1. Roksana Korchynsky, PhD VA Pittsburgh Healthcare System Roksana.Korchynsk@va.gov PA Women Veterans Symposium, June 7, 2014

2. Who Am I? Licensed clinical psychologist with VAPHS with 10+ years experience in the assessment & treatment of sexual trauma VAPHS’s Military Sexual Trauma Coordinator – provide education and training to providers caring for Veterans who have experienced sexual trauma; monitor screening and referral process; provide treatment VAPHS’s Evidence Based Psychotherapy Coordinator – promote best practices for the treatment of PTSD and other mental health disorders Cognitive Processing Therapy (CPT) provider & trainer

3. Roadmap for today… Overview of MST (definitions, prevalence, sexual trauma in context: military setting & culture) Diagnoses/problems/treatment themes commonly associated with MST Accessing care through VHA Recovering from sexual trauma Evidence-based psychotherapies

4. 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 Both men and women can experience MST Era of service does not matter MST is an experience, not a diagnosis

5. What is MST (cont.) 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, drugged) Pressured into sexual activities (e.g., with threats of consequences or promises of rewards – “command rape” )

6. What is MST (cont.)? 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

7. How common is MST? 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 Because MST is an experience, not a diagnosis, these data cannot address what percent of those who screened positive need or want treatment 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

8. Context: ST in Military Setting In the military… Victim typically knows the perpetrator Victim is typically chronologically & developmentally younger Risk is typically on-going because: Victim & perpetrator live & work together Victim may be dependent upon perpetrator and/or perpetrator’s associates for basic necessities (food, shelter, protection, medical care) No way to leave – leaving means going AWOL

9. Context: ST in Military Setting (cont.) In the military… High value placed upon loyalty & teamwork Taboo to divulge negative information about peers MST is that much more incomprehensible to victims High value placed upon strength & self-sufficiency Reduces social support available, increases likelihood of invalidating response Being a “victim” conflicts with desired identity Disruption of career goals

10. In the military… The same institution is responsible for the care of the victim & the adjudication of the perpetrator Increased sense of betrayal, being alone, helplessness, & entrapment Parallels with childhood abuse Context: ST in Military Setting (cont.)

11. At the time of assault, may be far from friends and family Availability of social support is also impacted by societal messages, especially to the extent they are internalized At homecoming or discharge, may believe or be told by others that their experiences are not as “legitimate” as combat trauma experiences May not disclose to providers or seek out help May not report experiences to authorities Experience of OEF/OIF/OND Veterans may be different due to Department of Defense reforms

12. Other Complicating Factors… Rates of childhood and pre-military trauma are high among MST survivors and military personnel more generally OEF/OIF/OND Veterans in particular face concurrent exposure to combat and a generalized decreased sense of safety Research has shown that exposure to multiple types of trauma increases the risk of negative mental health outcomes Effects of trauma appear to be dose-specific—the more traumas or the worse the trauma, the worse the outcome Aftereffects of earlier trauma may impair ability to cope with later trauma

13. Not All Traumas Are 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

14. 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

15. Diagnoses Commonly Associated with MST (cont.) Other mental health diagnoses common among sexual trauma survivors include: Eating disorders Dissociative disorders Somatization disorders A range of physical health conditions are also associated with sexual trauma (e.g., gynecological sx’s or sexual dysfunction, chronic fatigue, chronic pain, GI problems, fibromyalgia)

16. One Reaction to Trauma: PTSD Symptoms (per DSM5): Intrusion sx’s (intrusive thoughts; nightmares; flashbacks; strong emotional and physiological reactions to reminders) Avoidance sx’s (avoiding distressing thoughts or feelings; avoiding external reminders) Negative alterations in cognitions & mood (“I’m bad, dirty”; anger/guilt/shame; diminished interest; detachment; inability to experience positive emotions) Arousal & reactivity sx’s (trouble sleeping; irritability/anger; trouble concentrating; easily startled; on edge/ hypervigilant) Must last for more than one month Must cause distress or impairment in functioning

17. Other Difficulties Commonly Associated with ST Difficulties that may not rise to the level of a formal diagnosis Interpersonal difficulties or avoidance of relationships Difficulties getting & maintaining employment Difficulties with school Difficulties with parenting Difficulties with identify and sense of self Spirituality issues/crisis of faith Homelessness

18. Common Treatment Themes Difficulties with intimacy, trust, safety, and other core features of relationships Interpersonal difficulties Strong reactions to situations in which one individual has power over another Difficulty identifying and setting interpersonal boundaries that are not too high or too low Struggles with issues related to power and control Self-blame and self-doubt Difficulties managing distress and/or limited coping strategies

19. Common Treatment Themes (cont.) Problems with sexual functioning and sexuality Problems with sexual identity and sexual orientation Body image and/or problematic eating patterns Risk of re-victimization Relationships with abusive partners, unsafe sex, prostitution, poor boundaries with others / trusting too easily, putting self in dangerous situations…

20. Accessing Care: What is VA Doing? Universal Screening Recognizing that many survivors of sexual trauma do not disclose their experiences unless asked directly, it is VHA policy that all Veterans seen for health care are screened for MST

21. Accessing Care: What is VA Doing? (cont.) FREE MST-Related Care VA provides free care (including medications) for all physical and mental health conditions related to MST Service connection is not required Treatment is independent of the VBA disability claims process Veterans do not need to have reported the MST at the time or have other documentation Veterans may be able to receive free MST-related care even if they’re not eligible for other VA care There are no length of service or income requirements to receive MST-related care Veterans with Other Than Honorable discharges may be able to receive MST-related care with VBA Regional Office approval

22. Accessing Care: What is VA Doing? (cont.) Every VA Medical Center has providers knowledgeable about MST Every VA 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

23. What are Evidence Based Psychotherapies? Specific psychotherapies, or “talk therapies,” that have repeatedly been shown in clinical research (RCTs) to be effective for a variety of mental health conditions including PTSD, depression, couples issues, serious mental illness, and substance abuse. Recovery oriented, collaborative, time limited Staff are specifically trained in the delivery of EBPs through VA National Training Programs

24. EBPs for PTSD Cognitive Processing Therapy (CPT) & Prolonged Exposure (PE) Both originally developed to be used to treat victims of sexual assault Recommended as frontline treatment by VA/DoD Institute of Medicine International Society of Traumatic Stress Studies

25. What is Cognitive Processing Therapy (CPT)? In CPT, the focus of the therapy is on how the traumatic experience changed one’s thoughts and beliefs (the interpretation and meaning of the event) and how those beliefs influence current feelings and behaviors. Goals of treatment: Accepting that the trauma has occurred. Allowing emotions to run their course. Modifying maladaptive interpretations and meanings.

26. What can patients expect? A very active, recovery-focused process Approximately 12 weekly sessions, lasting 50-60 minutes Weekly practice assignments designed to help patients identify and change distorted beliefs that emanated from the trauma Weekly monitoring of symptoms (PTSD Checklist, Beck Depression Inventory)

27. Structure of CPT Phase 1 – Pre-treatment assessment & issues (Patient educational video) Phase 2 – Education re: PTSD, thoughts & emotions (Sessions 1 – 3 ) Phase 3 – Processing the trauma (Sessions 4 – 5) Phase 4 – Learning to challenge (Sessions 6 – 7) Phase 5 – Trauma themes (Safety, Trust, Power/Control, Esteem, Intimacy) (Sessions 8 – 12)

28. Helping Patients Get “Unstuck” “Stuck points” that reflect self-blame, undoing “I should have known he would hurt me.” “If I had been paying attention, I would have seen it coming.” “Maybe he didn’t hear me say ‘no!’” “If I hadn’t been drinking, it would not have happened.” “I must have given off some vibe that it was okay to do that.” “I should have fought harder.”

29. Helping Patients Get “Unstuck” (cont.) “Stuck points” that are extreme or overgeneralized “If I let other people get close to me, I’ll get hurt again.” “I must be on guard all the time.” “Men cannot be trusted.” “I am dirty, unlovable, damaged.” “I have no control over my future.” “I am worthless.” “I deserve to have bad things happen to me.”

30. Final thoughts from a patient… “People that have known me for years have noticed a marked improvement in my behavior, attitude, and way of living. Early into my sessions, I recall telling my therapist that I spent many years surviving, which moved into struggling to survive, which has now become living. After more than 32 years of being stuck and holding myself hostage, I can honestly say that through CPT, I have learned to ‘really live.’”

31. Questions?