive injuries, their consequences, and services to assist recovery. Santa Monica, CA: RAND Corporation.



APA (6th ed) citation for this podcast:

Singer, J. B. (Host). (2011, July 7). Cultural Considerations in Military Social Work: Interview with Dr. Anthony Hassan [Episode 69]. Social Work Podcast. Podcast retrieved Month Day, Year, from http://socialworkpodcast.com/2011/07/cultural-considerations-in-military.html

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