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

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?

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

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

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

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

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.

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

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

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

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

Response to Treatment Cason, et al., 2002

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

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

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

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

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

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

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”

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

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

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

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). (DoD Personnel and Procurement Statistics) (DoD Personnel and Procurement Statistics) (DoD Sexual Assault Report for 2005 with 06 Summary) (DoD Sexual Assault Report for 2005 with 06 Summary) learning.net/librix/loginhtml.asp?v=librix ( Military Sexual Trauma Veterans Health Initiative) learning.net/librix/loginhtml.asp?v=librix ( Military Sexual Trauma Veterans Health Initiative) learning.net/librix/loginhtml.asp?v=librix learning.net/librix/loginhtml.asp?v=librix (National Center for PTSD). (National Center for PTSD).