Operation Surf Uses Surfing to Help Veterans

Photo Credit: ESPN

Every day roughly twenty veterans commit suicide. It is estimated that 22% of all suicide deaths in the US are veterans. Former professional surfer Van Curaza wants to change that.

Curaza originally founded the nonprofit Amazing Surf Adventures (ASA) as a way to help at-risk youth by getting them into the ocean and off the streets. He expanded ASA to help veterans overcome the challenges caused by war with surfing – a program dubbed Operation Surf.

Operation Surf is a free program “that offers week-long adaptive surfing trips for wounded-veteran and active-duty military men and women.” They pair veterans “with their own individual surf instructor and develop a goal-based curriculum around their unique abilities. Operation Surf offers an environment of camaraderie and healing to its participants by giving them a shared experience in the water each day.”

Curaza and Operation Surf are featured in the award-winning Netflix documentary “Resurface.” The film is about Marine Corps veteran Bobby Lane. Bobby was planning on committing suicide, but he wanted to check surfing off his bucket list first. He ended up participating in Operation Surf and it changed his life. Not only did Bobby decide he wanted to keep living, but he decided he wanted to work with Operation Surf to help other veterans.

The first time I volunteered for Operation Surf I briefly met a young man named Tommy Counihan. He was learning how to kiteboard. With his long blonde hair and slender build, he looked more like a surf hippie than a veteran.

In 2011, while on deployment in Afghanistan the armored vehicle Tommy was in drove over an IED. It exploded directly under Tommy’s feet. His right foot ended up needing to be amputated. But it was more than a physical injury, “I felt like when I made that decision that day to amputate my foot that I lost more than just a physical part of myself,” he said. “It plays tricks on your head. It brings you to a really dark place that’s almost impossible to get out of on your own. I remember the times when I would sit there by myself and contemplate whether or not I should commit suicide.”

On the advice of his therapist, Tommy participated in Operation Surf. Even though Tommy had surfed when he was a teenager, he was skeptical that it would help him now. Then he caught his first wave, “I was just so ecstatic that I was able to stand up on that board because in that one instant I knew that everything that I thought I had lost was just something I was creating in my head. That I was going to be able to do it all. I just had to push myself to overcome these barriers that I placed in front of myself.” Tommy won the wounded warriors division at the Hawaii Adaptive Surfing Championship last year.

Surfing can have a profound impact on veterans’ mental health. Dr. Russell Crawford, Air Force veteran and licensed therapist, conducted a research study on Operation Surf participants and found that surfing decreased PTSD symptoms by 36%, decreased depression by 47%, and increased self-efficacy by 68%.

Surfing can help veterans overcome the challenges caused by war. It has given Bobby, Tommy, and hundreds of other veterans a new lease on life. You can show your support by volunteering or donating to Amazing Surf Adventures and Operation Surf by visiting their website.

Will Veteran Suicide and Mental Illness Rate Improve?

Even in Afghanistan, I will seek pet therapy! – Rick Rogers (pictured above)

It was about 9 years ago.  I decided to put down the rifle and pick up the DSM. You see, I was an infantryman since I was age 17.  That means, since I was a child, I was literally trained to kill people.  Looking back at it, that sounds like a profound concept.

I am proud of my time in the military.  I am proud of my brothers and sisters who have ever answered the call.  But…  I am also worried.

As I said, 9 years ago, I decided to change my path.  I didn’t realize where that path would lead.  I seen multiple traumas and death happen to my fellow comrades.  I went through some trauma myself, but I still worried about others more than myself.  So, I decided to become a Mental Health Specialist in the military.

It’s been a long road going from Infantryman to Social Worker. There are a lot of learned attitudes and behaviors I had to change. Can you believe it? I literally had to learn empathy.  And that took a long time.

Just about anyone in the military knows that drinking alcohol is a part of the lifestyle. Everyone I looked up to drank and considered me a p**sy if I didn’t.  So… when I was sent to Germany back in the early 2000’s as a 19 year old kid, you better believe I drank. It was legal!

Looking back at my adventures between then and now, I don’t regret a thing. Yes, there were many embarrassing moments, and I have lost many friends along the way.  I also met some great people.  My alcohol use made my path rockier than anything else.

Many others have had this experience as well.  Between 1998 and 2008, binge drinking went from 35% to 47% of veterans, and 27% of that 47% experienced combat. 

Between 2002 and 2008, misuse of opiate prescriptions went from 2 percent to 11 percent in the military.  These prescriptions were mostly due to injuries sustained in combat, as well as the strain of carrying heavy equipment.

This concerns me. When I was young, I had a good time. Looking back, maybe it wasn’t.This might not be every veteran’s experience, but the culture encouraged substance use and discouraged getting help. There are others that would agree with me.

This could explain why 20 veterans a day on average commit suicide. This is actually down from 22 a day before the 2014 study from the VA.  However, it is a 32% increase since 2001. In 2014, veteran suicides accounted for 8.5% of U.S.’s adult suicides, and the rates were especially high among 19-29 year old compared to the older generation.

Let’s not forget about the infamy of PTSD. Up to twenty percent of veterans have suffered from this. Of course, those who suffer are more likely to admit their distress to a computer program than a battle buddy or their superior.  This, again, goes with the constant culture that causes our military to fear judgment.

These wars have been a constant the last two decades, and have cost all U.S. citizens a pretty penny. According to one report, the VA spends $59 billion a year on health care.  This number is 3 times as much as it was since before 2002.

And let’s not forget the cost this country has incurred for being in war for this long.  Well, we don’t really know an exact number.  The cost is estimated by many to be in the billions or even trillions.  This isn’t including the interest from borrowed money.

So, after looking at all these figures, I am overwhelmed.  How can I even make a dent in helping our nation’s veterans? The current administration is planning on increasing our presence in war zones.  I am expecting the rate of PTSD and suicide to increase once again.  Also, our country will continue to spend.  It seems to me that we are all participating in a death and mental illness factory.   The thing is, I didn’t even get to the physical injuries many of our combatants have suffered from.

I love our nation’s military.  I want every one of them to know that I am here to support them.  But most of all, we all need to be here to support each other.

Military Service Boosts Resilience, Well-Being Among Transgender Veterans

Transgender people make up a small percentage of active-duty U.S. military personnel, but their experience in the service may yield long-term, positive effects on their mental health and quality of life.

A study from the University of Washington finds that among transgender older adults, those who had served in the military reported fewer symptoms of depression and greater mental health-related quality of life. The findings were published in a February special supplement of The Gerontologist.

The paper is part of a national, groundbreaking longitudinal study of LGBT older adults, known as “Aging with Pride: National Health, Aging, Sexuality/Gender Study,” which focuses on how a range of demographic factors, life events and medical conditions are associated with health and quality of life.

Estimated numbers of U.S. military personnel who are transgender vary widely, but range between one-tenth and three-quarters of 1 percent of the roughly 2 million active-duty and reserve forces. A study from UCLA estimates about 134,000 transgender veterans in the United States.

The new paper, by researchers from the UW School of Social Work, explores how military service affects transgender people because previous data indicated that, among LGBT people over age 50, those who identified as transgender were more likely to be veterans than lesbians, gay men or bisexuals.

Reports have indicated that transgender individuals serve in the military at higher rates than people in the general population. In the 2015 U.S. Transgender Survey of 28,000 individuals, 15 percent said they had served, compared to about 9 percent of the U.S. population overall. And yet, little is known about how military service influences the well-being of transgender veterans later in life.

Other studies have shown that transgender veterans suffer higher rates of depression than other veterans. UW researchers were somewhat surprised, then, to learn that the transgender veterans they surveyed tended to have better mental health than transgender people who hadn’t served, said lead author Charles Hoy-Ellis, a former UW doctoral student who is now an assistant professor at the University of Utah College of Social Work.

The traditionally masculine culture of the U.S. military would seem to be a potentially difficult environment for someone who doesn’t identify with the gender they were assigned at birth, he said.

But military service creates its own kind of identity, the authors said, because it presents often dangerous and traumatic challenges; overcoming those challenges builds resilience. And that’s where the identity as a transgender person enters the picture.

“Many people develop an identity as a military person — that it’s not just something they did but something that they are,” said Hoy-Ellis. “If transgender people, who are among the most marginalized, can successfully navigate a military career, with so many of the dynamics around gender in the general population and in the military, then that experience can contribute to a type of identity cohesiveness.”

The internalizing of negative stereotypes, such as those around sexual orientation, is considered a risk factor for poor mental health, added co-author Hyun-Jun Kim, a UW research scientist in the School of Social Work. Military service could be the opposite — a protective factor.

“Often when people think of the transgender population, they focus on the risk factors, but it’s equally important to focus on the protective factors and nourish those resources. In this case, what aspects of military service contribute to being a protective factor?” Kim said.

Researchers said they were somewhat limited by the size of their study sample: Out of the 2,450 people ages 50 to 100 who were surveyed for Aging with Pride, 183 identified as transgender. Of those nearly one-fourth, or 43, had served in the military. Of those who had served, 57 percent identified as female. People of color made up 29 percent of the transgender veterans in the study.

But as awareness grows about gender-identity issues, there is an opportunity to address support services for transgender veterans at the federal level and in the community, Hoy-Ellis said.

“This is a population that has served the country very proudly, and it’s important that we recognize that service,” he said. “Learning what we can about transgender older adults with military service may help us develop and implement policies and programs for people who are serving today.”

Other co-authors were Chengshi Shiu, Kathleen Sullivan, Allison Sturges and Karen Fredriksen-Goldsen, all in the UW School of Social Work. Funding was provided by the National Institutes of Health’s National Institute on Aging.

More Veterans Have Enrolled in College with Post-9/11 G.I. Bill

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Capt. Irvin Drummond, U.S. Army, studies at a computer 18 May 2007. (Photo by Chris Sanders, U.S. Army)

The Post-9/11 G.I. Bill, which covers educational costs for veterans beyond tuition, has boosted college enrollment rates among veterans by 3 percentage points compared with the earlier G.I. Bill, finds a new study by NYU’s Steinhardt School of Culture, Education, and Human Development. However, the increase in enrollment was much larger immediately after the bill’s adoption and has waned in recent years.

The study, published online in the journal Educational Evaluation and Policy Analysis, a journal of the American Educational Research Association, comes days after Congress passed a major expansion to the G.I. Bill, which – if signed into law – will provide additional educational benefits to veterans.

The Servicemen’s Readjustment Act of 1944, commonly known as the G.I. Bill, helped pay for college and other training for millions of World War II veterans. Since its inception, the G.I. Bill has been updated to continue providing educational benefits, with the most recent expansion being the Post-9/11 Veterans Educational Assistance Act of 2008, or Post-9/11 G.I. Bill.

“The original G.I. Bill not only significantly improved the human capital in the United States after World War II, but also democratized American higher education and created a robust middle class. Education benefits provided by the bill allowed veterans to go back to college and obtain necessary knowledge and skills, while also serving as an important entry point back to civilian life,” said Liang Zhang, the study’s author and a professor of higher education at NYU Steinhardt.

The Post-9/11 G.I. Bill, which took effect in August 2009, offers more generous educational benefits than the previous version of the bill. It covers full tuition and fees at in-state public schools (or up to a set amount for tuition and fees at private institutions), a monthly housing allowance, and up to $1,000 a year for books and supplies. All veterans who have served since September 2001 are eligible for the Post-9/11 G.I. Bill, meaning that those who did not take advantage of benefits under the previous bill were retroactively eligible.

In this study, Zhang examined the impact of the Post-9/11 G.I. Bill – including its monthly housing allowance and stipend to cover miscellaneous educational costs – on veterans’ college participation.

Zhang used 11 years of data (2005 to 2015) from the American Community Survey, which resulted in a sample of approximately 200,000 veterans who have served in the post-9/11 era. This sample enabled a comparison between data from before and after the 2009 adoption of the Post-9/11 G.I. Bill in order to determine how veterans might have reacted differently to the bill over time.

Zhang found that the Post-9/11 G.I. Bill increased overall college enrollment by about 3 percentage points when compared with enrollment prior to the bill’s adoption. However, the effect was much larger immediately after the bill’s adoption (approximately 4 percentage points) and has waned in recent years (to about 2 percentage points), suggesting that part of the initial enrollment burst was due to the retroactive nature of the bill.

Despite the increase in enrollment, Zhang noted that the effect of the Post-9/11 G.I. Bill is much smaller than the effects of typical financial aid programs, which have been shown to improve enrollment by about 3 to 6 percentage points for every $1,000 reduction in college costs.

In addition, Zhang examined how the bill affected college enrollment among veterans ranging from 20 to 60 years old, given that veterans typically follow a different educational trajectory than that of nonveterans. He found that the Post-9/11 G.I. Bill has had a consistent and positive impact on college enrollment among veterans of all ages, even among older veterans who are usually considered less likely to enroll in college.

“This suggests that older veterans may be more responsive to financial incentives, echoing previous research findings that older students are more responsive to financial aid than younger students,” Zhang said.

Finally, Zhang looked at the levels of existing educational attainment among veterans, since the Post-9/11 G.I. Bill can be used for a variety of educational and training programs, including both undergraduate and graduate education. He found consistent and positive enrollment effects across veterans with all levels of education, with those already holding master’s degrees taking the most advantage of the bill’s educational benefits.

Zhang concluded that it is both important to evaluate the effect of veterans’ programs on college enrollment, as well as to consider the social impact of the bill – which is broader and more profound than any college-related outcomes could possibly measure.

“While providing generous education benefits to veterans could ease the financial burden of going to college, research shows that veterans can face additional challenges associated with service-related injuries and disabilities, as well as being older students. Higher education institutions must continue to better understand and support this growing, yet potentially vulnerable student population, to best serve those who served the country,” said Zhang.

What Do Service Women Need: Invisible Veterans but Resilient Leaders

As a military health researcher, I hear veteran women tell me all the time that they sometimes feel invisible. The Service Women’s Action Network is calling for active duty, reserve, Guard, and veteran women to help change that.

Take our 2017 needs assessment and help government, community, and advocacy groups develop THE RIGHT programs to meet the needs of military women past, present, and future. The survey is short and easy, and it will help us make our community’s diverse voices heard.

Our assessment last year helped us understand and share information about belonging and support – it shed interesting light on the need for service organizations to open their doors to women in new, inclusive ways.

You see, women veterans share many of the exact same concerns as our male colleagues; yet we also face unique issues, especially when it comes to accessing services after we leave active duty.

Some of the most important places veterans connect, network, and socialize while transitioning our Military and Veteran Service Organizations (MSOs/VSOs). However, our team’s latest research in the Journal of Veterans Studies indicates that women veterans participate less and even report feeling unwelcome in those very spaces.

Be part of the solution this year by taking the survey! Military women are some of the most resilient leaders you’ll meet, and you can change our reintegration experiences if you help make that visible.

Loneliness Kills: Lessons From a Combat Hospital

Kate Hendricks (center)

I used to think I understood health. I worked in fitness and told people about it for a living. I WAS WRONG. Focusing only on movement and nutrition, I was missing the bedrock concept upon which real health is built. We are wired to connect and social health is the foundation of human well-being. (Check out the science behind this in my just-released TEDx talk).

This is what I study today, but in a life quite different than my current as a suburban mom and public health professor, I was a Marine Corps Military Police Officer. I have a little brother who also joined the Marines and we’ve always been very close, probably because we had to be! When we were young we moved over 20 times – there was many a summer where my siblings were my only friends because we were the new kids.

I was already deployed to Iraq when he e-mailed me to share his grand romantic plans to propose to his girlfriend before he headed over. She was a civilian schoolteacher that I had yet to meet. I was in my cynical deployment mode and I was surrounded by Marines receiving what we call “Dear John” letters. They often read the same, “the grind of deployment is too much, our relationship is over, I already have a new significant other, the end.” I didn’t think his proposal would wind up any differently because he was headed to Iraq right behind me, but I wanted to be supportive so I told him I didn’t have a problem with the proposal but admonished him to buy her a ring made out of cubic zirconia. No sense in buying a diamond he might never get back.

As younger brothers often do, he ignored my advice and bought her a beautiful ring.

Well, that is some cash he will never see again! Should have listened to me!

When he was coming in I had convoyed south and I was able to be there at the hangar in the middle of the night when he flew in. Even armed and incredibly well-trained my brother will always look like a little kid to me. He was walking towards me with a huge pack on his back, a Kevlar on his head, and a rifle in his hands. All I could see were his big, blue eyes peeking out like a turtle under all that gear and I thought, “who let a ten year old on the plane with a rifle???”

As I stood watching his C-130 unload on the tarmac I forgot to feel invincible for a moment and my heart sunk – I knew where he was heading and I knew what was happening there. I had some big sister notions of telling him what he needed to know to stay safe during his deployment and for the first time it occurred to me that may not be enough.

Soon after I was headed home to the states and I didn’t know it at the time, but he was as well. Except that an improvised explosive device made sure that his trip home was wounded and on a stretcher.

When a service member is medically evacuated and they make it to the stateside hospital, there are no guarantees and a lot of unknowns.

When my brother arrived at Bethesda, we didn’t know what he might be facing. Our family came together to be there for him, but even with our support system gathered, Bethesda was a dark place some days.

Into this world walked my brother’s civilian schoolteacher.

Frankly, I didn’t yet know if she was part of our close-knit family. I had stereotyped her on sight—mostly because she was a pretty girl who often wore makeup and always had on matching accessories. I was waiting for her to fall apart.

She never did.

When her leave ran out at work she went back to teaching all day long in nearby Virginia, but made the drive every night to sleep in a chair at my brother’s bedside. I was terrible in that hospital room always dropping things – just graceless. She kept him smiling and focusing on their future together. She kept him connected to their community of friends when he left the hospital and had to spend his days in a reclining chair. She kept him looking forward to new plans to build a family, even when they had to install bars over his bed at home and he needed help with the most basic tasks.

That makeup had fooled me; she was more than serious. She showed up, and she was a foundation for my little brother when he really needed one.

They got married and she gained three sisters that would help her hide a body today if she asked.

She has a really good memory though. Every now and again, I hear about that cubic zirconia comment.

The Science of Social Cohesion

Here’s the truth about human health – nothing will kill you faster than loneliness.

We know all of this because scientists have studied social cohesion from a variety of angles and proven that disconnection is dangerous! We’ve studied partner relationships, friendships, and civic involvement – it is all important and comprises our social health. In one study, medical students without many friends had depressed immune systems. A 30 year study out of Roseto, PA found that support protected against heart disease even when the diet wasn’t ideal. My own research has demonstrated convincingly that people without partnerships are at greater risk for depression.

We talk in public health about behaviors that offer something called protective effect and upping your social support has more protective effect than quitting smoking. Don’t hear me wrong – smoking is still bad!

The reason for that can be found in our physiology. Stress hormones surge when you’re feeling lonely or rejected, and if this happens too often or for too long, you start seeing problems.

Cortisol and adrenaline are useful when facing a real threat – they fire us up to respond, but they also shut down everything non-essential. Our heart rate and our breathing rate jump up and blood flows to our biggest muscles. Energy to the logical brain, digestive system, and even blood flow to our extremities is diverted.

If hormone levels stay up, you can imagine the problems your body starts to face. At first, diminished blood flow to the extremities is just cold fingers and toes. Over time it might become neuropathy. Then, you stop feeling and have trouble picking things up or even balancing – in this way our body is trying to signal us – loudly, in the only way that it can – social numbing becomes physical numbing.

Our brain activity being interrupted may mean initially only that it becomes tough to find our car keys. Soon enough, we begin to have difficulty communicating, displaying empathy, or engaging in high-level thinking. This makes connecting with others even more challenging, and our isolation can easily become self-perpetuating.

I work in military public health today, and for a long time, all we talked about was the correlation between post-traumatic stress and combat deployments. That’s not the whole story, though – it’s far too simple. The riskiest time for veterans is the first six months of coming out into the civilian world. We face that complex mix of losing identity, our purposeful, all-consuming work, and the biggest loss – our tightly-bound community.

Conclusion: So-What Factor

When social support is happening the way we want it to, you get a veteran reintegration story like my brother’s.  In our family, he is still everyone’s favorite. He’s now a dad and a slightly-intense High School English teacher.  His wife is hilarious and keeps us all on our toes.

When it’s not, you get one like mine, and like too many of our service members leaving active duty today.

I struggled with pulling the right people around me after deployment and that time at the hospital. I was angry, guilty, then angry some more. I drew inward and sought to surround myself with people who had similar experiences to my own.

The results for me weren’t pretty. I worked too hard, drank too much, and communicated not at all. I found a relationship that was as volatile and crazy as I was feeling on the inside. I didn’t know the meaning of the word “introspection” or the phrase – ‘I need help.’” There was a time I could’ve wound up an isolated, angry statistic.

The social health issues I’m talking about aren’t strictly veteran problems. The angry veteran, the elderly shut-in, and the person in an emotionally abusive relationship all deal with the same physical effects.

All of us have to prioritize it.

I was never lonely exactly, I certainly had people around me, but I had too many of the wrong people, and I had no one who ever challenged the way I was doing things.

We all need the strength that an uplifting group of different – and thus complementary – personalities brings us. So I had to ask myself, as I encourage you to ask yourself – how are my people?

Do they support you? We need affirming, yes.

Do they challenge you? We also need different.

Connect. Be willing to get a little uncomfortable – It can completely change your health.

Trauma-Informed Care for Veterans

By Kate Hendricks Thompson and Sarah Plummer Taylor

wic-plummer-friend

An increase in trauma-informed care leads to more efficient and effective response at every level of patient care, and thus, a reduction of wait times at VA Hospitals.

Rebecca served nine years as a Marine Officer, and had relied upon the Veterans Administration Medical Center (VAMC) for her health care since departing active duty.  She was a devoted runner trying to get back in shape, but a few months into this well-intentioned effort she found herself calling the VAMC appointment line.  Her Achilles tendon was swollen and painful, and she found herself limping through busy days. The first call to the appointment line resulted in a referral, a message taken, and the promise of a call back. The nurse who called back wasn’t authorized to book anything beyond 24-hours out, and the promise of a return call was again offered. A week later, the phone had not rung, and Rebecca was still limping along without an appointment.

Military veterans consistently report access problems with Veterans Affairs (VA) hospitals and outpatient clinics.  Patients in Phoenix reportedly died while waiting for slow cancer care.  The issue is an administrative and ethical conundrum; veteran satisfaction rates and overall patient wait times must be improved.

The solution is not entirely structural, though more infrastructure and staff would directly reduce wait times because more providers are available.  The answer to date has been the bandage of increased oversight – stipulating tighter regulation and monitoring of recorded wait times. The intention of such accountability measures is consistently undermined by employees incentivized to modify the numbers, and it is a rare whistle-blower willing to call attention to the statistical maneuvering.

If adding more directives to reduce wait times has been met with maintenance of the defunct status quo, how can we improve accountability while working within the current system reality?

The answer involves expanding the standard of care and embracing holistic wellness. First and foremost, we need to make the process of receiving care easier, more effective, and more efficient, and one of the best and most empirically validated ways to do so is to offer trauma-informed care. Trauma-informed means knowing the history of past and current abuse or trauma in the life of the consumer with whom one is working and to understand the role that violence and victimization play in the lives of most consumers of mental health and substance abuse services, thereby utilizing that understanding to design service systems that accommodate the vulnerabilities of trauma survivors and allow services to be delivered in a way that will facilitate consumer participation in treatment. With trauma at the center of understanding, all parties – clients, providers, clinicians, and programs – will benefit.

We must begin providing trauma-informed care at all levels of care, from point A to point Z in the care cycle for our veterans, working with existing VA employees, staff, and providers. Our veterans are coming from a place of trauma, be that trauma combat or simple transition.

VA hospitals are not public hospitals. Therefore, trauma-informed care must be a requirement for any person in the VA.

 Research has convincingly shown that it is not just mental health care providers who need a trauma-informed approach, and sadly even many of those providers do not have this background. For instance, psychiatrists are not taught to account for cultural, environmental, economic, gender, or trauma history differences among clients. Social workers, for example, are exclusively trained and educated from this perspective of the prevalence of trauma and the impact of environmental factors.

How does this impact wait times?  Education of the entire staff is required, not just the person the veteran encounters after the 5th stage of waiting (multiple phone calls, an employee they encounter in the parking lot, the volunteer at the front desk, employees inside the building, the receptionist at the clinic office) because all of those stages of interaction impact how care is sought, followed up with or not, or perceived by the patient.  Part of wait time computation involves the actual time but some of it is the perception of time – sometimes a 2 hour wait can feel worse than a week long wait; it depends on how the person who is addressing you talks to you. Veteran perceptions are important and impact how they feel about care received.

  • Improving the staff’s trauma-informed perspective improves wait times by improving and tailoring the environment. Frankly, this trauma-informed paradigm can be used as an incentive to the care provider because the whole process becomes more humane to them. As they are trauma-informed they address people differently.
  • Trauma-informed personnel are more likely to address issues more effectively and efficiently. As empathy and understanding increase, so does efficiency because veterans come in to be treated, feel safe doing so, are being treated one time, versus becoming overwhelmed and leaving, necessitating another visit. For instance, if a veteran enters the hospital and is yelled at by the person behind the desk, or harassed by a janitor, he or she very well may turn around and leave. The veteran will then have to call in again, make another appointment, likely be perceived as disrupting the system and be chastised for not showing up for their appointment. The whole process not only may be re-traumatizing, but will add to the backlog of appointments.
  • Trauma-informed care creates safer environments. Feelings of safety are fundamental to effective health care, especially effective mental health care. Thus, veterans are more likely to feel comfortable coming in for proactive and preventative care versus waiting until they find themselves in a most extreme case which then often requires more resources for a longer amount of time, resulting in more pressure on the system again.
  • Trauma-informed care creates better-informed clients. Veteran patient clients, when treated with the respect a trauma-informed model demands, are well-informed at every stage of care, from administrative matters to the care itself. Lack of information leads to confusion and threatens the basic need for feelings of safety. Waiting for return phone calls that never come, or waiting in a waiting room for hours on end well after their scheduled appointment time, are re-traumatizing (and common) occurrences for veterans seeking care at VA hospitals. Trauma-informed care standards would mandate that appointment times be honored, that waiting room facilities are safe and comfortable, and that a patient is communicated to regularly and with respect about the process required to receive care.

Every single employee at a VA hospital needs some trauma-informed education and training, not just psychiatrists. Through a trauma-informed lens, any staff member can see issues more clearly and solve problems where they occur. This would mean, for instance, having a person at the entrance of the VA Hospital who is calm, clear and helpful; not an untrained, random volunteer. Having staff members who are trained in harm reduction and de-escalation techniques is also critical to trauma-informed training, education, and care provision. To shift culture, you cannot just train the leaders. All employees at the VA should receive at least a basic level of training of trauma-informed care. This absolutely also includes care providers.

We do not need more regulations and stipulations on time-frames, which are already in place and already not being followed. Veterans and the families who support them are calling for a true cultural shift in care, one that can be achieved with training and standard of care expansion.

Editor’s note: This article was jointly authored. Sarah Plummer Taylor, MSW is an established leader in the field of resilience building, holistic wellness, and leadership training. Learn more at SEMPER Sarah®. Kate Hendricks Thomas, PhD is an Assistant Professor of Public Health at Charleston Southern University. 

Mental Fitness Training: A New Military and Veteran Mental Health Paradigm

ptsd-treatment-protocols-05
The idea that PTSD is an unalterable, lifetime sentence is neurologically untrue. This is good news!!! So why haven’t our conversations about military mental health moved from narratives of broken veterans and disability diagnoses? Let’s have a new conversation with military personnel about mental health –

Stress Injuries vs. PTSD

Stress injuries are very natural responses to unusual situations and exist along a spectrum. Whether you’ve experienced a single traumatic event or multiple stressors over a long period of time, your body likely responded in a totally appropriate way by adapting to the threat. Your nervous system kicked into high gear – your body and brain woke up and went into overdrive.

savasanaYour response was vital to navigating a stressful or dangerous situation well. However, now that imminent danger is past, your stress response may still activate out of context. When this happens, empathy may disappear, your focus may degrade, and you may struggle to make logical decisions.

It’s true that severe stress injury (also known as PTSD) is a complicated disorder. However, healthcare practitioners often apply the “chronic” label to mild or moderate stress injuries – which are 100% recoverable. This label can be psychologically deadly – sapping resilient people of the agency they need to learn and apply tools to quickly de-escalate the body and brain’s response to perceived threats.

The truth is that PTSD is not everyone’s stress injury. A misdiagnosis suggests irrecoverable brokenness, and can layer on a host of additional anxieties and worries.  It also keeps us talking about problems rather than focusing on solutions and prevention through mental fitness.

Road to Recovery

One of the most empowering first steps you can take toward recovery is to seek out information about stress physiology – work to understand what is happening in your body.

Self education is an incredibly empowering step. You’ll discover that your out-of-context responses are natural, and you’ll simultaneously find ways to calm your body and mind through a variety of self care practices.

When you put these tools into practice on a daily basis, your body and brain will respond in some really interesting ways. Your neurons will fire differently, you’ll shrink the amygdala (the part of your brain that activates the fight or flight response) – your brain will literally start to look different. Stress hormones will drop, too.

Not only will your body and mind change, but so will your behavior. You’ll find that you’re better able to handle a fight with your partner. You’ll be able to focus better and exist with more empathy. Of course, you’re still human. Your stress response will still fire. But by practicing effective self care, you can begin to respond to others in a more deliberate way.

But what if a vet’s stress injury is severe?

Some people experience permanent changes to their brains. If your injury co-occurs with a Traumatic Brain Injury, depression, or an anxiety disorder, that is totally normal, but incredibly challenging. When you have a major stress injury and you’re dealing with a chronic condition, the symptoms can be extremely debilitating.

The symptoms of severe stress injuries can be improved upon, but – much like a bad back injury – you may need to accept that your condition will need to be managed for many years to come.

* For severe stress injury, you will need highly individualized clinical help. Seek medical guidance and talk to your clinician about your specific stress injury and wellness techniques.

Training for Mental Fitness

What is really exciting for today’s law enforcement, military, and emergency management communities is that mental fitness and resilience can be taught, trained for, and tested.

The three pillars of a resilient life are social support, self-care, and spirituality. The individual value of these pillars is backed irrefutably by science, and – when practiced together – their benefits increase exponentially.

Ready to get started? Here are some simple tactics you can start using today to build a better life.

  1. Social Support: Surround Yourself with Good People

The first and most important step in building resilience is making the hard choice to surround yourself with great people. If you don’t have them around you, you can’t get started. You won’t start or keep growing.

Take a moment to honestly evaluate the influence of the people in your life. Is their influence negative and destructive or positive? If you don’t have great people around you right now, that’s ok. It means you have plenty of room to grow.

  1. Self-Care: Calm Your Body and Mind

Start here by choosing just one or two healthy practices you can incorporate as daily habits, then track how they benefit your life. Don’t worry about trying to change everything at once.

By practicing effective self-care to calm your body and mind, you can become less reactive to external stressors. When you’re less reactive, you’re more capable of engaging in positive social interactions. There’s a ripple effect here that’s really exciting.

Self-care can be as simple as cooking at home or going back to the gym. What you’re looking for is something that makes you feel relaxed. You might be working hard, but you’re going to feel your sympathetic nervous system (body and mind) calm down. Some people call it a click. An exhale.  A down-shifting. When you feel it, you’ll know you found your thing.

  1. Spirituality: Find Your Meaning

Finally, there’s a clear correlation between physical, mental, and emotional resilience and a sense of meaning in our lives. We all need a connection to someone higher – with God, or a sense of personal purpose. Whether you approach this aspect of resilience from a secular perspective (think Maslow’s hierarchy with transcendence at the top) or with a theological view, give yourself some time to ask questions about the source of purpose and meaning in your life.

To plug into a community that supports you as you explore this aspect of resilience, consider getting involved with a faith group, volunteering, or taking time to study some concepts of purposeful living you’re curious about.

Remember – the practices that make us a better warrior also make us better parents, partners, friends, and professionals. Make the time for mental fitness, whether you are recovering, preparing, or both!

5 Ways a PTSD Service Dog Can Help

U.S. Navy Hospital Corpsman 3rd Class Sean Stevenson takes a knee while on a security patrol in Sangin, Afghanistan, June 6, 2011. Stevenson is a corpsman with Combined Anti-Armor Team 2, Weapons Company, 1st Battalion, 5th Marines, Regimental Combat Team 8. The U.S. Marines conduct frequent patrols through the area to show a presence and interact with the community to find ways to help the populace. (U.S. Marine Corps photo by Cpl. Nathan McCord/Released)
U.S. Navy Hospital Corpsman 3rd Class Sean Stevenson takes a knee while on a security patrol in Sangin, Afghanistan, June 6, 2011. Stevenson is a corpsman with Combined Anti-Armor Team 2, Weapons Company, 1st Battalion, 5th Marines, Regimental Combat Team 8. The U.S. Marines conduct frequent patrols through the area to show a presence and interact with the community to find ways to help the populace. (U.S. Marine Corps photo by Cpl. Nathan McCord/Released)

Post-traumatic Stress Disorder (PTSD) is a mental disorder that results from a traumatic experience. Common symptoms are nightmares, flashbacks, intrusive memories, depression, and anxiety following a traumatic event. Living with PTSD can be very difficult. Public outings may result in flashbacks while depression can become overwhelming if the person stays at home.

The risk of depression is high as well as the risk of suicide. While there are very effective treatments available for people with PTSD, a service dog can be a very useful support. Here are a few reasons you might want to consider getting a PTSD service dog.

They Encourage Exercise

Any dog needs someone to play with them and take them for walks. This physical activity is a very beneficial way to help treat PTSD. The positive endorphins that are produced during exercise can help combat depression and anxiety as well as improving physical fitness. Even on bad days, it’s hard to say no to a dog begging for a walk.

They Prevent Social Isolation

0-4Dogs are a wonderful way to cushion social interactions. They attract friendly people who want to pet them while providing something for you to talk about. Walks or trips to the dog park will force you to get out and see other people rather than isolate yourself in your home.

They Can Make Public Outings More Feasible

A trained service dog will be able to recognize when you have an episode and either comfort you or lead you to safety. They can also be trained to lead you to the nearest entrance in anticipation of an episode. These specialized skills can make going out in public safer, easier, and more comfortable for their handler.

They Can Recognize and Act Upon Nightmares

For at-home assistance, service dogs may be trained to fetch medication or even interrupt nightmares. When you are having a nightmare, the dog may be able to wake you and halt the nightmare, making it easier to recover and go back to sleep. If you have woken up from a nightmare, the dog will be able to provide comfort in the form of pressure or affection, also helping to prevent insomnia.

They Make Therapy Sessions Easier

Attending therapy for PTSD can be very difficult. You will need to discuss your trauma, the symptoms you are experiencing, and other potentially painful subject matter. With a dog by your side to stroke and seek comfort from, talking about these topics can become easier. The dog can also become part of your treatment plan, whether that means taking it to a new destination each week or simply spending a few hours a day on training sessions.

Though a dog is certainly a financial responsibility and a well-trained service dog can be expensive, the benefits a service dog has to offer are worth it. Even an untrained dog can be a wonderful addition to your home if you are suffering from PTSD. The unconditional love, encouragement to exercise, and help in social situations might even be all you need to start recovering.

https://www.youtube.com/watch?v=nZOaR1vnBik

How Do We Alter the Dialogue About Resilence

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Despite the vast news coverage of the wars in Iraq and Afghanistan since 2001, one figure has remained mysterious: the number of suicides among US servicemen and women, compared to combat casualties. Here’s one statistic to contemplate: In 2012, the US military lost 295 soldiers, sailors, airmen, and Marines in combat in Afghanistan. But over this same time period, 349 took their own lives.

Right now, we are losing more veterans to suicide than to combat. I’m a pretty decisive person with limited ability to ask for help and zero trouble-taking risks; there was a time I could have become one of those statistics.

Those figures are mysterious because even as we throw money and resources at clinical mental health treatment and blame rising rates on multiple deployments, the answers are elusive. The narrative of the “broken veteran” struggling with combat stress just doesn’t ring quite true to those of us who served over the last decade, and the issue is more complicated than simple statistics can show.

I became a Marine to serve, and I loved being part of the Corps. As with anything I have ever loved intensely, the military changed and shaped me. To the casual observer looking in, the world seems brutal and intense. That casual observer isn’t entirely wrong—the military is some of those things. Shared hardship and challenge are vital parts of the refining and rebuilding process that changes a civilian into a warrior. If you ask anyone who served, they wouldn’t have it any other way. No one wants what comes easily or is handed to just anyone.

That process of obstacles, mastery experience, and shared suffering offers growth and transformation, but coming back to civilian life afterward can be incredibly hard. Standards are different. Camaraderie is different. Culture is absolutely different. I witnessed firsthand the toll that leaving the service took on many of us.

Stressful work environments, high rates of divorce and domestic violence, family separation, and repeated combat deployments all contributed, but the biggest reason for the reintegration problems many of us faced is cultural. We subscribe to unbalanced notions of what it means to be a warrior and uphold silent suffering as a virtue. Mistakes are shameful; pain is weakness. Saying that something is hard or stressful just isn’t done.

I don’t want to contribute to the silence that surrounds these issues anymore. Too many aspects of warrior culture are destructive lies we tell ourselves.

Who are we maintaining this veneer for?  What do we have to prove anymore?

Constant invulnerability is an illusion, and cultural mandates to be “together” in every way become dangerously prescriptive. We lose our authenticity in this way; we don’t know how to reach out to each other when stresses start to overwhelm us. Too many of us who are used to appearing strong would, indeed, rather consider suicide than admit to being human, fallible, or broken.

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Dr. Kate Hendricks Thomas

My own public story was of crisp uniforms, physical fitness metrics, and successes. I always looked good on paper. My private story involved destructive choices, broken doors and holes in the walls, hiding weapons in the house, and getting dragged across the living room floor by my hair. I was as far from God as a person could be but had no idea at the time.

As a Marine Officer, I was not supposed to make mistakes, feel depressed, or need help. But I did. Tough places and situations became tougher because I didn’t know that people might be okay with an imperfect version of me. For too long I chose silence over reaching out to loved ones. I opted for deeply felt, visceral shame over openness and vulnerability.

When serving in the military we are trained to lead with confidence. Presenting a certain and effective façade requires some incredibly useful skills. We make decisions quickly and responsively, but these very same skills become incredibly destructive when we never learn how to turn them off. This description fits most service members. We tend to be a driven, almost comically dysfunctional, lot.

What if I told you that I am not perfect?

What is so useful about sharing our experiences with one another is that we offer each other the opportunity to say that kindest of phrases: “Me too.”

We are not alone.

The determined avoidance of care-seeking I lived through is disturbingly normal in the military community that I call home. For me, learning to do better involved stumbling by accident into the three key components required to build human resilience. My later academic study brought a wry smile to my face as I realized that the answer had always been there; I just hadn’t known it when I needed to.

What if I had training in resilience before hitting rocky shoals?

To get to a healthier space, I had to make some hard choices, choices that involved leaving destructive patterns and people in the rearview mirror. It felt like dying to do so, but it allowed me space to breathe and to focus on becoming a new version of myself. Once I deliberately and consciously began stepping outside old patterns and belief systems to connect with and serve my community, embrace a healthy lifestyle, and seek and find an authentic relationship with God, the world stopped spinning in quite such an unforgiving fashion.

It wasn’t a chaplain or a counselor who pointed me in the direction of wholeness, though I certainly tried those routes. I keenly remember sitting in my first counseling session with a well-intentioned professional, answering her with short sentences and half-truths. While I have great respect for clinical mental health practice, many of us are not interested in embracing the identity of a patient. I never was. I sneered at things that would have been really useful!

You can keep your couch.

I’m a true nerd at my core, and when the dust cleared in my personal life I became motivated to learn all I could about how we as veterans are talking about mental health. I went back to school for an interminably long period of time and threw myself into community-based programming and health promotion. When I really drilled down in my issue analyses, I didn’t much like what I found. We are killing ourselves alone in apartments and no one is seeing any symptoms—we are that good at hiding out. It really isn’t that services aren’t available to veterans and military personnel when things become difficult, we just won’t use them.

No matter what magic we do in the clinical realm, focusing on treatment requires a disempowerment narrative that is perceived as being incompatible with the cultural values of military veterans. We cannot overcome such norms by asking warriors to become patients and pop pills, no matter how dedicated, innovative, and gifted the clinician is. While treatment is certainly part of the solution, it is not culturally acceptable for it to be the entire answer.

I know this to be true on both an academic and a personal level and believe we need to alter the dialogue about resilience. We must flip the current paradigm and turn words that currently connote weakness (like authenticity, self-care practices, and social cohesion) into training mandates and metrics of performance.

There is tremendous work to be done.

Trying to do that work is a translational team coming together at the 2016 Service member to Civilian Summit. S2C brings together researchers, practitioners, government employees, veterans, and military-connected family members to talk about best practices and processes to improve veteran health and reintegration. Speakers include field leaders like:

There is still time to join us. Register today.

Telemental Health: Improving Access to Veterans’ Mental Healthcare

By Brian Neese

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Photo Credit: Dublin VA

Military members comprise less than 1 percent of the U.S. population, yet veterans represent 20 percent of suicides nationally, according to the National Alliance on Mental Illness. Each day, about 22 veterans die from suicide.

An issue affecting mental healthcare for veterans is accessibility. In the spring of 2014, the U.S. Department of Veterans Affairs (VA) wait time scandal emerged when allegations surfaced of veterans dying while waiting for care at the Phoenix VA Health Care System, according to Military Times. Wait time issues and manipulated appointment scheduling highlighted a nationwide problem and resulted in several top officials resigning or retiring.

Months later, Congress passed a $15 billion bill allowing more veterans to seek care in the private sector through the VA Choice program. Meanwhile, the VA continued focusing efforts on telemental health, or the use of telecommunications technology to provide behavioral health services, to try to improve veterans’ access to mental health services, National Psychologist reports.

Accessibility

Nearly one in four active duty military members show signs of a mental health condition, based on a study in JAMA Psychiatry. With 44 percent of veterans returning home from Iraq and Afghanistan to rural zip codes, accessibility becomes an important topic for veterans’ mental healthcare. This is a natural strength of telemental health services, which can include clinical assessment, individual and group therapy, educational intervention, cognitive testing and general psychiatric treatment.

The first telemental health program funded by the VA’s Office of Rural Health is at the Portland VA Center in Oregon. Through telemental health sessions, veterans saved 826,290 miles driven and $161,126 worth of gasoline in 2013, program director Mark Ward said. Some veterans who live far from Portland and lack high-speed internet are given electronic tablets and notebooks for videoconferencing.

Telemental health can increase veterans’ access to services and eliminate travel. Another benefit is that telemental health can help veterans overcome the perceived stigma sometimes associated with seeking mental health treatment. Veterans who might feel embarrassed or ashamed to get help in person can receive care in their home.

The VA delivered a total of more than 650,000 telemental health sessions nationally from the program’s inception in 2004 through 2014. The VA anticipated delivering 300,000 telemental health visits for 115,000 veterans in 2014, an increase from more than 200,000 telemental health visits for 80,000 veterans the previous year. Additionally, the VA has created free smartphone apps that veterans can use to help with post-traumatic stress disorder (PTSD), such as the PTSD Coach application developed by the VA and the Department of Defense.

Telemental health has made progress in improving accessibility for veterans’ healthcare, and it will be needed to make further ground. The Government Accountability Office found that 18 months after the wait time scandal, the VA still struggled with wait times and patients’ schedules.

Effectiveness

The first large-scale assessment of telemental health services was published in Psychiatric Services. This study assessed clinical outcomes of 98,609 mental health patients before and after enrollment in telemental health services of the VA between 2006 and 2010. During this time, psychiatric admissions of telemental health patients decreased by an average of about 24 percent, and patients’ hospitalization lengths decreased by an average of nearly 27 percent.

A survey of veterans found high levels of satisfaction and perceived safety with home-based telemental health provided by the VA pilot program in Portland, according to the International Journal of Psychiatry in Medicine. Findings support the feasibility and safety of using technology in the home for the delivery of mental health services. Additionally, results suggest fewer no-show appointments in home-based telemental health compared to clinic-based telemental health.

Currently, telemental health is regarded as appropriate for general clinical use. Yet, the VA cautions that more needs to be known about using telemental health services for conditions such as PTSD, which Jama Psychiatry says is 15 times higher for those in the military than civilians. “While preliminary research has clearly established that a variety of telemental health modalities are feasible, reliable, and satisfactory for general clinical assessments and care, less is known about the clinical application and general effectiveness of telemental health modalities employed in the assessment or treatment of PTSD,” the VA says.

The Need for Behavioral Health Professionals

Approaches such as telemental health can support better access to behavioral healthcare and are expected to grow as a result. Yet, more professionals are needed for rising populations of veterans, children and others in need of services.

The online B.A. in Behavioral Health from Alvernia University enables students to meet this need. Some graduates enter fields such as addiction counseling, long-term care and child welfare, while others enter graduate studies. The program takes place in a convenient online format to accommodate students’ work and personal schedules.

9 Mobile Apps for Social Workers

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Add digital skills to the many skill sets we wear as social workers. Our clients are carrying around devices that can serve as a secondary tool to support practice and our primary connections. Many practitioners feel that technology is taking away from the human interaction. However, technology can actually enhance our practice and empower our clients while scaling our efforts.

For instance, we can reach people in rural areas we weren’t able to reach before, empower clients to monitor their moods outside of sessions and have real time data to discuss in session, make connections with children on the autism spectrum that is difficult for a human to make, assess suicidal ideations, alert authorities/contact of domestic violence situations in real time, and the list goes on.  We must not fear technology as it is here to stay.  In fact, they are now moving into the world of the Internet of Things (IOT) such as wearable technology.

The social work practice will not progress by chance, we will have to embrace and educate ourselves on technology in order to most effectively advocate for our clients and the profession.

  • “Most social workers have no access to data in the field, even though worldwide global mobile access is above 87%.” Northwoods Business Brief
  • “Smartphone owners use an average of 24 apps per month but spend more than 80 percent of their [in app] time on just five apps.” Forrester Data
  • “To date, 85.5 percent of the world subscribes to mobile phone services…” Technology for good: Innovative use of technology by charities

Mobile apps are a wonderful tool, however they are just that: a tool.  They should not replace the relationship but rather enhance and augment the work you are doing.

1.     PTSD Coach – “The PTSD Coach app can help you learn about and manage symptoms that often occur after trauma. Features include:

  • Reliable information on PTSD and treatments that work
  • Tools for screening and tracking your symptoms
  • Convenient, easy-to-use tools to help you handle stress symptoms
  • Direct links to support and help
  • Always with you when you need it

Providing you with facts and self-help skills based on research.” (iTunes, Google Play)

Tags: Veterans, Mental Health

2.     Northwoods Compass CoPilot – “It’s the ideal solution for mobile social workers at child and adult protective services agencies, and other workers who visit clients in their homes or other locations. Social workers in the field use Compass CoPilot to access all case and client information, forms, and documents, just as they would in the office. It’s the only social services software to ensure that social workers are never without the files and information they need while they’re on the road. During client visits, social workers can use Compass CoPilot to record interviews, take photos, document, and notate their findings — all while they are in the field. Being able to accomplish all of this with a tablet makes the information gathering less intrusive, which helps put clients at ease and allows for better interactions. Our innovative social service software syncs the new information with the agency’s Compass® system back at the office.” (iTunes)

Tags: Child Welfare, Case Mangement

3.     Classdojo – “Easily encourage students on participation, perseverance, or something else? Customize ClassDojo to work for your classroom.  See a timeline of students’ progress, share a beautiful timeline of all the wonderful things your students do. Students love how positive classrooms are and it saves teachers valuable class time, too.” (iTunes, Google Play)

Tags: School Social Work, Autism

4.     TF-CBT Triangle of Life – “new [free] mobile game app helps children who have experienced trauma by letting them use their tablets or smartphones to practice life skills they have learned in the therapist’s office. With the tagline “Change how you think; change your life,” the TF-CBT Triangle of Life game is designed to help children age 8-12 better understand their thoughts, feelings and behaviors, and move toward a better quality of life. During this game, the player takes the role of the lion in a jungle story, guiding other animals toward more positive experiences and relationships.” (iTunes,Google Play)

Tags: Mental Health, Trauma, CBT, Therapist

5.     Aspire News – “A domestic violence app is disguised as a normal icon and even has a decoy home page, so you’ll be safe if your abuser takes your phone. The most important feature of the Aspire News app is called the GO Button, which you can activate the moment you are in danger. Once activated, the GO Button will send a pre-typed or pre-recorded message to multiple trusted, preselected contacts, or even 911, saying that you are in trouble. Additionally, once the app is activated, your phone will begin recording audio of everything that is going on in the room, which can be used as evidence for any legal proceedings that may stem from the incident. Robin emphasizes that it’s important to always have your location services activated, as many of the app’s features require it. For example, the app can be used to locate the shelters and resources closest to you.” (iTunes, Google Play)

Tags: Domestic Violence

6.     The Savvy Social Worker – “Trying to stay abreast of developments in social work and human services practice? Few practitioners have the time to identify all the key sources of information on the web. This app, developed by the University at Buffalo School of Social Work, will help you stay current with new developments in social work practice, especially evidence-based practices and best practices. We bring information about key practice resources and practice research findings to you all in one place, in an e-news reader format. You select the information providers (channels) that you would like to monitor, and we do the rest. Included in our list are key sources such as the Substance Abuse and Mental Health Services Administration (SAMHSA), the Cochrane Collaboration, the Campbell Collaboration, ad Information for Practice.” (Google Play)

Tags: Social Work, Resources

7.     Suicide Safety – “Suicide Safe, SAMHSA’s new suicide prevention app for mobile devices and optimized for tablets, helps providers integrate suicide prevention strategies into their practice and address suicide risk among their patients. Suicide Safe is a free app based on SAMHSA’s Suicide Assessment Five-Step Evaluation and Triage (SAFE-T) card.” (iTunes, Google Play)

Tags: Therapist, Suicide, Social Work

8.     The DBT Diary Card – “DBT Diary Card is the only DBT iPhone app designed and created by a licensed and DBT intensively trained psychologist.” (iTunes)

Tags: Therapist, Social Work, DBT

9.     Dialysis Finder – Dialysis Finder App quickly identifies your location and lets you choose the nearest Dialysis Clinic as well as get other information about the location. A convenient way to find a US Dialysis Clinic near you. (iTunes)

What is Superhero Therapy?

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Did you ever want to be a Superhero? Did you ever wish that you could possess magical powers, like Harry Potter, or travel around the world in a time machine, called the T.A.R.D.I.S. with an alien who calls himself The Doctor? What if you could, in a way?

Many of us wish we had some kind of magical or extraordinary abilities, and many of us strongly identify with fictional characters, like Batman, Superman, Buffy the Vampire Slayer, characters from Harry Potter, Firefly, and many others. Recent research findings suggest that identifying with fictional characters can actually be extremely beneficial as it can teach us empathy, remind us that we are not alone in our painful experience, inspire us to eat healthier, and allow us to better cope with difficult life transitions.

The goal of Superhero Therapy, therefore, is to help patients who identify with a particular fictional character to use that relationship with that character in order to identify and process their own experiences and feelings, as well as to encourage them to make meaningful changes in their lives. Thus, the goal of Superhero Therapy is to teach us how to become the very magical Superhero-Jedi that we need in order to become the very best versions of ourselves. Superhero Therapy refers to using examples of Superheroes, as well as characters from fantasy and science fiction in research supported therapy, such as cognitive behavioral therapy (CBT) and acceptance and commitment therapy (ACT).

Why Superhero Therapy?

Many people have a hard time identifying their own thoughts and emotions, either because it’s too painful, or they’ve never thought about it. I see many patients with posttraumatic stress disorder (PTSD), including active duty service members, Veterans, and non-military civilians. I find that a lot of the time when I ask my patients how they felt at the time of the traumatic event, or even about which emotions they are experiencing in the present moment, many state that they aren’t sure or do not wish to answer.

However, discussing how a specific character felt at a given moment can be helpful in understanding our own emotions. For example, in the Defense Department’s recent efforts to assist Veterans with PTSD, they’ve contracted an independent company, Theater of War, to put on theatre plays for Veterans with combat-related themes, based on Ancient Greek plays. One of these plays, Ajax, for example, tells a story about a character struggling with his symptoms after the war and eventually committing suicide. Veterans and their spouses who saw the play reported that the play helped them understand their own emotions by relating to the characters. One Veteran in particular was moved by the play, stating: “I’ve been Ajax. I’ve spoken to Ajax.”

Talking about fictional characters’ emotional experiences might seem safer than talking about our own, so with my patients, that is where we often start, later drawing parallels to their own feelings and subsequently switching over to focusing on those. For instance, many service members and Veterans I’ve worked with strongly identify with Superheroes, in particular, Batman, Superman, and The Hulk. Let’s take a look at Superman.

Superman (real name Kal-El) is a comic book character who is an alien from another planet, Krypton, who was sent to Earth as a child. His Earth name is Clark Kent, and while in the Solar System, including Planet Earth, he appears to have superhuman abilities: he possesses super strength, super speed, he can fly, he can fight, he has X-ray vision, and many other cool powers. It is no surprise that Superman is a role model to many service members and Veterans, who believe him to be invincible. The phrase or a variation of the phrase I often hear in this population is “I wanted to be Superman… I failed.” This is a common response many people have, harshly judging their own experiences of having PTSD. This is a common dialogue I’ve engaged in with many of my patients:

Patient: “I just feel like such a failure.”

Therapist: “What makes you say that?”

Patient: “I wanted to be like Superman, you know? Strong.”

Therapist: “And now you don’t feel that way?”

Patient: “No, I have PTSD.”

Therapist: “And what does that mean about you?”

Patient: “It means that I’m weak.”

Therapist: “Wow, that’s harsh. Let me ask you this, did Superman have any vulnerabilities?”

Patient: “No.”

Therapist: “No?”

Patient: “Well, there’s Kryptonite…”

Therapist: “Right. What is it and what does it do?”

Patient: “Kryptonite is this radioactive material from Krypton, where Superman was born. It takes away his powers and can kill him.”

Therapist: “So Kryptonite makes him vulnerable?”

Patient: “Yes.”

Therapist: “And does this make him any less of a Superhero?”

Patient: “No, of course not… Oh, I see what you mean, that having PTSD doesn’t mean I’m not Superman.”

This is an example of how cognitive behavioral therapy (CBT) could look when using Superhero examples in session. CBT is a type of therapy that looks at the relationship between thoughts, feelings, and behaviors, which are bidirectional, meaning that they affect one another. In the example above, the patient’s thought: “because I have PTSD, that means I’m weak, and I failed in being Superman” is affecting his feelings (making him feel more depressed) and is affecting his behavior (for example, not wanting to socialize with others).

Some of the thoughts we have might not be 100% accurate, often leading to some painful emotions, and maladaptive behaviors. By challenging the validity of the thoughts (testing to see whether or not the thought is accurate), we can get out of the maladaptive loop. A CBT therapist’s job is to teach a patient how to implement the skill of challenging their own thoughts, to change the maladaptive behaviors in order to help the patient recover, as well as become their own therapist, to be able to help themselves in the future.

The other type of therapy that lends itself nicely to Superhero Therapy is acceptance and commitment therapy (ACT). I often describe it as Superhero Training, as ACT teaches us to become the very Superhero (or witch/wizard, vampire slayer, Jedi, or any other title that seems most helpful) that we wish to be by following our values, (the most important things to us, like family, friends, creativity, altruism, spirituality, and others), and by facing whatever dragons show up along the way (thoughts, feelings, personal stories we tell ourselves, such as “I’m a failure” or “I’m not good enough”) and practicing the Jedi-like skill of mindfulness.

Let’s take a look at how Harry Potter can be used in therapy to teach us some of these skills. Briefly, Harry Potter is a young wizard in training, whose parents were killed by Lord Voldemort, an evil wizard. Harry and his friends, Ron and Hermione, are studying magic at Hogwarts School of Witchcraft and Wizardry. When Lord Voldemort and his followers, the Death Eaters, start to come back to power, aiming to exterminate all non-magical humans (called Muggles), as well as all Muggle-born witches and wizards, it is up to Harry and his friends to stop them.

In the first book of the Harry Potter series, Harry, Ron, and Hermione find out that Lord Voldemort is attempting to come to power by trying to steal the Philosopher’s Stone, which grants immortality to its owner. In trying to stop him, Harry and his friends have to undergo a series of dangerous tests. One of them, the Devil’s Snare, is a magical plant that uses its tentacle-like branches to suffocate the person that touches it.

The Devil’s Snare presents a great ACT metaphor of acceptance and experiential avoidance: the plant seems to respond to tension levels, the more one struggles with it, the tighter its grip and the more likely it is to choke them. This is experiential avoidance, trying to escape the present experience, and just like the Devil’s Snare, in most cases, the more we try to escape, the deeper our struggle becomes. However, if we stop struggling and are willing to experience this discomfort (acceptance), then we are more likely to survive – when Hermione lets go of the struggle with the plant, for example, the Devil’s Snare releases her.

Here is how Superhero Therapy using ACT can look in a clinical setting. One of my clients was struggling with panic disorder and was too scared to go to places where a panic attack might take place and where escape might be difficult (this is called agoraphobia). The patient (let’s call her “Lucy”) stated that as a result of her fears of getting additional panic attacks she had to drop out of college, move back in with her parents, was unable to spend time with her friends, was unable to volunteer in a community theatre, which was something she really enjoyed, and essentially put her life on hold. While she did not have many panic attacks when staying at home, Lucy’s life became constricted, based solely around her anxiety disorder. Lucy stated that she would not be willing to go to unfamiliar places until her panic attacks went away completely and she was absolutely sure that they would not happen again. Her thoughts, such as “if I go out, I will have a panic attack” and “I’m weak” prevented her from living the kind of life she wanted.

In our sessions together we talked about the Harry Potter series; her favorite character was Harry’s friend, Ron Weasley. She said that she identified with Ron because of his fear of spiders. While Lucy herself did not have a fear of spiders, she stated that she could relate to Ron because “he knows what it’s like to be really scared, he gets so overwhelmed by spiders that he can’t even move. That’s exactly how I feel.”

In discussing Ron in therapy, Lucy was able to identify that as scared as Ron was of the spiders, when it was really important, specifically, when Hermione was Petrified (turned to stone) by an unknown monster in Harry Potter and the Chamber of Secrets, Ron (as well as Harry) followed the spiders into the Forbidden Forest in order to get the information needed to save Hermione and other Petrified students. This is a great example of the ACT concept of values. No one who read the books can deny that Ron was terrified when he followed and interacted with the spiders. He was probably also doubting his own abilities and might have had many insecure thoughts, such as “I will fail,” or “I’m not good enough,” or maybe even “I’m a coward.” And yet, despite his fear he was able to follow through, he was willing to experience whatever terrifying emotions and thoughts showed up in order to save his friend, showing true courage and heroism.

I will never forget the first time that Lucy and I drove around her block as a part of her facing her fears. She was trembling and was saying that she did not think that she could do it. However, she got behind the wheel, tightened her Gryffindor scarf, and turned on the engine. It took less than 5 minutes to go around the block and when we were finished Lucy was ecstatic. She was in tears, she was laughing, and saying, “I can’t believe I just did that!”

Lucy and I continued working on taking “superhero steps” in her valued direction and practiced driving to a movie theatre and other locations. Lucy still gets anxious sometimes but just like a true Superhero that she is, she courageously goes out with her friends, she’s back in school, and has even traveled abroad with her family.

I always say that the bravest people I know are my patients. It takes a lot of courage to experience overwhelming, and at times, incapacitating, anxiety, to come to treatment, and to face our fears. Many people believe that fear is bad, something that needs to go away for us to live a normal life. However, fear can actually be quite advantageous. In a recent Doctor Who episode, Listen, we learn that fear can be a Superpower. Doctor Who is a British science fiction TV show about an alien, who calls himself The Doctor. The Doctor travels around the universe in a time machine, called the T.A.R.D.I.S. (which stands for Time and Relative Dimension in Space) and saves those in need.

The Doctor is over 2,000 years old, and seems to know a thing or two about fear. His take is this: Fear is a Superpower. Fear causes the release of adrenaline, which makes us think faster and fight harder, suggesting that we don’t need to run away from fear, fear might actually be helpful.

The bottom line is that running away from fear and not living our lives according to our values isn’t helpful, whereas learning how to face our fears in the service of what’s most important to us, that’s what being a Superhero is all about.

Serving Our Veterans: Micro vs Macro (Part 3 of 4)

Part one of this series analyzed the impact of the Bonus Army, and part two looked at the survival of the Private vs. Public argument when providing services to those who fight our nation’s wars. In this third installment, I will be analyzing micro vs macro an even greater tension that has persisted from the Depression to present day, and it still continues to influence our effectiveness at serving our veterans.

Bronfenbrenn-system-bigSocial work as a field is constantly living within the Micro vs. Macro tension, as were the Bonus Army veterans also known as the Bonus Expeditionary Force (B.E.F.). At the most basic micro level, social workers aim to assist individuals in need. At the macro level, social workers aim to change policy and environmental conditions that support social change and afford individuals some level of security and autonomy. All along the way, we can observe tension among individuals and agencies, who place a higher priority on one or the other.

In the Anacostia Flats during the summer of 1932, there were certainly veterans of the B.E.F. who were there for their own personal motives, operating from a micro perspective. There were also veterans among them, who were motivated by a macro perspective, hoping to effect change for the entire veteran population. Life in Anacostia for these WWI veterans during the Bonus March had its own Micro vs. Macro tensions as a result.

During the same time veterans of the B.E.F. were impacting macro level change; the field of social work was taking a similar approach. Throughout the 1920’s and 1930’s social workers advocated for changes at the macro level, often taking the form of community organizing. Even the field of social work itself was founded in macro level approaches. Through Jane Addams’ Hull House and the settlement house concept of the late 1800’s, social work gained its foot hold as a profession by working with groups and communities, advocating for policy change, and even Addams herself was a political leader.  After a few decades however, the field of social work began to shift more toward micro level perspectives.

As time progressed and our society continued to challenge the status quo at the macro level, social workers by and large became distracted at the micro level. This change was largely fueled by an increase in Freudian ideology, which brought social workers out of the community and into their offices as individual counselors and case workers. With social work changing its focus to the micro level practice of diagnosing and counseling individual clients, the field had much less workers on the macro scale advocating for public services and had very little stake in the changing political climate of the 1960’s and 1970’s as a result. Only within the past decade or two has social work begun to step back into the macro level as a viable agent. So we observe this Micro vs. Macro tension shifting among social work over time.

As Bertha Reynolds (1935) pointed out, “social case work rather finds its function in dealing with difficulties in the relationship between individuals or groups and their physical or social environment”. Her observation, which was made during the same period as the events of the Bonus Army, was true before these events and is still true to this day. The tension between Micro vs. Macro is likely to continue to persist.

What can we learn from this? If these tensions will persist indefinitely, what’s the point? I would argue that by acknowledging the existence of these tensions, we are more apt to finding better solutions that will help us be more effective at serving our veterans for the long haul. So what are the implications of these tensions in how the U.S. government addresses it’s military veterans now? What can we do better? Stay tuned for the final segment of this series to find out.

References:

Addams, J. (1893). The objective value of a social settlement. Philanthropy and social progress (pp. 27-40). New York: Thomas Y. Cromwell.

Andrews, J. & Reisch, M. (1997). Social work and anti- communism: A historical analysis of the McCarthy era. Journal of Progressive Human Services, 8, 29-49.

Fisher, R. & Karger, H.J. (1997). Macro practice: Putting social change and public life back into social work practice. In Social work and community in a private world: Getting out in public (pp. 117-147). New York: Longman.

Perlman, H.H.(1957). Freud’s contribution to social welfare. Social Service Review, 31, 2, 192-202

Reynolds, B.C. (1935). Whom do social workers serve? Social Work Today, 2, 6, 5-8.

Seigfried, C.H. (2009). The courage of one’s convictions or the convictions of one’s courage: Jane Addams’ principled compromises. In M. Fischer, D. Nackenoff, & W. Chmielewski (Eds.). Jane Addams and the practice of democracy. University of Illinois Press.

Waters, W.W. & White, W.C. (1933). B.E.F.: the whole story of the bonus army. Mass violence in America. (1969). New York, NY: Arno Press & The New York Times.

Serving Our Veterans: Public vs Private (Part 2 of 4)

Part one of this series analyzed the history of the Bonus Expeditionary Force (BEF) and their actions during the Great Depression, and how its influence dramatically affected how the US government treated its brave men and women that go to war. In this second installment, I will take a  look at a key tension that has persisted from the days of the BEF up until our modern era. It is important to consider the historical context of these tensions when attempting to understand how we serve our nations military veterans.

Public vs Private
Public vs Private

The Public vs Private tension continues to work its way into social welfare discourse in the 21st century, but during the 1930’s it was just as rampant. In regard to social work, public represents services administered by a public agency, while private represents services provided through private charities, individuals, and groups. Previous to the Great Depression, by and large the aid and relief services were provided by private charities and local governments. Once the Great Depression hit, these private agencies were stressed to serve the needs of the millions who were suffering and starving; many of the available services at the time could not even shelter the homeless or feed the hungry.

Before the 1930’s and the Great Depression, issues like poverty and unemployment were primarily viewed as problems with the individual, rather than problems with the environment that individual lived within. Through that perspective, the common approach of the time was to address individual problems through private charity. With millions beginning to suffer from the Great Depression, the perception of social welfare began to shift. More people started to see that issues surrounding poverty had to be elevated to a public issue rather than maintain the narrow scope of a private or individual issue.

During this paradigm shift, it became evident to social workers and policy makers that the rising needs brought on by the Great Depression could only be addressed by public agencies . “Voluntary charity simply could not cope with the situation; only public agencies could deal with the collapse of the economy, mass unemployment, and widespread destitution”(Trattner, 1999) . As a result of this change in perspective, we created the U.S. Social Security Act of 1935, among several other programs. Public assistance worked its way into social policy and between 1929-1940 the number of persons on assistance or work- relief programs rose from less than a million to 9 million.

This tension between Public vs Private assistance took time to play out, and it had a direct impact on the wait time that veterans in the 1930’s seeking their Bonus had to endure. This was due to the observable conflict among political powers during the Bonus March era. President Hoover was adamant that assistance to the needy had no place for the public sector for a variety of reasons: “[f]or him, relief was a moral, not merely an economic, matter; private charity (such as he had distributed in war-ravaged Europe) was fine, but public aid, especially from national government, was a ‘dole’” (Trattner, 1999). As a result of these conflicts, it created several barriers to passing legislation that supported public assistance.

Subsequently, although the Great Depression proved that public agencies were the only group capable of providing adequate aid to those in need, tension existed and continues to this day. Unfortunately, the veterans of the Bonus Expeditionary Force just happened to be caught in the middle of all of it. Present day, those who are in need of services, including veterans, get caught in tension between the power sources who advocate for Public vs Private assistance.

In the next two parts of this series, I will be analyzing Micro vs. Macro and the long term implications of these paradigm shifts. Please stay tuned.

References:

Fisher, J. (1980). Social Work: The thirties as a watershed. In J. Fisher, The response of social work to the Depression (pp. 233-241). Boston, MA: G.K. Hall & Co.

Gordon, L. (1992). Social insurance and public assistance: The influence of gender in welfare thought in the United States, 1890-1935. American Historical Review 97, 19-54.

Trattner, W.I. (1999). Depression and a New Deal. In W. I. Trattner, From poor law to welfare state: A history of social welfare in America (6th ed.) (pp. 273-303). New York: Free Press.

Serving Our Veterans: WWI vets set the stage (1 of 4 Part Series)

World War I Memorial
World War I Memorial

As humans evolve, there is the expectation that we will function on a higher plane with each cycle of evolution. Learning from past mistakes and failures, it is expected this new knowledge will assist future generations in better preparation. When the United States entered the first World War, we were not prepared to handle the needs of veterans upon their return. Since then, our country has continued to amass the greatest arsenal of weaponry on the planet, and no other country’s military rivals that of the United States.

But, what did we learn about the treatment of our veterans and their families once they returned home, and did we make equilateral adjustments in how our country treats those who go to war? Over the course of a four-part series, I will be discussing the treatment of veterans returning home from war, but I think its imperative for me to begin with the past. Have we made the same strides in making improvements or is history repeating itself?

When the Great Depression set in, millions of people found themselves without food, shelter, work, and little hope for a change in circumstances. This was particularly troubling for many of the four million veterans that recently returned home from the First World War. Many were frustrated that the men who stayed home during the war had gained better and more secure career opportunities, which they missed during the time they were gone, fighting in Europe.

Having lost out on these opportunities, hundreds of thousands of veterans were suffering from unemployment, homelessness, and sometimes even starvation. For most of these veterans, the potential of a Bonus check was their only chance of obtaining enough capital to pull themselves out of poverty and have a chance at a bright future.

The Adjusted Compensation Act of 1924 put into law that veterans would be compensated, but not until they died or until 1945, whichever came first. Due to this stipulation, it became known as the Tombstone Bonus. During the peak of the Depression, the U.S. had millions of veterans that held certificates they were unable to cash in. Attempts to pass legislation to award veterans an early compensation occurred multiple times over the course of a decade, with no results. Veterans around the country were rife with frustration and desperation, which culminated in the formation of the Bonus Army.

A veteran of World War I from Portland, Oregon, by the name of Walter Waters, managed to rally a few hundred veterans to march on D.C. and demand action. The veterans of this collective effort called themselves the Bonus Expeditionary Force (B.E.F.). As they traveled across the country via train, veterans all along the way joined them. News media from around the country were covering the B.E.F. and the U.S. government began making secret preparations to deal with a possible threat of civil unrest. As the B.E.F. arrived in the U.S. capital in the summer of 1932, they numbered in estimates between 25,000- 45,000 veterans and family members.

The B.E.F. quickly established camps to shelter the veterans and their families as well as organized many community mechanisms to keep it running smoothly such as lobbyists flooding the capitol buildings daily, camp enforcement to weed out Communist agents and covert U.S. military intelligence officers, libraries by the Salvation Army, entertainment, and other necessities. The main camp was at Anacostia Flats, which has been noted for pioneering integration and unification of multiple races in a time when racial segregation was still the norm.

Groups of veterans in these camps were not formed by race, but rather upon which states they traveled from, so it was common for groups to be multi-racial. As James O. Horton notes in the PBS Home Video, The March of The Bonus Army, “Military experience has the potential for transcending things like race… and for black veterans to be in company with white veterans was a revolutionary thing”.

Roy Wilkins, an African American writer associated with the NAACP, visited Anacostia Flats and observed, “Men and women can live, eat, play and work together be they black or white, just as the B.E.F. demonstrated. Countless thousands of people know it, but they go on pretending, building their paper fences and their cardboard arguments”. Ahead of their time, the B.E.F. was unwittingly empowering the civil rights movement. To this diverse group of veterans at the height of the Depression however, the main concern was their own livelihoods.

Within two weeks of occupying the capitol, the House managed to pass a Bonus Bill, which went on to be defeated in the Senate. Distraught Waters, Commander of the B.E.F., tried to encourage the veterans to stay in D.C. until democracy worked for them. As the days passed, the U.S. government became increasingly worried and agitated with the B.E.F. presence. President Hoover grew weary and considered having the federal government step in to evict the veterans from their encampments.

Soon, at the leadership of General Douglas MacArthur along with two other notable officers under his command, Major Dwight Eisenhower and George S. Patton, the U.S. military moved in to disperse the veterans. Armed with tanks, tear gas, cavalry, machine guns, and several companies of infantry, the U.S. military cleared the veterans out of their camps and set their shanty buildings on fire. At the end of the day, “two veterans had been shot to death, an eleven-week old baby had died, an eight year old boy was partially blinded by gas, two police had fractured skulls, and a thousand veterans were injured by gas”. The physical presence of the Bonus Expeditionary Force was removed from Washington, but their legacy would live on.

Three years later, on November 10th, 1935, officers of the Veterans of Foreign Wars and American Legion made a pact to continue fighting for an early Bonus and they quickly brought the Disabled American Veterans into the coalition. This was the first time since the war that all three groups would work together to effect legislature and by the end of January, 1936, after congress over-rode Roosevelt’s veto, a Bonus Bill was finally passed.

Between the eviction of the B.E.F. in 1932 and the passage of the Bonus Bill in 1936, a very sobering event occurred, which may have influenced congress changing their views toward veterans and the Bonus. Many Bonus March veterans were shipped to Federal Emergency Relief Administration camps in the Florida Keys to build a bridge that connected the Keys. They were caught in one of the worst hurricanes on record in 1935 that killed many of them. As the government tried to cover up the event, Ernest Hemmingway, a veteran himself, traveled to the Keys and wrote some scathing words that blamed the government for the deaths of these veterans, claiming they were sent to Florida to keep them out of Washington.

With this hurricane event on the minds of members of congress, the attitude toward awarding a Bonus early was finally accepted by the majority. The legacy of the B.E.F. continued on to 1944 as well, when Roosevelt signed into law the GI Bill of Rights, which paid college tuition for millions of veterans around the country and is believed by many to be a huge contributing factor to the economic boom of the second half of the 20th century. Not only did the GI Bill pay for tuition, it helped finance 11 million of the 13 million homes that were built in the 1950’s. What is now known as “the Greatest Generation” is a direct result of the efforts of the veterans of the B.E.F. and their legendary Bonus March.

As we can see, the Bonus Expeditionary Force moved mountains in creating policy that serves military veterans, the economic development of our country, and was even ahead of its time in relation to social rights issues and race tensions. In my next article, I will analyze the struggles and achievements of the B.E.F. in the context of key tensions and future implications in modern-day society.

References:

Daniels, R. (1971). The bonus march: an episode of the great depression. Westport, Connecticut: Greenwood.

Dickson, P. & Allen T. B. (2004). The bonus army: an American epic. New York, NY: Walker.

Public Broadcasting Service. (2006). PBS Home Video. The march of the bonus army. Washington D.C.: New Voyage.

Schram, M. (2008). Vets under siege: how America deceives and dishonors those who fight our battles. New York, NY: St. Martin’s Press.

Waters, W.W. & White, W.C. (1933). B.E.F.: the whole story of the bonus army. Mass violence in America. (1969). New York, NY: Arno Press & The New York Times.

Zinn, H. (1999). A people’s history of the United States. New York, NY: HarperCollins.

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