1. MILITARY SEXUAL TRAUMA Susan Knoedel, LCSW MST Coordinator William S. Middleton VA Hospital

2. Today’s Agenda  VA definition of MST  Incidence of MST  Barriers to reporting  Types of reporting in military  What affects survivors’ reactions to MST  Event characteristics  Individual characteristics  Environmental characteristics  Treatments that work  Accessing VA services

3. 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

4. How Common is MST?  Rates of MST among veteran users of VA healthcare are higher than in the general military populations.  Based on a 2000 national survey of 3,632 women veterans using VA healthcare, 23% reported at least one sexual assault while on active duty.  Reported rates of sexual assault while in the military are higher than lifetime rates among women in the general population.

5. How Common is MST? (cont.)  Based on VA’s 2002 national MST surveillance data from approx. 1.7 million VA patients, 22% of women and 1% of men have experienced MST.  Even though MST is far more common in women, 54% of all VA patients who screen positive for MST are men.  National totals of veterans in VA care endorsing having experienced MST are nearly 60,000 men and 60,000 women.

6. Barriers to reporting  Fear of harm/retribution  Embarassment  Denial  Co-occuring offenses (drug/alcohol/fraternization)  Reputation  Lack of knowledge  Fear for career  Fear of being blamed  Fear of not being believed

7. Reporting a Sexual Trauma  Two methods  Restricted  Unrestricted

8. Restricted Reporting  Allows victim to confidentially disclose details to specific individuals without triggering the investigative process  Gives victim access to medical care, counseling and support without pressure of others finding out  Commander will be notified of an assault and any other non-identifying information

9. Specified Individuals (Restricted Reporting)  Individual who are NOT required to report  SARC (Sexual Assault Response Coordinator)  VA (Victim Adocate)  Chaplains  Medical Personnel  Military OneSource

10. Unrestricted Reporting  Allows the Service Member who is sexually assaulted to report the assault and permits the commencement of an official investigation of his or her allegations using the current reporting channels.  The victim will still receive prompt sensitive support, medical treatment and counseling.

11. What Affects Survivors’ Reactions?  Characteristics of the experience(s):  Single event vs. ongoing set of events  Rape vs. sexual harassment  Single perpetrator vs. multiple perpetrators  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  Need to keep seeing/working with the perpetrator  Military culture

12. Characteristics of the Individual: Childhood or Other Prior Trauma  High rates of childhood trauma among veterans, particularly those who experience MST (Merrill et al., 2001; Rosen & Martin, 1996; Sadler et al., 2003)  Later traumas seen as confirmation that the world is a bad and dangerous place  Aftereffects of earlier trauma (e.g., poor social support; self-blame) may impair ability to cope with later trauma  Effects of trauma appear to be dose-specific—the more traumas or the worse the trauma, the worse the outcome

13. Childhood Trauma Can Leave People Particularly Vulnerable  Typically more “complex traumas”  Ongoing over a period of time  Interpersonal victimization by a known perpetrator  Occur early in development  Experiences that are even more psychologically destructive than “simple” traumas  Given rates of childhood and post-military trauma among veterans, working with survivors of MST often means working with multiply traumatized individuals (Merrill et al., 2001; Rosen & Martin, 1996; Sadler et al., 2003)

14. Revictimization / Insufficient Self-Protection  Relationships with abusive partners, unsafe sex, prostitution, poor boundaries with others / trusting too easily, putting self in dangerous situations…  Rates of revictimization are high  16% - 72% of female childhood sexual abuse survivors experience sexual or physical revictimization as adults (Messman & Long, 1996)  Sadler and colleagues (2003) found that 37% of women reporting a history of MST had been raped at least twice during their military service  Few studies exist for men, but some suggest sexual revictimization rates comparable to those for women

15. Characteristics of the Individual: Gender – Impact on male victims  Men may be taught that being victimized implies they are weak, and thus, not a man.  Shame, stigmatization, and negative reactions from others may also result from the social taboos.  Resulting confusion about their sexuality and their gender role (their role as men).  Overcompensating through hypermasculinity.  Guilt and shame if they experienced physical arousal.

16. Gender Identity Concerns of male victims 16  Calls into question unexamined assumptions about male gender in the culture at large o heterosexual o physically strong o unemotional o in control.......Conclusion: “I am no longer a real man”

17. Sexual Identity Concerns (of male victims) 17  Confusion over sexual identity  “Am I gay?”  “I must be gay.”  “I am gay and I can’t face it.”  Result : Attempts to “prove” their heterosexuality  Multiple “conquests” of women/promiscuity  Early or impulsive marriage

18. Characteristics of the Individual: Tendency towards Self-Blame 18 “I must have done something to provoke the attack” “I must have wanted it” “ What did I expect when I …. (joined the military, hung out with male soldiers…)” “It happened because I am gay, as punishment” (gay patient) “It happened because I am weak” “I should have been able to fight him off?”” “I am damaged, there is something about me that perpetrators can identify”  (esp. if child trauma)

19. Characteristics of the Environment: Military Context  In the military…  The victim typically knows the perpetrator  The victim is typically chronologically and developmentally young  Can’t just quit, AWOL  Perception that career goals will be jeopardized by disclosing MST  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

20. Characteristics of the Environment: Role of Military Culture 20  Implicit message in Basic Training is that a good soldier: o Does not question authority o Subsumes his/her emotional needs to the mission o Is loyal and focused on teamwork, unit cohesion o Ignores the physical needs/messages of his/her body o Is strong and self sufficient o Does not divulge negative information about peer o Maintains Esprit de Corps o Is “owned” by the military

21. Characteristics of the Environment: Substance Abuse 21  “Gender-acceptable” & military-condoned way to manage/numb intrusive thoughts, feelings, & images of rape  Creates appearance of being “just like all the other guys”  PTSD symptoms may go undetected by veteran himself  Facilitates aggression, re-enactment and re-victimization  May be the “identified problem” unless MST is identified during screening

22. Sexual Trauma Is A Particularly Toxic Stressor Probability of Developing PTSD RapeCombat Molest- ation Physical Abuse Women45.9%--26.5%48.5% Men65.0%38.8%22.2%22.3% (Kessler et al, 1995)

23. Sexual Trauma Is A Particularly Toxic Stressor (cont.) Study of Gulf War Veterans Probability of Developing PTSD MSTCombat Women 5x higher rates 4x higher rates Men 6x higher rates 4x higher rates (Kang et al., 2005)

24. Multiple impacts of MST  Physiologically  Body sensitized to threat  Prone to all-or-nothing reactions  Disrupted memory / cognitive processing  Emotionally  Intense feelings that are difficult to contain  Normal regulatory systems that promote homeostasis are overwhelmed  Tendency towards all-or-nothing reactions  Cognitively  Affects how we view the world  Disrupts sense of power and control, beliefs about trustworthiness of others, sense of self…  Tendency towards all-or-nothing thinking

25. Diagnoses Associated with MST  PTSD is the formal diagnostic category most frequently associated with sexual assault.  Other diagnoses often associated with MST:  Depression Suicidal thoughts and/or suicide attempts  Substance abuse/dependence  Other anxiety disorders  Dissociative disorders  Somatization disorders  Eating disorders  Borderline personality disorder  Physical health problems (e.g., lower back pain; headaches; pelvic pain; GI pain/symptoms; sexual dysfunction; gynecological symptoms; chronic fatigue)

26. Themes/Issues Common in Working with MST Survivors  MST (as opposed to other types of trauma) is particularly associated with:  Feelings of self-blame  Difficulties trusting self and others – especially formal authorities  Difficulties with hierarchies, sensitivity to issues of justice  Boundary issues  Concerns about sexual identity / sexuality / sexual orientation  Revictimization  Multiply traumatized individuals are particularly likely to evidence these types of difficulties

27. Treatments that Work: Evidence- Based Practices  Therapies tested with randomized controlled trials (RCTs) and found to be effective are referred to as Evidence-Based Practices (EBP’s)  Examples of widely-used EBPs appropriate for treating the aftereffects of MST:  Cognitive Processing Therapy (CPT)  Prolonged Exposure (PE)  Seeking Safety  Dialectical Behavior Therapy (DBT)  Acceptance & Commitment Therapy (ACT)

28. Recovery  Overarching framework provided by 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

29. A Loose Categorization of Some Commonly Used 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)

30. Treatment issues that arise in working with MST: Keeping the Secret 30  Expectation of stigma in treatment settings  Concerns about MST designation in medical records  Lack of control over which providers have access to this information

31. What Do We Know About MST Among OEF/OIF Veterans?  Still learning  Issues to consider:  Trauma is recent, reactions are acute  Interaction between combat exposure and MST is unclear  How TBI may affect treatment is unclear  Issue of compounding factors of being away from home, usual support systems

32. Improving Our Sensitivity: Reconceptualizing Symptoms  Underlying logic to many ‘symptoms’ if you look more closely  Allowed the victim to survive the event at the time, but have persisted into different, inappropriate contexts and/or  Represent best efforts to deal with (overwhelming) uncharted territory  Particularly true in the case of early or complex trauma (and thus often MST) – the trauma occurred before the victim had developed more sophisticated coping strategies

33. Examples of Looking for the Underlying Logic ProblemUnderlying Logic Self-blameWay to avoid confronting helplessness/ vulnerability – allows to believe that have control over what happens to him/her. Allows to avoid confronting idea that the perpetrator had intent. Emotional constrictionAllows to experience only a limited, less- threatening range of emotions All-or-nothing thinkingOver-generalization / over-protectiveness more likely to ensure safety than under- reaction Difficulties trusting self or others Way to prevent it from happening again

34. Examples of Looking For the Underlying Logic (cont.) ProblemUnderlying Logic Preoccupation with justice issues / sensitivity to power & control dynamics Way to prevent it from happening again to self or anyone else. Way to express outrage at own perpetrator’s behavior. Substance use / abuseHelps calm physiology, tolerate social situations, and gives the illusion of aiding sleep Boundary issuesProfound violation of own boundaries makes it hard to know what is okay and what is not okay. May be related to trusting too easily, to avoid acknowledging vulnerability.

35. Examples of Looking For the Underlying Logic (cont.) ProblemUnderlying Logic DissociationIn situations where there is nothing you can do to avoid the inevitable, allows escape from chronic feelings of terror, hypervigilance, and impending doom Starving oneself or overeatingMakes self undesirable (believing this may prevent future attack) and gives sense of control over something. Way to self-soothe Self-harm behaviors (e.g., cutting) Way to distract from overwhelming feelings, to experience more controllable pain, or to avoid feelings of numbness

36. What’s the logic?  Trusting too easily as a way to deny prior trauma and/or avoid facing one’s vulnerability  Intoxication (for self-medication) reduces sensitivity to / awareness of danger  Lack of self-trust leads to discounting internal alarms  Remaining with an abuser as a way to maintain hope about others and/or reflects reluctance to see self as a victim

37. Helpful general principles 1. Adopt a strengths-based approach 2. Empathy goes a long, long way 3. Provide ongoing normalization / validation 4. Be transparent and genuine 5. Offer choice, restore control 6. Help the veteran balance the big and little picture 7. Don’t assume you know what the worst part of the veteran’s experience was (and is) 8. Prioritize self-care, so that you can remain engaged

38. VA Resources: MST Coordinators  Chicago (Jesse Brown VAMC): Megan Null (312) 569-7209  Hines: Kris Lopez (708)202-8387 x24718  Iron Mountain: Julie Gendron (906) 774-3300 x32388  Madison: Susan Knoedel (608) 280-7084  Milwaukee: Mitzi Dearborn (414) 384-2000 x41674  North Chicago: Julianne Hish (224) 610-5798  Tomah: Catherine Routh (608) 372-3971 x61757

39. Thanks!  To SAPRC’s  To MST Support Team for resources for this presentation