Veterans Health Administration Care for Mental Health Problems Related to Military Sexual Trauma

1. Veterans Health Administration Care for Mental Health Problems Related to Military Sexual Trauma Antonette M. Zeiss, Ph.D. Deputy Chief Consultant, Office of Mental Health Services Department of Veterans Affairs

2. Basic principle: • MST is an experience, not a diagnosis. • It is associated with a number of physical and mental health conditions

3. Definition of Sexual Trauma in Veterans

4. Public Law 102-585 defines sexual trauma in veterans • “Physical assault of a sexual nature, battery of a sexual nature, or sexual harassment.” • Sexual harassment: “repeated, unsolicited verbal or physical contact of a sexual nature which is threatening in character.” • Experiences must have occurred while veteran was • on active duty (PL102-585) • or active duty for training (PL108-422).

5. Public Law Mandates That VA • Provide priority care for mental and physical health conditions associated with sexual trauma occurring in the military • Care must be available to men and women • There are no limits on duration of such care • Engage in outreach to overcome barriers to receiving MST-related services • Provide employees with education about MST-related issues * (PL 102-585; PL 103-452; PL 106-117; PL 108-422)

6. VA Directives require • Screening of all veterans for sexual trauma experienced while in the military • Free, priority care for all physical and mental health conditions related to these experiences • Employee education about sexual trauma-related issues • Outreach to overcome barriers to receiving MST-related services • Monitoring of MST screening, referral, and treatment

7. Screening for MST in Veterans Health Administration

8. All VA Patients Are Offered Screening for MST • Usually occurs in primary care • Triggered via a clinical reminder: “While you were in the military… • Did you receive uninvited and unwanted sexual attention, such as touching, cornering, pressure for sexual favors, or verbal remarks? • Did someone ever use force or the threat of force to have sexual contact with you against your will?”

9. Veterans who respond positively to either item are considered to be a positive screen for MST • A positive screen does not indicate • veteran’s current subjective distress • diagnosis • interest in or need for treatment • A positive response does not indicate if the perpetrator was a member of the military

10. Screening Outcomes • VHA screening all male and female veterans for MST since 2nd Quarter of FY 2002 • 5,777,169 veterans have been screened • Male veterans: 61,126 ( 1.1%) have screened positive • Female veterans: 59,690 (19.9%) have screened positive

11. Treatment • MST is an experience, not a diagnosis • Associated with a number of physical and mental health conditions • Top 5 primary diagnoses for MST-related mental health encounters in 2007: • PTSD • Depressive disorders • Schizophrenia and psychoses • Bipolar disorders • Drug abuse

12. Mental Health Treatment Received • In FY07, veterans with positive screen for MST who received mental health treatment for a problem judged to be related to MST • 57.1% of female veterans with positive screen • about 11% of all female veterans • 34.5% of male veterans with positive screen • less than 1% of all male veterans • Total MST-Related Mental Health Encounters • Female veterans: 207,675 encounters • Male veterans: 106,582 encounters

13. Types of Care Available • Every VA facility currently provides care for mental health conditions related to MST • Most care provided as outpatient • Over 40 facilities have specialized outpatient treatment teams to facilitate MST-related care • 16 specialized inpatient/residential care programs with specific emphasis on intensive care for severe MST-related mental health conditions

14. Residential and Inpatient Environment • Keyless locked entry systems being installed • Female therapist must be available • Increasing use of women-only groups as component of treatment • Sites offer a chance to increase comfort in an environment for both men and women

15. Organizational Structure to Ensure Provision of Mandated Services

16. National Level: MST Support Team • Staff in Boston and Palo Alto • Connected to Divisions of the National Center for PTSD • Funded by and reports to Office of Mental Health Services in VA Central Office • Team monitors MST screening and treatment related to MST • Team oversees MST-related education and training

17. VISN Level: MST Point of Contact • Every VISN has a primary point of contact for MST • Ensure that MST policies are implemented throughout the VISN • Communicate with national, VISN, and facility-level stakeholders and leadership

18. Facility Level: MST Coordinator • MST Coordinator for every facility and its Community Based Outpatient Clinics • Ensure that MST policies are implemented • Serve as point person, source of information, and problem-solving for MST-related issues • Establish and monitor mechanisms to ensure that • Veterans are screened • Those with experiences of MST have access to appropriate treatment

19. Frequent, Consistent Communication Among Levels • Quarterly conference calls between MST Support Team and MST POCs • Email distribution lists for • MST POCs • MST Coordinators • Clinicians and other staff interested in MST • Discussion forums on VA intranet MST website for MST Coordinator and POCs • Monthly training calls, averaging over 100 participants attending each call

20. Selected Training Efforts for Evidence-Based Care

21. National Rollout of Cognitive Processing Therapy • Evidence-based treatment for PTSD • Originally developed with sexual assault survivors • Adapted for combat-related PTSD • National conferences with a training manual • Training materials specific to veterans • Specific components on MST-related PTSD • Conference participants then see cases and attend ongoing case consultation calls • About 1,000 VA staff trained to date

22. National Rollout of Prolonged Exposure Therapy • Evidence-based treatment for PTSD • Originally developed with sexual assault survivors • Adapted for combat-related PTSD • National rollout similar in nature to Cognitive Processing Therapy • Started this year; several hundred trained

23. National Rollouts of Acceptance & Commitment Therapy (ACT) and Cognitive Behavioral Therapy • Evidence-based treatments for anxiety and depression • National rollout similar in nature to Cognitive Processing Therapy

24. National MST Support Team Has Partnered With Each Rollout • Ensure training materials have • MST-relevant examples • Discussion of issues unique to working with MST survivors • Ensure that clinicians working with MST-related mental health issues receive advance notice of training conferences • National training calls for MST clinicians with overviews of these therapies

25. What’s Ahead? • Increased attention to current returning veterans • To date, they have lower rates of positive screening for MST (both men and women) • Unclear if that is an accurate reflection of changed military experience, or other factors • Increased attention to male veterans who have experienced MST • Acceptance of screening • Increased utilization of treatment for MST-related mental health problems