OIF/OEF Women

1. OIF/OEF Women Darrah Westrup, Ph.D. Women’s Mental Health Center Women’s Trauma Recovery Program National Center for PTSD VA Palo Alto Health Care System womenvetsPTSD.va.gov darrah.westrup@va.gov

2. OIF/OEF Women • What do we need to know about OIF/OEF women? • How are they different? • What are their particular treatment needs? • How can we best serve OIF/OEF women? • What services are needed? • What are the effective treatments?

3. Women Veterans • Women are one of the fastest growing segments of the veteran population. They comprise: • 15% of active military • 20% of new recruits • 17% of reserve and National Guard • 13% of OIF/OEF troops (59 casualties as of April ’06) • 5% of 27 million veterans are women and this number is expected to increase to 10% by 2010 • Women veterans have greater health problems than their nonveteran female counterparts • 87% of women veterans do not use VA care

4. Specific Needs of OIF/OEF Women • Less in-service social support • Different determinants of social support • Role transition • Intimate partner violence • Behavioral health • 29% of OEF/OIF women veterans who use VA are diagnosed with mental health disorders • PTSD – SUD comorbidity

5. OIF/OEF and Family • Family issues are paramount • Often in caregiver role • Partner conflict • Parenting skills • Domestic violence • Young children • Individuation from family of origin

6. OIF/OEF Women: Presenting Problems Comorbid Difficulties • Depression • Anxiety/panic • Substance use • Personality disorders • Somatization • Sexual dysfunction • Eating disorders • Self-injurious behavior

7. Military Sexual Assault • Higher rates of Military Sexual Trauma • Physical attacks and sexual assaults of women by comrades exceed casualties by enemy actions. • As many as 25% of military women have been sexually assaulted. • Sexual assaults and harassment that occur in military may be more damaging than other work settings.

8. MST is associated with • Increased suicide risk • Major depression • PTSD • Alcohol/drug abuse • Long-term sexual dysfunction • Disrupted social networks • Occupational difficulties • Asthma • Breast cancer • Heart attacks • Obesity

9. Combat-related Exposure • Problems similar to those for sexual assault • Drug-related disorders • Accidental deaths • Higher level of general psychiatric distress • More frequent somatic complaints • Anxiety/panic • PTSD

10. Service Model • Designated women’s clinic • Gender specific services • Prevention and educational services • Mental health presence in primary care • Couples and parent-child therapies • Drop-in groups with childcare • Evening hours • Evidence-based treatments

11. VA Services for Women Only 19% of VA facilities provide any MH services in a Women’s Health Center Space Only 7% of facilities provide any services by a specialized women’s MH team These services will be especially important for the younger, less chronic, women OEF/OIF veterans

12. Response to Treatment Cason, et al., 2002

13. Evidence-Based PTSD Treatments • Clinical Practice Guidelines (ISTSS) • Cognitive behavioral therapy • Pharmacotherapy • Group therapy • Cochrane Review (Bisson & Andrew, 2005) • Trauma focused cognitive behavioral (TFCBT) group and individual therapy, and stress management are effective treatments for PTSD • TFCBT is superior to stress management between 2 and 5 months following treatment • TFCBT is more effective than other therapies

14. Empirically-Supported Treatments for Women with PTSD • Seeking Safety (Najavitz et al., 1996) • For women with PTSD and substance disorders • Fits Herman’s “first stage” of treatment • No exposure work • 24 weekly sessions for 90 minutes • Group format • Manualized • Easily transferable

15. Empirically-Supported Treatments for Women with PTSD (cont.) • Cognitive-Processing Therapy (Resick & Schnicke, 1992, 1993) • Based on Information Processing Theory • 12 sessions • Education about trauma meaning • Cognitive therapy – challenging beliefs • Disclosure about the trauma (written) • Skills building – safety, trust, power, self- esteem, and intimacy

16. Empirically-Supported Treatments • Acceptance and Commitment Therapy (Hayes, Strosahl, & Wilson, 1999) • 12 sessions in “building block” format • Control of private events as the problem • Self as context rather than content • Letting go of the struggle • Commitment and behavior change

17. Clinical Presentation • Interpersonal problems • Social isolation • Identity disturbance • Impulsivity • Emotion dysregulation • Numbing/dissociation • Problematic thinking

18. Clinical Presentation (cont.) • They are in despair • They want better lives • They deserve our best effort • “Coping” strategies impede therapeutic growth • Difficulties can be longstanding and entrenched • Providers are necessarily impacted by the work

19. Clinical Factors that Affect Treatment • Difficulty establishing the therapeutic alliance • Approach based on relationship history • Blended with familial and military dynamics • Situation evokes vulnerability • Evokes issues with “control”

20. Providers’ Challenge - Maintaining a Therapeutic Stance • Caring for those who can make it difficult • Managing the negative impact • On oneself • On the patient or client • On other patients/clients

21. Strategies to Help Maintain a Therapeutic Stance • Protect your compassion • Language matters • No need to be “above it all”, get support • Expect to fall from grace • Be rigorous • Be intentional vs. reactive • Be aware of your limits • Human behavior is purposeful • Even illogical behavior has a function • Focus on the behaviors vs. labeling • Never forget people can and do get better

22. Program Planning Resources • Women Veterans Health Program Handbook • Women Veterans Health Program Plan of Care • VA Directives • Mental Health Strategic Plan • Women’s Mental Health Committee

23. Suggested References • Kimerling, R., Ouimette, P., Wolfe, J. (2002). Gender and PTSD. New York: Guilford Press. • Washington, D. L., Yano, E. M., & Horner, R. D. (Eds.). (2006). VA Research on Women’s Health [Special issue]. Journal of General Internal Medicine, 21 (3). • http://siadapp.dior.whs.mil/index.html (DoD Personnel and Procurement Statistics) • http://www.defenselink.mil/news/Mar2006/d20060316SexualAssaultReport.pdf (DoD Sexual Assault Report for 2005 with 06 Summary) • http://www1.va.gov/VHI/page.cfm?pg=32 -- https://www.ees-learning.net/librix/loginhtml.asp?v=librix (Military Sexual Trauma Veterans Health Initiative) • http://www.ncptsd.va.gov/index.html (National Center for PTSD).