2. Military Sexual Trauma Margret Bell, Ph.D. MST Support Team, VA Office of Mental Health Services Patricia A. Bennett, Ph.D. Rochester Vet Center

7. What Is Military Sexual Trauma (MST)? VA term for sexual assault or sexual harassment occurring during military service Definition in Public Law: “Physical assault of a sexual nature, battery of a sexual nature, or sexual harassment” [“repeated, unsolicited verbal or physical contact of a sexual nature which is threatening in character”] that occurred while a veteran was serving on active duty or active duty for training. US P.L. 102-585, 1992; 108-422, 2004

8. What does MST look like? A man in the Air Force who was raped by a superior officer after a party A woman in the Air Force who was molested by the doctor when she went in for a routine visit A woman in the Navy who was raped by the man sharing guard duty with her

9. What does MST look like? A woman in the Army whose commanding officer would do a daily check to make sure that she was wearing a bra A woman in the Army whose commanding officer would kiss her when they were being chauffeured in a hostile country A woman in the Marines whose commanding officer asked her to perform oral sex on him

10. Prevalence of MST VA estimates are 1 in 5 women and 1 in 100 men FY2013 : 24.3% women and 1.2% men Or, 77,681 women and 57,586 men Studies of MST prevalence vary according to the method of assessment & definition used 20-43% of women 1-4% of men

11. Risk factors for MST MST is associated with Entering the military at a younger age Being of enlisted rank Less likely to have completed college History of child sexual abuse 49% of women with MST reported joining the military to escape their home environment Suris and Lind (2008)

12. How is Sexual Trauma That Occurs in Military Settings Unique? MST occurs in a setting where the victim lives and works Increased feelings of entrapment, powerlessness, & risk of revictimization Need to rely on perpetrators for basic needs Disruption of career goals Particular aspects of military culture compound feelings of helplessness and betrayal Typically considered to be a complex trauma

13. Context : Military Culture In the military… The victim typically knows the perpetrator The victim is typically chronologically and developmentally young Risk is typically ongoing Repeated, continuing exposure to the perpetrator Given military hierarchy, victim may be dependent upon the perpetrator and/or his/her friends in many areas of life

14. Context: Military Culture Military values may compound feelings of helplessness, isolation, and betrayal Loyalty Teamwork Strength Self-sufficiency

15. What Affects Survivors’ Reactions? Characteristics of the experiences Single event vs. ongoing set of events Rape vs. sexual harassment Single perpetrator vs. multiple perpetrators Known vs. unknown perpetrator Characteristics of the individual Gender Developmental level at time of the event Prior trauma experiences Available coping strategies Characteristics of the environment Response of others at the time Continued contact with perpetrator Military culture

16. How Does Trauma Affect People? Physiologically Body sensitized to threat Prone to all-or-nothing reactions Disrupted memory / cognitive processing Emotionally Normal regulatory systems that promote homeostasis are overwhelmed Tendency towards all-or-nothing reactions Cognitively Affects how we view the world Affects how we view ourselves Tendency towards all-or-nothing thinking

17. Psychological consequences Feelings of sadness and depression Increased anxiety, including panic attacks Dissociative reactions Re-experiencing the assault Feelings of guilt, shame, and self-blame Use of avoidance Increased irritability

18. Psychological consequences Increased arousal reactions Hypervigilance Negative self-image Use of alcohol & drugs for coping Sexual dysfunction Interpersonal difficulties

19. Social consequences Strained relationships with family, friends, & partner Less frequent contact with social network Less emotional support from social network Less likely to marry

20. Diagnoses Associated With MST Posttraumatic Stress Disorder Depression Suicidal thoughts and/or suicide attempts Substance abuse / dependence Eating disorders Dissociative disorders Borderline Personality Disorder / Complex PTSD Somatization Disorders Physical health problems (e.g., lower back pain; headaches; pelvic pain; GI pain/symptoms; sexual dysfunction; gynecological symptoms; chronic fatigue)

21. Relative to Other Traumas, MST is Particularly Associated With… Extremes of emotion Feelings of self-blame Difficulties trusting self and others and/or trusting too easily Sensitivity to justice issues and power & control dynamics Difficulties with rules and hierarchy Difficulties establishing appropriate boundaries with others Difficulties being in environments dominated by men Revictimization, self-injurious behavior, and suicidal thoughts Men in particular may evidence: Homophobia Confusion about sexual identity Hypermasculinity Hypersexuality

22. Getting Help Therapy is available and free Rochester Vet Center Just call or walk-in Canandaigua VAMC Contact the MST coordinator: Dr. Hoffman Ask your PCP for a referral

23. Tammy Franklin, LCSW Women Veterans Program Manager

24. In response to the alarming prevalence of sexual harassment and sexual assault reported by military Veterans, Congress passed Public Law 102-585 in November 1992. This law authorized VA to provide counseling to women Veterans to overcome psychological trauma resulting from experiences of sexual assault or sexual harassment during their military service. Later laws expanded this benefit to male Veterans as well as female Veterans, repealed limitations on the required duration of service, and extended treatment to include not only mental health conditions related to MST, but physical health conditions related to MST as well.

25. VA is mandated to provide :  Treatment for conditions related to MST  Training and Education on MST to ALL staff  Outreach to Veterans about services available

26. It is VA policy that all Veterans must be screened for experiences of MST using the clinical reminder in the computerized patient record system. Universal screening is good clinical practice:  Many patients do not spontaneously disclose a trauma history and asking about MST can be the first step in getting them the help they need.  Understanding that a patient has a history of MST may provide context for his or her presenting problems.  Knowing that a patient has experienced MST helps tailor care and avoid engaging in behaviors that may cause unnecessary distress.

27.  VA treatment for all mental and physical health conditions related to MST is free and unlimited in duration. Veterans do not need to have a disability rating, did not have to report the incident(s) at the time, or need to have other documentation that MST occurred in order to receive free MST-related care.  VA has specialized treatment programming available for MST survivors. Providers have special evidence-based training related to MST and PTSD.  EVERY VA facility has an MST Coordinator who serves as a point person for MST-related issues. The MST Coordinator serves as a resource to both veterans and VA employees.

28. Canandaigua VA/ROPC offers:  Individual and group therapy, including gender specific groups  Domiciliary Care for men and women with a secured, women’s only wing  Designated Women’s Health Providers who have MST related training  “Relaxation” therapy massage chair (ROPC) available to relieve anxiety before exams for patients with PTSD/MST Batavia VA offers:  Batavia VA has a Residential Treatment Program that serves men and women Veterans struggling with PTSD related to war zone experiences, Military Sexual Trauma, and other in- service trauma. The experience of trauma while serving in the military is a requirement for admission; however, if one has also experienced civilian trauma, it may be addressed in treatment as well.

29.  VA MST Coordinators:  Canandaigua VA and Rochester Outpatient Clinic:  Dr. Debra Hoffman, MST Coordinator (585) 393-7929  Vet Center  www.vetcenter.gov  (585) 232-5040 e  VA Intranet MST Resource Homepage  http://vaww.mst.va.gov http://vaww.mst.va.gov  Education and resources for VA Employees  VA Internet website  www.mentalhealth.va.gov/msthome.asp www.mentalhealth.va.gov/msthome.asp  Information for Veterans tnities

30. Margret Bell, Ph.D. MST Support Team, VA Office of Mental Health Services Debra Hoffman, Ph.D. MST Coordinator Canandaigua VAMC Military Sexual Trauma: An Evidence- Based Approach to Treatment

31. MST Survivors Need… Practical assistance (e.g., finding safe housing) Sense of safety Sense of control To talk about their experiences To not talk about their experiences Help in managing symptoms and regaining stability emotionally To know they’re not crazy To re-establish boundaries, internally and externally

32. A Case Example-In her own words 60 year old Caucasian veteran of the US Marine Corps Kidnapped, beaten and sexually assaulted by an acquaintance while stationed in San Diego Tried to “forget about it”, but 40 years later she is triggered by a routine gynecological exam Decides to attend a residential treatment program for women with PTSD

33. Case Example-In her own words Letter to rapist Letter to Marine corps

34. So What Do We Do? An Overarching Framework for Treatment Judith Lewis Herman’s Trauma and Recovery: The fundamental stages of recovery are… 1. Establishing safety 2. Remembering and mourning 3. Reconnection and meaning-making Not necessarily a linear progression through these stages Parallels common distinction between skills- building (stabilization) and trauma processing (exposure) work

35. A Loose Categorization of Some Commonly Used Evidence-Based Protocols Establish safety Remember and mourn Reconnect and make meaning Seeking Safety Dialectical Behavior Therapy (DBT) Cognitive Processing Therapy (CPT) Prolonged Exposure (PE) Acceptance & Commitment Therapy (ACT)

36. Questions? Phone: 585-259-6568 Email: Debra.Hoffman@va.gov

37. Kimberly D. Kalish, Ph.D. Consulting Psychologist: Warrior Salute Clinical Assistant Professor of Psychiatry, School of Medicine & Dentistry, University of Rochester

38. Be familiar with the definition of MST Understand the importance of MST Screening and Assessment Follow best practice approaches in the screening/assessment of MST

39. Sexual assault or repeated, threatening sexual harassment that a veteran experienced during his or her military service

40. Unwelcome verbal or physical conduct of a sexual nature that occurs in the workplace or academic or training setting

41. Any sort of sexual activity between at least two people in which one of the people is involved against his or her will

42. Prevalence Impact/Related Symptoms Highly Underreported

43. Active duty military: 5-6% women and 1% of men: military sexual assault 78% of women and 38% of men: military sexual harassment All of VA data 1 in 4 females have experienced MST 1 in 100 men have experienced MST 2004; http://www.va.gov.vhi

44.  psychological well-being, physical health  satisfaction with health, work  difficulties finding work, alcohol, drug use MDD, PTSD: men (65%), women (45.9%) Anger, shame, guilt, self-blame Relationship disturbances

45. Stigma Shame Military Culture Fear of Consequences (real or perceived)

46. Mandated universal screening Medical record auto prompt

47. Compassion Privacy Confidentiality Avoid labels Normalize

48. “While you were in the military: (a) Did you receive uninvited and unwanted sexual attention, such as touching, cornering, pressure for sexual favors, or verbal remarks?; (b) Did someone ever use force or threat of force to have sexual contact with you against your will?”

49. No specific MST measures The Sexual Experience Questionnaire Sexual Experiences Survey The National Women's Study Interview Life Events Checklist PTSD Measures (e.g., PTSD Checklist, CAPS) Depression (PHQ-9, BDI) Substance Abuse Assessment Full Clinical Diagnostic Interview

51. No specific MST measures The Sexual Experience Questionnaire Sexual Experiences Survey The National Women's Study Interview Life Events Checklist PTSD Measures (e.g., PTSD Checklist, CAPS) Depression (PHQ-9, BDI) Substance Abuse Assessment Full Clinical Diagnostic Interview

52. In your life, have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you: Have had nightmares about it or thought about it when you did not want to? YES NO Tried hard not to think about it or went out of your way to avoid situations that reminded you of it? YES NO Were constantly on guard, watchful, or easily startled? YES NO Felt numb or detached from others, activities, or your surroundings? YES NO ¾ “yes” responses = positive screen. Positive screen warrants further investigation Positive screen warrants suicidal ideation screen

55. Records from law enforcement, crisis centers, counseling centers, hospitals, or physicians. Pregnancy tests or tests for sexually transmitted diseases. Statements from family, friends, professionals, service members Request for transfer to another military duty assignment. Deterioration in work performance. Substance abuse. Episodes of depression, panic attacks, or anxiety without an identifiable cause. Unexplained economic or social behavioral changes. Relationship issues, such as divorce. Sexual dysfunction.

56. Respect Empathize/Validate Support Patient’s perceptions Educate/normalize Clinician’s perceptions Triage (SAFETY, refer)

57. Negative questioning Labeling Implicit assumptions about the patient Body language Pushing

58. MST assessment is an important part of any comprehensive assessment Screening and assessment for MST must be done with respect and sensitivity Next Steps: Safety, Referral

60. Thank you for attending the 2014 Serve. Honor. Support. Symposium, and for all that you do to support the Veterans and military service members in our community!