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.govdarrah.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 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. 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). 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://siadapp.dior.whs.mil/index.html (DoD Personnel and Procurement Statistics) http://siadapp.dior.whs.mil/index.html http://www.defenselink.mil/news/Mar2006/d20060316SexualAssaultReport.pdf (DoD Sexual Assault Report for 2005 with 06 Summary) http://www.defenselink.mil/news/Mar2006/d20060316SexualAssaultReport.pdf (DoD Sexual Assault Report for 2005 with 06 Summary) http://www.defenselink.mil/news/Mar2006/d20060316SexualAssaultReport.pdf 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://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://www1.va.gov/VHI/page.cfm?pg=32https://www.ees- learning.net/librix/loginhtml.asp?v=librix http://www1.va.gov/VHI/page.cfm?pg=32https://www.ees- learning.net/librix/loginhtml.asp?v=librix http://www.ncptsd.va.gov/index.html (National Center for PTSD). http://www.ncptsd.va.gov/index.html (National Center for PTSD). http://www.ncptsd.va.gov/index.html