Healing the Invisible Wounds: Understanding and Treating PTSD Among Military Veterans

Post-traumatic stress disorder (PTSD) has become one of the most pressing mental health issues among military veterans, particularly in the wake of modern conflicts in Iraq and Afghanistan. Years of exposure to intense combat, guerrilla warfare, and constant danger have left many veterans struggling with lasting psychological trauma. Despite increased public awareness and advances in treatment, PTSD continues to impose severe emotional, social, and economic burdens, both on individuals and on the healthcare system (Reisman, 2016).

PTSD among veterans is not a new phenomenon – it is a modern understanding of a condition that has existed as long as warfare itself. Historical records describe symptoms akin to PTSD as far back as ancient Greece, and over the centuries it has been labeled by many names, from “shell shock” during World War I to “battle fatigue” in World War II. The diagnosis of PTSD became formalized only in 1980, after the Vietnam War made clear the long-term psychological cost of combat. Contemporary studies estimate that between 13% and 30% of Iraq and Afghanistan veterans have experienced PTSD, with as many as half a million diagnosed cases over the past two decades (Reisman, 2016).

The condition rarely exists in isolation. Many veterans with PTSD also suffer from depression, anxiety, substance use disorders, and chronic pain, which together complicate both diagnosis and treatment. Depression is the most common comorbidity, and substance use is widespread among those attempting to cope with symptoms of trauma. Such overlapping conditions lead to higher rates of suicide, social isolation, and medical complications, making recovery a complex process requiring integrated care. Women veterans are particularly vulnerable, not only because of combat exposure but also due to the high prevalence of military sexual trauma, which can heighten the risk of developing PTSD (Reisman, 2016).

Diagnosis of PTSD involves both clinical interviews and self-report tools. Instruments such as the Clinician-Administered PTSD Scale (CAPS-5) and the PTSD Checklist (PCL-5) help determine symptom severity and functional impairment. The DSM-5 defines PTSD through four main symptom clusters—intrusion, avoidance, negative mood and cognition, and arousal—which reflect the range of ways trauma manifests in the mind and body. These diagnostic criteria guide clinicians toward evidence-based treatment approaches.

Cognitive-behavioral therapy (CBT) remains the most effective psychological treatment for PTSD. In particular, cognitive processing therapy (CPT) and prolonged exposure (PE) therapy are strongly supported by clinical evidence and widely used in veteran care. CPT focuses on identifying and restructuring distorted thoughts about the traumatic event, while PE encourages controlled and repeated engagement with trauma memories to reduce fear responses. Another therapy, eye-movement desensitization and reprocessing (EMDR), once met with skepticism, is now recognized internationally as an effective intervention that helps patients process trauma through guided eye movements and attention refocusing (Reisman, 2016).

While psychotherapy is the preferred first-line approach, pharmacological treatments are also important, particularly for those who do not respond fully to therapy. Selective serotonin reuptake inhibitors (SSRIs) such as sertraline and paroxetine are the only FDA-approved drugs for PTSD, although others like fluoxetine and venlafaxine are used off-label. These medications help regulate mood and anxiety symptoms but rarely lead to full remission. Researchers are increasingly investigating alternative pharmacological pathways, such as those involving GABA and glutamate neurotransmission. New drugs like vortioxetine, vilazodone, and even certain anticonvulsants such as topiramate are under study for their potential to modulate fear and memory processes. Some veterans also report relief from cannabis use, though its medical application remains controversial and tightly regulated (Reisman, 2016).

Combined treatment approaches – using both medication and psychotherapy – are often the most effective, particularly for veterans with severe or treatment-resistant PTSD. However, benzodiazepines, once commonly prescribed to manage anxiety, are now discouraged due to their limited efficacy and potential for dependency. The Veterans Affairs (VA) system has begun implementing education and shared decision-making programs to reduce benzodiazepine use and encourage evidence-based alternatives.

Beyond treatment, systemic and social barriers continue to hinder recovery. Many veterans face long wait times at VA facilities, limited access to mental health providers- especially in rural areas – and the persistent stigma associated with seeking psychological help. Cultural attitudes within the military often equate mental illness with weakness, deterring individuals from pursuing care. The VA has responded through public awareness campaigns like “About Face,” which normalizes PTSD treatment, and through telehealth services that provide remote therapy options. Studies indicate that telemedicine not only increases accessibility but also improves engagement and treatment adherence among veterans living far from urban centers (Reisman, 2016).

As more veterans seek care outside the VA system, the preparedness of community-based mental health providers has become a growing concern. Many civilian clinicians lack the training to address combat-related trauma effectively. To bridge this gap, the VA established the PTSD Consultation Program for Community Providers and partnered with organizations such as the Center for Deployment Psychology and Star Behavioral Health Providers, which train professionals in veteran-specific mental health care.

Despite ongoing research and program development, PTSD remains one of the most significant public health challenges facing veterans. Its economic cost exceeds billions of dollars annually, and its human cost is measured in the thousands of suicides that occur each year among former service members. Continued investment in both psychological and pharmacological research, alongside improved access to culturally competent care, is essential. Addressing PTSD requires not only medical intervention but also systemic reform and societal understanding to ensure that those who have endured the traumas of war receive the comprehensive care and dignity they deserve (Reisman, 2016).

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Strengths-Based Approaches in Social Work

Strengths-based approaches (SBAs) in social work represent a significant shift from traditional models that often focus on deficits and needs. Instead, SBAs prioritize the inherent strengths, assets, and capacities of individuals, families, and communities. This philosophical and practical approach encourages empowerment, resilience, and co-production, aiming to improve well-being and foster independence. Emerging prominently after the implementation of the Care Act 2014 in England, SBAs have become a central framework for adult social care, emphasizing personal well-being and outcomes-focused practices. This article explores the theoretical foundations, implementation strategies, challenges, and impacts of SBAs, drawing on findings from a comprehensive study conducted between 2020 and 2021.

The theoretical underpinning of SBAs lies in a salutogenic perspective, which prioritizes health and capacity over pathology and deficiency. Saleebey’s seminal work in 2009 emphasized focusing on the strengths and resources available to individuals rather than their problems. This approach aligns with the values of self-determination and human resilience, urging practitioners to view individuals as active agents capable of participating in their own care. Central to this perspective is the belief that by identifying and leveraging existing strengths—whether within individuals, their communities, or their broader networks—greater autonomy, independence, and long-term well-being can be achieved.

In practice, SBAs have been embraced by many local authorities in England as part of their adult social care strategies. The study referenced here used a two-stage design to understand how SBAs are being implemented and what outcomes they generate. The first stage involved an online survey completed by 32 social care practitioners, including social workers, managers, and commissioners. The second stage comprised in-depth interviews with ten participants from the survey cohort, allowing for nuanced insights into the practical application of SBAs.

Implementation of SBAs varied widely across different settings, from mental health services to safeguarding teams and community-led support initiatives. Many practitioners employed specific models, such as the “Three Conversations” approach, which focuses on listening, intensive work, and building a better life for service users. However, most respondents reported adapting these models to fit their local context, creating hybrid frameworks tailored to organizational needs and individual circumstances. For some, SBAs were not confined to a specific method or toolkit but represented an overarching ethos influencing all aspects of practice, from policy formulation to frontline interactions.

Training played a vital role in the adoption of SBAs, equipping practitioners with the skills and knowledge required to integrate these principles into their work. While many participants expressed satisfaction with the training they received, others noted that it often reiterated existing practices rather than introducing genuinely innovative concepts. This reflects a broader challenge in conceptualizing SBAs, as many practitioners felt they were already applying similar principles under other frameworks, such as person-centered or personalized care. The lack of a clear, distinctive definition of SBAs sometimes led to confusion about their unique contributions to social work.

The impact of SBAs on service users has been overwhelmingly positive, fostering a sense of control, engagement, and hope. By emphasizing strengths rather than deficiencies, SBAs help individuals feel valued and empowered, encouraging active participation in managing their own care. For many, this approach has led to improved well-being, greater trust in social care services, and enhanced independence. Community-level benefits have also been observed, with stronger relationships, better support for carers, and increased utilization of local resources contributing to a more holistic care environment.

Social care practitioners themselves reported significant benefits from adopting SBAs. Many felt a renewed sense of purpose and professional identity, as the approach allowed them to move beyond procedural tasks and focus on meaningful, person-centered interactions. This shift not only improved their job satisfaction but also fostered creativity and autonomy, enabling them to explore innovative solutions to complex problems. However, these positive outcomes were not universal. Some practitioners experienced increased anxiety due to the heightened responsibility and autonomy required by SBAs, particularly when operating in resource-constrained environments. The lack of sufficient managerial support or reassurance compounded these challenges, underscoring the need for robust organizational structures to support SBA implementation.

Organizational processes have also been significantly influenced by SBAs, with many local authorities streamlining bureaucratic systems to align with the ethos of the approach. Simplified assessment forms, reduced paperwork, and more efficient triaging systems have not only saved time but also improved the quality of interactions between practitioners and service users. For example, shifting the focus from procedural compliance to meaningful conversations has enhanced the immediacy and relevance of care provided at the first point of contact. Nevertheless, these systemic changes often required significant restructuring and resource investment, posing challenges for organizations operating under financial constraints.

Despite the many benefits of SBAs, their implementation is not without challenges. Resource limitations, both in terms of funding and workforce capacity, emerged as a critical barrier. Many practitioners found it difficult to consistently apply SBA principles in the face of high workloads and limited time for in-depth assessments. Additionally, existing financial and commissioning systems often conflicted with the ethos of SBAs, requiring practitioners to adapt or compromise their approaches to meet organizational requirements. The COVID-19 pandemic exacerbated these issues, highlighting the fragility of community resources and the increasing demands on social care services.

A key area of concern is the potential for SBAs to inadvertently place undue responsibility on individuals, particularly in cases where systemic or structural barriers limit their capacity to act on their strengths. For instance, emphasizing personal resilience without addressing broader social inequalities risks alienating or further marginalizing vulnerable individuals. Practitioners also noted that not all service users were receptive to the SBA ethos, with some preferring more traditional, directive forms of support. These challenges highlight the need for a nuanced application of SBAs, balancing individual empowerment with systemic support and structural change.

Looking ahead, the future of SBAs in social work depends on addressing these challenges and building a stronger evidence base for their effectiveness. While qualitative data from practitioners underscores the transformative potential of SBAs, robust quantitative evaluations are needed to capture their full impact. Engaging directly with service users and their carers will also be crucial in understanding how these approaches intersect with lived experiences and contribute to long-term well-being. Policymakers must ensure that sufficient resources and systemic support are available to sustain the adoption of SBAs, recognizing their potential to reshape social work practice and improve outcomes for all stakeholders.

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Understanding and Treating ADHD

Attention Deficit Hyperactivity Disorder (ADHD) is one of the most prevalent neurodevelopmental disorders in children and adolescents. Characterized by persistent symptoms of inattention, hyperactivity, and impulsivity that do not align with a child’s developmental stage, ADHD can significantly impact academic performance, social relationships, family dynamics, and self-esteem. The early detection and treatment of ADHD are vital to ensuring a child’s successful development and functioning across these various domains.

ADHD typically emerges in early childhood and persists for at least six months. While symptoms often extend into adolescence and adulthood, the disorder must be observed in two or more settings—such as school and home—to confirm a diagnosis. Studies suggest that ADHD has a strong genetic component, with environmental influences playing a contributing role. Neuroimaging and neuropsychological research have linked the condition to dysfunctions in the prefrontal cortex, basal ganglia, and cerebellum—areas of the brain involved in executive functions, working memory, and temporal processing.

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) classifies ADHD into three main presentations: combined (both inattentive and hyperactive-impulsive symptoms), predominantly inattentive, and predominantly hyperactive-impulsive. Each of these requires a specific symptom threshold: at least six symptoms for children and five for individuals aged 17 and older. Symptoms must be chronic and not better explained by other conditions such as oppositional defiant disorder or intellectual difficulties.

To assist in diagnosis, a symptom recording format has been suggested to capture specific behaviors and their consequences across various environments. The severity of ADHD is classified as mild, moderate, or severe based on symptom number and the extent of functional impairment.

A thorough evaluation for ADHD includes a detailed clinical history covering medical, psychiatric, academic, and family backgrounds. Both direct and indirect observations of the child’s behavior in multiple settings are essential, often involving questionnaires and structured interviews with parents and teachers. Physical examinations help rule out other medical causes, such as vision or hearing problems, anemia, or thyroid dysfunction. Intelligence testing can help differentiate ADHD from intellectual disabilities, while neuropsychological assessments provide insight into executive functioning, attention, and memory. Additional tools such as EEG, MRI, or genetic testing may be employed to rule out epilepsy or brain abnormalities. Emotional assessments are also critical to identify anxiety or depression that may mimic or coexist with ADHD symptoms.

Given the symptomatic overlap with other disorders, differential diagnosis is essential. Generalized anxiety disorder, for example, involves persistent worries and physiological symptoms, while depressive disorders manifest primarily through mood disturbances and low energy. Bipolar disorder includes mood swings and grandiosity, which differ from the impulsivity seen in ADHD. Specific learning disorders, conduct disorder, and oppositional defiant disorder also require careful differentiation. Notably, ADHD can co-occur with these conditions, necessitating a nuanced diagnostic approach.

Once a diagnosis is confirmed, psychoeducation is often the first step in treatment. This involves educating the child and their family about ADHD, including its causes, symptoms, possible comorbidities, treatment options, and long-term outcomes. Psychoeducation dispels myths and builds a foundation of understanding and collaboration between families and healthcare providers, guiding them toward appropriate resources and professionals.

Behavioral therapy is another central component of treatment. For children, the goal is to enhance social skills such as self-control, patience, emotional regulation, and effective communication. Positive behaviors are reinforced through praise and rewards, while disruptive behaviors are managed using techniques like time-out or overcorrection. For parents, behavioral training helps them establish consistent boundaries, structured routines, and empathetic support strategies that promote better home environments and reduce stress.

Cognitive-behavioral therapy (CBT) focuses on enhancing self-regulation and problem-solving skills by teaching children to use internal speech and self-instructions. Through a progressive process, children learn to guide themselves through tasks by first hearing instructions from an adult, then repeating them aloud, and eventually internalizing them. CBT can help children plan, set goals, and manage impulses more effectively.

Cognitive rehabilitation, meanwhile, addresses specific deficits in attention, memory, and other cognitive functions. This therapeutic approach aims to improve the child’s overall cognitive performance and can be tailored to individual needs.

Pharmacological treatment is generally considered when symptoms are severe or when non-pharmacological approaches prove insufficient. The choice to use medication depends on factors such as symptom intensity, age, presence of comorbid conditions, previous treatment responses, and the child’s adherence to therapy. Medications are broadly categorized into stimulants and non-stimulants. Stimulants, like methylphenidate, act on dopamine pathways and are available in various formulations. Non-stimulants, such as atomoxetine and guanfacine, target noradrenaline metabolism and are often used when stimulant medications are contraindicated. It is generally recommended to combine pharmacological treatment with behavioral and psychological therapies to ensure a more comprehensive approach to managing ADHD.

In conclusion, ADHD is a complex, multifaceted disorder requiring a careful and comprehensive approach to diagnosis and treatment. Understanding its presentations, underlying neurological basis, and symptomatology is crucial for early intervention and effective management. Collaboration among healthcare providers, educators, and families plays a key role in creating supportive environments where children with ADHD can thrive. Importantly, a diagnosis of ADHD should not be seen as a limitation but rather as a foundation for tailored support that nurtures a child’s strengths and potential.

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NHS: ADHD in children and young people

Understanding Adolescent Health in the Social Work Perspective

Understanding adolescent health from a social work perspective requires a multidimensional appreciation of the complex and dynamic changes occurring during adolescence, as well as the systemic factors that influence these changes. Adolescents, typically defined as individuals between the ages of 10 and 19, undergo significant physical, emotional, psychological, and social transformations that shape their development and identity. Social workers engaging with adolescents must be equipped to recognize these transitions and respond holistically to the needs that arise during this critical period.

The adolescent stage is marked by biological changes such as puberty, which initiate physical growth spurts and the development of secondary sexual characteristics. Alongside these bodily changes, adolescents experience cognitive and emotional growth, characterized by increased abstract thinking, self-awareness, and the formation of identity. These developmental changes bring about a need for autonomy and a desire for peer acceptance, often leading to conflicts with parental authority and experimentation with new behaviors and roles. Social workers must therefore understand adolescence not as a problem to be managed, but as a normal and essential developmental stage that, while challenging, presents opportunities for growth and resilience.

Stages of Adolescent Development

Adolescence is commonly divided into three distinct stages: early adolescence (10–13 years), middle adolescence (14–16 years), and late adolescence (17–19 years). Each stage presents specific developmental tasks and challenges. In early adolescence, individuals experience the onset of puberty, resulting in rapid physical growth and hormonal changes. This stage is often marked by increased self-consciousness, heightened sensitivity to peer influence, and an emerging sense of identity. During middle adolescence, cognitive development advances, allowing for more complex reasoning, abstract thinking, and questioning of authority. Emotional intensity peaks, and adolescents often strive for greater independence from parental control while seeking approval from peers. By late adolescence, individuals typically gain greater emotional stability, clearer identity formation, and improved decision-making abilities. This period also involves preparation for adult roles, including vocational planning and the establishment of intimate relationships. Social workers must tailor their approaches according to the developmental needs and cognitive maturity of adolescents in each stage, ensuring interventions are age-appropriate and supportive of healthy growth.

In understanding adolescent health, it is essential to contextualize it within broader determinants. The family, school, peer group, media, and community each play a critical role in shaping an adolescent’s behavior and health outcomes. For instance, family structures and parenting styles can have profound effects on adolescents’ emotional well-being and behavior. Supportive family environments tend to encourage healthy development, while families experiencing conflict, neglect, or abuse can contribute to poor outcomes such as substance abuse, depression, or delinquent behavior. Similarly, the school environment can either support or hinder adolescents’ development. Schools that foster inclusivity, participation, and a sense of belonging can act as protective factors, whereas those marked by bullying, academic pressure, or neglect may exacerbate vulnerabilities.

Peers also become increasingly influential during adolescence. Peer groups offer adolescents the opportunity to form social identities and practice autonomy. While positive peer influence can promote healthy behaviors and reinforce social norms, negative peer influence may lead to risk-taking behaviors such as smoking, drinking, or unprotected sex. Media and technology, especially social media, also significantly impact adolescents’ mental and emotional health. The constant exposure to idealized lifestyles, peer comparison, and online bullying can increase stress, anxiety, and depressive symptoms. Social workers must therefore consider these social determinants in their interventions and work collaboratively with families, schools, and communities to promote adolescent health.

One of the significant areas of concern in adolescent health is mental health. Adolescents are particularly vulnerable to mental health issues such as anxiety, depression, and self-harm, often exacerbated by academic pressure, social isolation, or identity crises. Mental health challenges in adolescence frequently go unrecognized or untreated due to stigma, lack of awareness, or limited access to mental health services. Social workers play a critical role in early identification, prevention, and intervention by providing counseling, advocating for supportive school environments, and linking adolescents with appropriate mental health services. Building trusting relationships with adolescents is essential, as it encourages openness and helps in addressing underlying issues in a nonjudgmental manner.

Another central issue is reproductive and sexual health. Adolescents often lack accurate knowledge about sexual and reproductive health, resulting in early pregnancies, sexually transmitted infections (STIs), and unsafe abortions. Inadequate sex education and cultural taboos further contribute to misinformation and risky behaviors. Social workers can provide adolescents with age-appropriate, culturally sensitive education that empowers them to make informed decisions about their bodies and relationships. Promoting open communication about sexuality, ensuring access to contraceptives, and addressing gender-based violence are key strategies to improve adolescent reproductive health.

Substance use is another prevalent concern during adolescence. The desire for experimentation, peer influence, and coping with stress or trauma can lead adolescents to use tobacco, alcohol, or drugs. Early initiation of substance use is associated with long-term health problems and social consequences. Social workers must adopt a preventive approach that involves raising awareness about the risks of substance use, building adolescents’ coping skills, and supporting families in creating protective environments. For adolescents already engaging in substance use, harm reduction strategies and rehabilitation services must be made accessible and non-punitive.

Nutrition and physical health also play a crucial role in adolescent development. Adolescents have increased nutritional needs due to rapid growth, but they often adopt poor dietary habits influenced by peer norms, media, and lifestyle changes. Malnutrition—both undernutrition and obesity—can have lasting impacts on health, affecting physical development, academic performance, and self-esteem. Encouraging healthy eating habits, regular physical activity, and body positivity is vital. Social workers can contribute by organizing community-based health programs, advocating for adolescent-friendly health services, and engaging with schools to ensure balanced nutrition and physical education.

From a social work perspective, promoting adolescent health requires a rights-based, strengths-focused approach. Adolescents are not merely passive recipients of care; they are active agents in their development. Social workers must empower adolescents to voice their concerns, participate in decisions affecting them, and access opportunities that nurture their potential. This includes advocating for adolescent-friendly policies, improving access to education and health care, and addressing systemic inequalities that marginalize certain groups of adolescents, such as those with disabilities, LGBTQ+ youth, or those in conflict with the law.

Cultural sensitivity and ethical practice are fundamental to effective social work with adolescents. Interventions must respect adolescents’ dignity, privacy, and autonomy while recognizing the role of cultural norms and values in shaping behaviors. At the same time, social workers must challenge harmful practices such as child marriage, female genital mutilation, or honor-based violence. Balancing cultural competence with advocacy for adolescent rights is a delicate but essential task.

In conclusion, understanding adolescent health through a social work lens entails a comprehensive appreciation of developmental, psychological, social, and systemic factors that influence health outcomes. Social workers must adopt a holistic, preventive, and participatory approach that addresses the unique challenges adolescents face while fostering resilience and empowerment. By working in partnership with families, schools, communities, and policy-makers, social workers can contribute significantly to the promotion of adolescent health and well-being, ensuring that this critical phase of life becomes a foundation for a healthy and productive adulthood.

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Dialectical Behaviour Therapy: A social work intervention?

Dialectical Behaviour Therapy (DBT) has emerged as a pivotal intervention in addressing the complex challenges associated with Borderline Personality Disorder (BPD), particularly within the field of social work. As a modified form of Cognitive Behaviour Therapy (CBT), DBT integrates cognitive and behavioural strategies with mindfulness and dialectical philosophy, making it uniquely suited to the emotional dysregulation and interpersonal instability characteristic of BPD. The therapeutic approach was developed by Marsha Linehan, initially as a treatment for individuals experiencing chronic suicidality and self-harming behaviours. Over time, DBT has evolved into a comprehensive psychosocial treatment, combining individual therapy, skills training groups, phone coaching, and team consultation to support both clients and therapists.

Social work practice is deeply rooted in values of client-centred care, empowerment, and the therapeutic alliance. DBT aligns well with these principles by emphasizing validation, collaboration, and skill-building. The therapy does not pathologize emotional suffering but instead recognizes the dialectical tension between acceptance and change. Clients are encouraged to accept their current realities while simultaneously working towards behavioural and emotional improvements. This dual emphasis supports social work’s commitment to both respecting clients’ lived experiences and fostering meaningful transformation.

Central to DBT is the biosocial theory of BPD, which posits that the disorder arises from a transactional relationship between an emotionally vulnerable individual and an invalidating environment. Emotional vulnerability includes heightened sensitivity to emotional stimuli, intense emotional responses, and a slow return to baseline. An invalidating environment dismisses or punishes emotional expression, leading individuals to doubt their internal experiences and seek external validation through extreme behaviours. This conceptual framework resonates with social work’s ecological perspective, which views human problems within the context of systemic and environmental influences. It also invites practitioners to address broader social and relational dynamics rather than focusing solely on intrapsychic pathology.

The structure of DBT involves several interlocking components. Individual therapy sessions are designed to help clients apply DBT skills to specific challenges and to work through motivational issues that may hinder progress. Skills training groups, which often function more like psychoeducational classes than traditional group therapy, teach core skill sets in four modules: mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness. Phone coaching offers in-the-moment support, helping clients generalize skills to real-life situations, while therapist consultation teams ensure practitioners receive ongoing support and supervision. This multifaceted structure enhances treatment fidelity and helps social workers manage the emotional toll of working with high-risk populations.

Mindfulness, the foundational skill in DBT, draws heavily from Zen Buddhist practices and emphasizes nonjudgmental awareness of the present moment. In the context of social work, mindfulness supports both clients and practitioners in cultivating emotional awareness, self-regulation, and a grounded therapeutic presence. Distress tolerance skills help clients survive emotional crises without resorting to self-destructive behaviours. These include distraction techniques, self-soothing strategies, and radical acceptance. Emotion regulation skills aim to reduce emotional vulnerability by increasing positive emotional experiences and decreasing emotional reactivity. Finally, interpersonal effectiveness skills teach assertiveness, boundary-setting, and strategies for maintaining self-respect in relationships.

For social workers, the integration of DBT into practice offers several advantages. The structured nature of the therapy provides a clear roadmap for treatment, while the emphasis on validation and nonjudgmental stance aligns with social work values of empathy and respect. Moreover, DBT’s evidence base is robust. Research demonstrates its effectiveness in reducing self-harm, suicidality, psychiatric hospitalizations, and treatment dropout rates. DBT has also been adapted for various populations beyond BPD, including adolescents, individuals with substance use disorders, and clients with eating disorders or post-traumatic stress.

However, implementing DBT within social work settings also presents challenges. The comprehensive nature of the therapy requires significant training, time commitment, and organizational resources. Many community-based agencies may lack the infrastructure to support all components of the DBT model, such as skills groups or consultation teams. Additionally, the emphasis on behavioural analysis and structured interventions may be unfamiliar to social workers trained primarily in psychodynamic or client-centred approaches. Bridging this gap requires ongoing professional development and interprofessional collaboration.

Despite these barriers, adaptations of DBT have made it more accessible to social work contexts. For instance, some programs offer abbreviated or skills-only versions of DBT, which retain core elements while reducing intensity. These adaptations can still be effective, particularly when delivered with fidelity to the therapy’s principles. Social workers can also incorporate DBT-informed strategies into their broader practice, such as using validation techniques, teaching emotion regulation skills, or encouraging mindfulness.

Furthermore, the relational aspects of DBT—especially the therapeutic alliance—are critical to its success and align closely with social work practice. Therapists are encouraged to balance acceptance and change strategies in their interactions with clients. This dialectical stance involves being warm, validating, and supportive while also setting limits, challenging behaviours, and fostering accountability. Such a balance is particularly important when working with clients who experience intense fear of abandonment, emotional lability, and chronic interpersonal difficulties.

The DBT approach also invites social workers to reflect on their own emotional responses and boundaries. Working with clients who self-harm or express suicidal ideation can evoke fear, frustration, and helplessness. DBT addresses this through consultation teams that provide peer support, case discussion, and skill development. This component fosters sustainability and reduces burnout among practitioners, reinforcing the importance of self-care and supervision in social work practice.

In conclusion, Dialectical Behaviour Therapy represents a powerful intervention for clients with Borderline Personality Disorder, particularly within the field of social work. Its structured, skill-based approach, combined with a compassionate and validating therapeutic stance, makes it both effective and congruent with social work values. While challenges in implementation remain, adaptations and DBT-informed practices allow social workers to integrate its principles in diverse settings. By doing so, they can enhance their capacity to support emotionally vulnerable clients, promote resilience, and foster meaningful change in the lives of those they serve.

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DBT tools

The Role of Social Work in Mental Health: Insights from Service Users

Social work has always occupied a vital position within mental health care, yet its specific contributions remain underexplored and frequently misunderstood. As debates over its unique value persist, understanding the perspectives of service users—those directly impacted by social work—is crucial. A recent study led by a collaborative team of academics and individuals with lived experience aimed to uncover what service users value most in mental health social work. By employing Best-Worst Scaling (BWS), the study provided a quantifiable understanding of service user preferences for ten key attributes of social workers. The findings shed light on both the profession’s strengths and areas requiring improvement, offering a roadmap for enhancing social work’s role in mental health.

The Importance of Continuity of Care

The study’s most striking finding was the overwhelming emphasis placed on relational continuity. Service users consistently ranked having a reliable and continuous point of contact as the most critical attribute of mental health social workers. This finding resonates with broader concerns about the frequent disruptions in care caused by staff turnover or system fragmentation. Many participants expressed frustration at having to retell their personal histories to new social workers, describing the process as exhausting and dehumanizing. Beyond practical inconveniences, these disruptions eroded trust and hindered the development of meaningful therapeutic relationships.

“The research finds the overriding concern amongst service users was that their social worker must provide a continuous and reliable source of support.”

The implications for mental health services are profound. While policy initiatives have focused on achieving continuity across service transitions, the relational aspect of care—ensuring that the same professional provides consistent support—remains elusive.

“Qualitative data unequivocally highlight the negative implications of interruptions to relational continuity. Partly this forms a frustration of having to ‘tell my whole life story again and again’ after ‘being thrown around backwards and forwards between different social workers’ (interviewee in Biringer et al., 2017, p. 7). Similarly, unreliable practitioners who miss appointments or do not deliver what is agreed can add to a sense of anxiety that can already accompany receipt of mental health services (Biringer et al., 2017).”

National studies have highlighted the scale of this issue, with many service users experiencing multiple changes in care coordinators within a year. Such instability not only undermines the effectiveness of care but also exacerbates the emotional strain on individuals already grappling with mental health challenges. Addressing this gap requires systemic changes, including workforce retention strategies and policies that prioritize long-term relational continuity.

Holistic Approaches: Seeing Beyond the Illness

Another highly valued attribute identified in the study was the ability of social workers to consider the whole person rather than focusing solely on their mental health condition. This aligns with the social model of mental health, which emphasizes the interplay between social, economic, and environmental factors in shaping an individual’s well-being. Service users appreciated social workers who demonstrated an interest in their broader life circumstances, such as housing, employment, relationships, and community engagement.

This holistic perspective is particularly significant given the widespread social disadvantages faced by individuals with mental health conditions. Many service users encounter systemic barriers, including poverty, discrimination, and social exclusion, which compound their challenges. By addressing these underlying issues, social workers can empower individuals to pursue recovery in a way that is both sustainable and meaningful. The study’s findings reinforce the importance of this approach, positioning social workers as uniquely equipped to bridge the gap between clinical interventions and broader social support.

The Role of Advocacy and Rights Protection

Protecting rights and entitlements was another attribute that service users valued, particularly among male participants. Social workers’ ability to advocate for fair treatment, ensure access to benefits, and navigate complex systems of entitlements was seen as an essential component of their role. For many, this advocacy represented a lifeline, particularly in contexts where individuals felt marginalized or overwhelmed by bureaucratic processes.

However, the study also revealed a potential disconnect between the importance of this role and its visibility to service users. While advocacy is a cornerstone of social work practice, its benefits are not always effectively communicated. Ensuring that service users understand and appreciate the significance of these efforts may enhance their overall perception of the profession’s value.

Challenges in Arranging Access to Services

Interestingly, the study found that arranging access to other services was among the least valued attributes. This may appear surprising given the emphasis on holistic care. However, the finding likely reflects deeper issues, including skepticism about the effectiveness of external resources and a lack of trust in the broader system. Service users with longer histories of mental health support were particularly dismissive of this attribute, suggesting that past experiences may have left them disillusioned.

This finding raises important questions for the profession. Are social workers adequately involving service users in decisions about referrals and external support? Is there a need for greater transparency about how these activities contribute to recovery? Addressing these questions could help rebuild trust and ensure that service users perceive liaison activities as beneficial rather than detached from their immediate needs.

Tailoring Support to Diverse Needs

The study also highlighted significant variations in preferences based on demographic factors. For example, younger participants and those newer to mental health services placed a higher value on non-judgmental attitudes, suggesting that they may be more sensitive to perceived biases or stigma. Conversely, older participants and those with extensive experience in the mental health system appeared more desensitized to professional judgment, prioritizing other attributes instead. Similarly, men valued rights protection more than women, potentially reflecting traditional gender roles in managing financial and legal matters.

These findings underscore the importance of personalized approaches in social work. By understanding the unique needs and priorities of different service user groups, social workers can tailor their practices to provide more effective and meaningful support.

Systemic Barriers and Professional Challenges

While the study illuminated key areas of value, it also highlighted systemic barriers that hinder the profession’s ability to meet these expectations. Continuity of care, for instance, is often beyond the control of individual social workers, shaped instead by organizational policies and resource constraints. High caseloads, staff shortages, and the pressures of multidisciplinary working environments further complicate efforts to provide consistent and personalized support.

Moreover, the study’s findings point to a broader issue of professional identity. Despite its distinct focus on social determinants and empowerment, social work’s role in mental health is often perceived as “invisible” or secondary to clinical professions. This lack of clarity not only affects how the profession is valued but also contributes to job dissatisfaction among social workers themselves.

Implications for Practice and Policy

The findings of this study offer several actionable insights for the profession. First, they underscore the need to prioritize relational continuity in mental health services. While achieving this requires systemic changes, individual social workers can play a role by advocating for smoother transitions and maintaining strong relationships with service users during periods of change.

Second, the study highlights the value of holistic, person-centered approaches. Social workers should continue to emphasize their unique ability to address the broader social and environmental factors affecting mental health, using this as a cornerstone of their professional identity. Clear communication about the benefits of these approaches can also enhance service users’ understanding and appreciation of social work.

“The second most valued attribute, and the most unique to social work according to the expert panel, was attention paid to ‘my whole life, not just my illness’.”

Finally, the findings call for a re-evaluation of how social workers engage in liaison activities. Greater involvement of service users in these processes, combined with efforts to rebuild trust in external resources, could make this aspect of social work more effective and valued.

Conclusion

This research provides a compelling case for centering service users’ voices in shaping the future of mental health social work. By identifying and prioritizing the attributes most valued by service users, the profession can refine its practices and strengthen its unique contributions to mental health care. At its core, social work is about relationships, empowerment, and holistic care—qualities that service users recognize and deeply value. However, achieving these ideals requires addressing systemic barriers, enhancing professional clarity, and fostering a culture of co-production that places service users at the heart of decision-making. In doing so, social work can not only meet the needs of those it serves but also reaffirm its essential role in mental health services.

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Addressing Self-Harm: Assessment, Management, and Prevention

Introduction
Self-harm, defined as intentional self-poisoning or injury irrespective of intent, remains a significant public health issue affecting individuals across all age groups and demographics. The behavior is often associated with underlying mental health conditions, emotional distress, or adverse social circumstances. To address this, the National Institute for Health and Care Excellence (NICE) released guideline NG225, offering evidence-based recommendations for assessing, managing, and preventing recurrence of self-harm. This article delves deeply into the key aspects of the guideline, designed for healthcare professionals, educators, social care practitioners, and others involved in supporting those who self-harm.

Understanding Self-Harm
Self-harm includes a wide range of behaviors, such as cutting, poisoning, or other acts of self-injury, that are intentional but may not always be intended to end life. Unlike stereotypical self-injurious behaviors seen in some developmental disorders, self-harm in this context often arises from emotional dysregulation, mental health disorders, or environmental stressors. It requires a holistic understanding that respects individual circumstances and avoids stigmatization.

Core Principles of Care
Providing care for individuals who self-harm must be grounded in respect, dignity, and empathy. Practitioners are encouraged to address the stigma surrounding self-harm and to adopt a collaborative approach with patients and, when appropriate, their families or carers. This collaboration should focus on shared decision-making, enabling individuals to have control over their care plans and fostering a sense of empowerment. Special attention should be given to inclusivity, ensuring care strategies are adapted to meet the needs of underserved or marginalized populations, such as those with disabilities, neurodevelopmental disorders, or from minority ethnic and LGBTQ+ backgrounds.

Assessment and Psychosocial Care
Timely and thorough psychosocial assessments are crucial in understanding the context of self-harm and addressing underlying issues. Mental health professionals should prioritize building a therapeutic relationship with the individual, exploring the functions and reasons for their self-harming behavior. Assessments should be conducted in private settings that promote confidentiality and are sensitive to the individual’s preferences and needs.
Key considerations include:

Assessing the individual’s emotional and mental state, social circumstances, and immediate safety.
Understanding the specific triggers and personal values associated with the behavior.
Tailoring assessments for specific populations, such as children, older adults, and individuals with learning disabilities, ensuring age-appropriate and context-sensitive approaches.
For children and young people, professionals should explore social, educational, and home environments while addressing potential safeguarding concerns. In older adults, factors such as loneliness, cognitive impairments, and physical health issues should be prioritized.

Prevention Strategies and Interventions
Preventing self-harm recurrence requires a multi-faceted approach that combines psychological support, safety planning, harm minimization, and coordinated care across services. Psychological interventions, particularly those informed by cognitive-behavioral therapy (CBT), are the cornerstone of treatment for individuals who self-harm. For children and adolescents experiencing emotional dysregulation and frequent self-harming episodes, dialectical behavior therapy adapted for adolescents (DBT-A) is recommended.
Collaboratively developed safety plans are integral to prevention. These plans should help individuals identify triggers, develop coping mechanisms, and access support during crises. Safety measures may include removing access to means of self-harm and providing practical tools for managing distress. Harm minimization strategies, such as education on wound care and safe practices, can also play a role when individuals are not yet ready to completely stop self-harming.
Safer prescribing is critical in minimizing risks for individuals at high risk of overdose. This involves reviewing medications, limiting quantities, and maintaining open communication with other healthcare providers. Pharmacological interventions, however, are not recommended as primary treatments for self-harm.

Role of Professionals in Various Sectors
Healthcare professionals, educators, and staff in social and criminal justice settings all play vital roles in supporting individuals who self-harm.
Healthcare settings must adopt integrated care models that bring together mental and physical health services. Emergency departments should ensure access to private spaces for assessments, maintain clear protocols for managing frequent attenders, and prioritize collaborative decision-making. Schools and educational institutions should have designated leads for mental health who ensure the implementation and regular review of self-harm policies. These policies should provide guidance on identifying self-harming behaviors, supporting affected students, and addressing the needs of their peers.
In criminal justice settings, staff should be equipped to identify and respond to self-harm, ensuring access to appropriate healthcare and safeguarding resources. Secure environments, such as immigration removal centers, must address the heightened risks of self-harm and suicide among their populations while providing staff with adequate support for their own mental well-being.

Training and Supervision
The guideline underscores the importance of regular training for all professionals working with individuals who self-harm. This training should address the psychological and emotional complexities of self-harm, cultural competency, de-escalation techniques, and the development of compassionate communication skills.
Staff in specialist roles, such as mental health professionals, should receive additional training in conducting psychosocial assessments and risk formulation. Regular supervision and emotional support for staff are essential to help them manage the challenges associated with working in this field, ensuring they can provide compassionate and effective care without burnout.

Conclusion
The NICE guideline NG225 provides a comprehensive framework for addressing self-harm through respectful, evidence-based care. By prioritizing timely assessments, tailored interventions, and collaborative prevention strategies, professionals can significantly improve outcomes for individuals who self-harm. This requires coordinated efforts across healthcare, education, and social sectors, supported by ongoing training and robust policies. Ultimately, fostering a culture of understanding and compassion is crucial in reducing the prevalence and impact of self-harm while ensuring that affected individuals receive the support they need to recover.

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