Homelessness and Military Sexual Trauma

Homelessness and Military Sexual Trauma Margret Bell, PhD National MST Support Team, VA Office of Mental Health Services margret.bell@va.gov June 14, 2012

Veterans, Trauma, and Homelessness • High rates of trauma among Veterans • High rates of prior trauma among homeless individuals • High rates of traumatic experiences while homeless • Homelessness as a “traumatic lifestyle” • “[Discrete] traumatic incidents such as sexual assaults are layered upon ongoing traumatic conditions such as struggling to meet basic survival needs and living with ongoing dangers and threats” (Goodman et al., 2006) • MST and sexual trauma more generally are intermingled with this larger picture

Resources on Developing Trauma-Informed Services A Long Journey Home: A Guide for Creating Trauma-Informed Services for Mothers and Children Experiencing Homelessness http://homeless.samhsa.gov/ResourceFiles/a4ik4an3.pdf MISSION-VET Treatment Manual (Section VII on Trauma-Informed Care) http://www.va.gov/HOMELESS/docs/MISSION_Veteran_Treatment_Manual.pdf Shelter From the Storm: Trauma-Informed Care in Homelessness Services Settings http://homelessness.samhsa.gov/ResourceFiles/cenfdthy.pdf Harris, M. & Fallot, R.D. (2001) Using Trauma Theory to Design Service Systems. San Francisco: Jossey-Bass.

Roadmap For Today • Definitions • Prevalence • Impact • The relationship between MST, other sexual trauma, and homelessness • Things VA is doing • Things you can do • Resources to learn more

What is MST? • VA’s definition of MST comes from federal law but in general is sexual assault or repeated, threatening sexual harassment that occurred during a Veteran’s military service • Can occur on or off base, while a Veteran was on or off duty • Perpetrator identity does not matter • Veterans from all eras of service have reported experiencing MST • Both men and women can experience MST

What is MST? • Any sort of sexual activity in which someone is involved against his or her will • Someone may be: • Physically forced into participation • Unable to consent to sexual activities (e.g., intoxicated) • Pressured into sexual activities (e.g., with threats of consequences or promises of rewards)

What is MST? • Can involve things such as: • Threatening, offensive remarks about a person’s body or sexual activities • Threatening and unwelcome sexual advances • Unwanted touching or grabbing • Oral sex, anal sex, sexual penetration with an object and/or sexual intercourse • Compliance does not mean consent

How Common is MST? • This can be difficult to know, as sexual trauma is frequently underreported • About 1 in 5 women and 1 in 100 men have told their VHA healthcare provider that they experienced sexual trauma in the military • These data speak only to the rate among Veterans who have chosen to seek VA healthcare; they do not address the actual rate for all those serving in the U.S. Military • Although women experience MST in higher proportions than do men, because of the large number of men in the military there are significant numbers of men and women seen in VA who have experienced MST.

MST Among Homeless Veterans • Little data currently exist • Veterans seen in VHA: • 39.4% of homeless female and 3.4% of homeless male Veterans seen in VHA screened positive for MST (MST Support Team, 2011) • 41% of female and 1.6% of male homeless Veterans domiciled in a VHA substance abuse treatment program had experienced MST (Benda, 2006) • This compares to rates of 22.4% among female and 1.2% among male Veteran VHA users more generally • Community sample: • 53% of homeless female Veterans experienced sexual assault while in the military; this compares to a rate of 26.8% among age-matched housed female Veterans (Washington et al., 2010) • Findings suggest that rates of MST may be higher among homeless Veterans than among non-homeless Veterans

Sexual Trauma Among Homeless Women • 92% of a racially diverse sample of homeless mothers had experienced severe physical and/or sexual violence at some point in their lives; 43% had experienced sexual abuse in childhood (Browne & Bassuk, 1997) • 13% of homeless women reported being raped in the past 12 months, with half of these women reporting being raped at least twice (Wenzel et al., 2000) • 9% of homeless women reported at least one experience of sexual victimization in the past month (Wenzel et al., 2000) • Compared to low-income housed counterparts, homeless women’s sexual assault experiences are more likely to be violent (Stermac & Paradis, 2001)

Impact • People are remarkably resilient in the face of trauma • There is no one way that Veterans respond to MST • Many cope quite well and recover without professional help • Some continue to have difficulties at times or strong reactions to certain situations • Some experience more profound or longer-term problems • May be particularly likely for multiply traumatized Veterans • OEF/OIF/OND Veterans’ MST experiences may be relatively recent and their distress more acute

Impact, Part 1: Diagnoses Commonly Associated With MST • Among users of VA health care, the mental health diagnoses most commonly associated with MST are: • PTSD • Depressive Disorders • Anxiety Disorders • Bipolar Disorders • Drug and Alcohol Disorders • Schizophrenia and Psychoses • Research suggests that the mental health burden may be even more significant for homeless Veterans who experienced MST

Diagnoses Associated With Sexual Trauma More Generally • Other mental health diagnoses common among sexual trauma survivors include: • Eating Disorders • Dissociative Disorders • Somatization Disorder • Rates of sexual trauma are high amongst individuals with certain personality disorders • A range of physical health conditions are also associated with sexual trauma

Impact, Part 2:Common Symptoms and Problems • Extremes of emotion and emotional lability • Emotional disengagement or flatness • Difficulties with attention, concentration, and memory • Re-experiencing and strong emotional reactions to reminders • Hypervigiliance • Trouble sleeping, nightmares • Suicidal thoughts or behavior • Self-harm • Disordered eating • Dissociation • Drinking and drug use • Revictimization • Difficulties with hierarchical environments

Impact, Part 2:Common Symptoms and Problems • Difficulties in core areas of functioning and well-being • Interpersonal difficulties or avoidance of relationships • Difficulties getting and maintaining employment • Difficulties with parenting • Difficulties with identity and sense of self • Spirituality issues/crisis of faith

Impact, Part 3: How Trauma Changes People • Diagnostic and Statistical Manual of Mental Disorders (4th ed.) definition of trauma: • Experienced, witnessed, or confronted with event(s) that involve actual or threatened physical harm to self or others • Reaction at the time involved intense fear, helplessness, or horror • Another way to think about this: • Parallel to physical trauma: “A serious injury or shock to the body” • Often incomprehensible • Often shatters previously held beliefs • Impacts physiology, emotional equilibrium, and cognitive approach to the world

Not All Traumas Are Created Equal • Research has shown that sexual assault is more likely to result in symptoms of PTSD than are most other types of trauma, including combat • Research also suggests that sexual assault in the military may be more strongly associated with PTSD and other health consequences than is civilian sexual trauma

Distinctive & Complicating Aspects of Experiencing MST • MST is an interpersonal trauma • MST may be ongoing over time • Social support is often limited at the time and afterwards • Servicemembersare often young at the time of their experiences • MST challenges Servicemembers’ socialization and values • Sexual trauma has certain societal messages and meanings associated with it • MST intersects with any other experiences of trauma a Servicemember may have had

The Relationship Between MST, Other Sexual Trauma, and Homelessness • Sexual trauma can be both a precursor to and outcome of homelessness • Sexual trauma is associated with other risk factors for homelessness (e.g., mental health problems, unemployment, abusive relationships) • Possible that sexual trauma is not an independent risk factor for homelessness, but instead has more impact on intermediate outcomes that themselves lead to homelessness • Sexual trauma may contribute to a “downward spiral” • Multiple adverse experiences and stressors that occur in combination, with no one more important than the other • “Mutually reinforcing challenges” that ultimately lead to homelessness (Hamilton et al., 2011)

The Relationship Between MST, Other Sexual Trauma, and Homelessness • Hamilton et al (2011): MST and other sexual trauma are part of a “web of vulnerability” for women Veterans • Identified five primary roots (initiators or precipitating factors for participants’ paths to homelessness): 1) pre-military adversity; 2) military trauma and/or substance abuse; 3) post-military interpersonal violence, abuse, and termination of intimate relationships; 4) post-military mental illness, substance abuse, and/or medical issues; and 5) unemployment • Five contextual factors promoted these pathways: 1) survivor instinct; 2) lack of social support and resources; 3) a sense of isolation; 4) a pronounced sense of independence; and 5) barriers to care

The Relationship Between MST, Other Sexual Trauma, and Homelessness • “It’s like for me, you start with the rape. Then you go into the drugs. And drugs lead to homelessness. You regroup. You go back to the rape. You go back to the drugs. Go back to the homelessness…You go to stay with people and they rape you. It’s a vicious cycle until something stops.” • “[Homelessness and MST] go hand-in-hand, with low self-esteem and no relationships.” (Hamilton et al., 2011)

MST, Other Sexual Trauma, and Homelessness (Hamilton et al, 2011) • “I wanted a career to make something of myself – to put the 20 years in and retire out. And it didn’t turn out that way. I was harassed, sexually, non-sexually. I did not feel a part of the family. I felt very pushed out, pushed away. And the harassment that I had gone through was so severe that I have anxiety, even more depression, major [PTSD]. I have a lot of physical and emotional and mental problems now…After the military, I felt so lost. I had no self-esteem. I didn’t know what to do. I thought everyone hated me. I couldn’t go back to my family. I felt I had to just take off somewhere and just isolate myself. I felt so detached from society.” (Hamilton et al, 2011)

So What Can We Do? What is the Department of Defense Doing? • For information about the Department of Defense’s current efforts, please visit: • www.myduty.mil or • www.sapr.mil

So What Can We Do? What is VHA Doing? • Universal screening • Free treatment • Staff education and training • Outreach to Veterans about services available • MST Coordinator at every VA healthcare facility, to serve as a point person for MST issues • National MST Support Team, to continue improving VHA’s response to MST

Free MST-Related Care • Free care is provided for all physical and mental health conditions related to MST • VA disability rating (“service connection”) is not required • Treatment is independent of the VA disability claims process • Veterans do not need to have reported the MST at the time or have other documentation • Many Veterans can receive free MST-related care even if they’re not eligible for other VA care • Never assume someone isn’t eligible for MST-related care • Veterans can ask to meet with a provider of a particular gender if it would make them feel more comfortable

Healthcare Services Available • Every VA Medical Center has providers knowledgeable about MST • Every VHA Medical Center provides MST-related mental health outpatient services • Formal psychological assessment and evaluation, psychiatry, and individual and group psychotherapy • Specialty services to target problems such as posttraumatic stress disorder, substance abuse, depression, and homelessness • Evidenced-based therapies are available at all VA Medical Centers • Many VHA facilities have specialized outpatient treatment teams or clinics focusing explicitly on sexual trauma • Vet Centers have specially trained counselors

Healthcare Services Available • For Veterans who need more intense treatment, many VHA facilities offer mental health residential rehabilitation and treatment programming (MH RRTP), a resource which is rare to non-existent in the private sector • Target rehabilitation, recovery, health maintenance, improved quality of life, and community reintegration in addition to specific treatment of medical conditions, mental illnesses, addictive disorders, and homelessness • VA also has inpatient programs available for acute care needs (e.g., psychiatric emergencies and stabilization, medication adjustment) • Nationwide there are almost two dozen programs that offer specialized MST treatment in residential or inpatient settings

Accessing Care • To access care, Veterans can: • Ask their existing VA healthcare provider for a referral for MST services • Contact the MST Coordinator at their local VA healthcare facility • Contact their local Vet Center • Veterans who were deployed for OEF, OIF, or OND can also contact the OEF/OIF Coordinator at their local VA healthcare facility • More information is available at: • www.mentalhealth.va.gov/msthome.asp • VA’s general information hotline (1-800-827-1000)

So What Can You Do? • Convey VA‘s commitment to the issue of MST

So What Can You Do? • If appropriate to your role, screen all Veterans for experiences of MST and other sexual trauma • Use a trauma-informed approach • Consider how program content, rules, environment, and your interactions might be experienced by a Veteran with a trauma history • Common triggers for sexual trauma survivors: touch; gender of provider; hierarchical environments; closed spaces; physical proximity; issues related to sleep • To the extent possible, be flexible • Seek to promote a sense of control and autonomy • Refer for mental health treatment as needed

Scenario #1: (Bebout, 2001, p.48) • “A woman repeatedly slept on the couch in the television room, ostensibly because the air-conditioning in her bedroom was not working properly. Staff started to pressure her to return to her room after the outside temperatures dropped, only to have the resident produce a different rationalization for continuing to sleep on the couch. …This was a carryover from an extensive history of…abuse that left the woman feeling safer in public places in the group residence, although the resident herself may not have understood this connection.”

Scenario #2:(Harris & Fallot, 2001, p.4) • “A woman and her children seek help because she is feeling overwhelmed and depressed. She has just lost her housing, has been drinking heavily, and cannot concentrate well enough to fill out a job application. She is referred to a family shelter, is given an appointment to meet with a psychiatrist, and talks with an addictions counselor; no one asks her about current domestic violence, much less about any history of childhood sexual abuse. She begins attending an addictions treatment program but the confrontational style leaves her feeling ashamed and frightened. She loses track of time and misses her appointments. The counselors call her but she feels too bad about herself to return….Her case is closed at the addictions program. She is deemed to be insufficiently motivated for treatment.”

Scenario #3:(Bebout, 2001, p.48) • “A woman in a supported apartment rarely slept at night and her anxiety and agitation led her to place many calls to the agency’s after-hours on-call service. This woman often slept through the day, thus making it difficult for her to keep appointments at the clinic or to maintain employment, although her skills were adequate and she was able to obtain jobs easily. Eventually this day-night reversal was attributed to her having been sexually abused in her childhood bedroom by an older male relative.”

Confusing Behavior • Sexual trauma creates dilemmas for survivors • Whether to trust others, when you know that even friends and “family” may prove untrustworthy • Whether to trust yourself, when you know the consequences of being wrong • Whether to form relationships and meet your needs for connection, when you know how severely others could hurt you • How to reconcile experiences of MST with the ideals that may have led you to enter the military • Whether to prioritize safety or freedom • Confusing behavior can reflect an attempt to manage the conflicting needs that underlie these dilemmas

So What Can You Do? • Consider the impact that a Veteran’s trauma history might be having on a his/her behavior • Begin by assuming there’s a healthy need being met • Think about the role that feelings of helplessness, vulnerability, or of being unsafe might be playing • Discuss what you can do to restore his/her feeling of being in control • Use your relationship as a tool • Model power-sharing and positive regard in relationships • Provide predictable, consistent, and respectful interactions

So What Can You Do? • Gently and nonconfrontationally, provide psychoeducationabout the impact of sexual trauma • “Imagine..trying to read a book with no plot…” (Harris & Fallot, 2001, p.14) • Monitor risk for re-victimization and actual re-victimization

So What Can You Do? • Seek consultation when necessary • Prioritize self-care • Create and connect with formal and informal sources of support at work • Remain grounded in what is meaningful, gratifying, and enjoyable to us in our lives more generally

Resources to Learn More • MST Coordinator at your VA Medical Center • VA Intranet MST Resource Homepage • vaww.mst.va.gov • Accessible to all VA staff/individuals with access to the VA intranet • Educational handouts for staff • Veteran outreach/informational materials • List of facility MST Coordinators

Resources to Learn More • VA Internet website • www.mentalhealth.va.gov/msthome.asp • Accessible to Veterans • National Center for PTSD’s PTSD Consultation Program • Free 1:1 PTSD consultation for any VHA provider or contractor • Call (866) 948-7880; or • Complete online form at vaww.ptsd.va.gov/consultation/ptsd_consult_req.asp; or • Email ptsdconsult@va.gov

Resources to Learn More • Goodman, L., Fels, K., & Glenn, C. (2006). No safe place: Sexual assault in the lives of homeless women. VAWnet Applied Research Forum. • Bebout, R.R. (2001). Trauma-informed housing. In M. Harris & R.D. Fallot, R.D. (Eds.) Using Trauma Theory to Design Service Systems, (pp.47-55).San Francisco: Jossey-Bass.

Thank You For Your Commitment to Our Veterans! Contact information: Margret Bell, PhD margret.bell@va.gov (note the unusual spelling of ‘Margret’)

Homelessness and Military Sexual Trauma