1. Amy P. Smith, Psy.D. MST Coordinator Amy.Smith5@va.gov

2. Agenda Why talk about MST? Definitions, legal mandates and VA responses Prevalence Impact on veterans Understanding confusing behavior Resources Recovery & intervention strategies Stages of treatment Tele-health

3. Why Talk About MST? VA is legally mandated to address MST and has resources available to help survivors Significant numbers of women AND men report having experienced MST MST is associated with a host of negative mental and physical health outcomes MST can sometimes lead to confusing interpersonal behavior, particularly towards those in the role of helper Point to ponder: There are a host of traumatic stressors that are an inherent consequence of the military’s very mission and purpose – MST is not

4. What Is Military Sexual Trauma (MST)? VA term for sexual assault or sexual harassment occurring during military service Definition in US Code: “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. Title 38 US Code 1720D

5. What Is MST? (cont.) Any sort of sexual activity in which someone is involved against his or her will. Someone may be… Pressured into sexual activities (e.g., with threats of consequences; with implied better treatment; “command rape”) Unable to consent to sexual activities (e.g., intoxicated) Physically forced into participation

6. What Is MST? (cont.) Can involve unwanted touching, grabbing, oral sex, anal sex, sexual penetration with an object and/or sexual intercourse. Physical force may or may not be used. Other examples include threatening and unwelcome sexual advances, unwanted sexual touching or grabbing, or threatening, offensive remarks about a person’s body or sexual activities.

7. VA is Legally Mandated to Address MST Since 1992, Congress has passed a series of laws mandating that VA… Provide care for physical and mental health conditions related to MST Provide staff with training on MST-related issues Engage in outreach to veterans about services available

8. Some VA Responses All veterans seeking VA care must be screened for MST All treatment (including medications) for physical and mental conditions related to MST is free, with no limit on duration Every facility must have a designated MST Coordinator Serves as a point person for MST issues at the facility Responsible for ensuring that MST-related monitoring, treatment, and education & training occur National OMHS MST Support Team to ensure that VA meets legal mandates Monitors screening and treatment of MST Oversees education and training Promotes best practices nationally

9. Screening for MST Two screening questions Sensitivity needed

10. Free MST-Related Care Incidents occurring on active duty for training count VA disability rating (“Service connection”) is not required Independent of VBA claims process No specific diagnosis (e.g., PTSD) is required Veterans may be able to receive care even if not eligible for other VHA care: No length of service, income, or other standard eligibility requirements; possible in some cases to get care even with other than honorable discharge from military. Incidents do not have to have been reported at the time Treatment for physical health conditions resulting from MST are also covered This benefit is not time limited Never assume someone is ineligible for care

11. A Momentary Digression About Documentation Indicate that a visit is MST-related by checking the MST checkbox in the encounter form for that visit This is the only way that Billing/Business Office knows not to charge the Veteran for this visit

12. A Momentary Digression About Documentation (cont.) Activate the encounter form checkbox by completing the MST Clinical Reminder in CPRS Updates Veteran’s status in medical record and in national monitoring data  Not okay to just add text to progress note It is possible to change a veteran’s MST status if he/she subsequently discloses MST For details on how to do this, see the Monitoring section of the MST Resource Homepage

13. How Common is MST? Data SourceTime frame MenWomen Sexual harassment Sexual assault Sexual harassment Sexual assault DoD 2002 Survey (active duty sample) Annual rates 23%1%54%3% Street et al., 2003 (reservist sample) Anytime during service 27%3%60%23% Skinner et al., 2000 (users of VA healthcare) Anytime during service -- 55%23% This can be difficult to know, as sexual trauma is frequently underreported

14. VA Screening Data From MST Clinical Reminder in CPRS PopulationTime frameMenWomen All VHA users FY 2007 Anytime during service 1.3% (47,719) 22.2% (45,564) OEF/OIF VHA users FY 2007 Anytime during service (i.e., not necessarily while deployed).8% (885) 16.7% (2,960) Why might rates be lower among OEF/OIF veterans? Possibly decreases in rates of MST Possibly delays in disclosure and/or seeking care (MST Support Team FY10 Screening Report; Kimerling, Street, Pavao, Smith, Cronkite, Holmes & Frayne, 2010)

15. Men Experience MST Sexual assault & sexual harassment are sometimes thought of as only women’s issues True that prevalence of MST is higher among women But given disproportionate ratio of men to women in the military, there are significant numbers of men and women seen in VA that report MST

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

17. 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)

18. Associated Conditions FY10 data from CPRS reveals that the diagnoses most commonly associated with MST among users of VA healthcare are: ▫ PTSD ▫ Depression and other mood disorders ▫ Psychotic disorders ▫ Substance use disorders ▫ Mania/bipolar disorders (MST Support Team; Kimerling et al., 2011)

19. Diagnoses & Difficulties Commonly Associated With Sexual Trauma Posttraumatic Stress Disorder Depression Suicidal thoughts and/or suicide attempts Substance Abuse / Dependence Eating Disorders Dissociative Disorders Borderline Personality Disorder / Complex PTSD Somatization Disorders

20. Diagnoses & Difficulties Commonly Associated With Sexual Trauma (cont.) Aftereffects not rising to the level of diagnosis Employment problems Relationship problems Readjustment issues Spirituality issues / crisis of faith Physical health problems Gynecological symptoms or sexual dysfunction Chronic pain (e.g., lower back pain, headaches) Gastrointestinal problems (e.g., Irritable Bowel Syndrome) Chronic fatigue Liver disease Chronic pulmonary disease…

21. How Does Trauma Affect People? 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

22. “MST is Not Just PTSD Plus Sex.” Why? Why can experiencing MST be different from experiencing other traumas? Why is MST such a toxic stressor? One (big) reason to consider: Context in which it occurs

23. Context: Military Culture Particular aspects of military culture may compound feelings of helplessness, isolation, and betrayal High value is placed upon loyalty and teamwork Being harmed by a fellow Servicemember may be that much more shocking and incomprehensible to victims Taboo to divulge negative information about peers High value is played upon strength and self- sufficiency Reduces social support available (particularly if far from home), increases likelihood of invalidating responses Being a “victim” conflicts with desired identity Stigma may be particularly strong for men

24.  Involve prolonged terror, captivity, and helplessness  Stress is more chronic, the emotions more intense, and the meanings less resolvable  Experiences that are even more psychologically destructive than “simple” traumas “Complex traumas”… Involve interpersonal victimization by a known perpetrator Occur early in development Are ongoing over a period of time

25. Context: Setting 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 perpetrator --Victim may be dependent upon the perpetrator and/or his/her friends in many areas of life --Threat of death is real “Complex traumas”… Involve interpersonal victimization by a known perpetrator Occur early in development Are ongoing over a period of time MST Can Typically Be Considered A Complex Trauma

26. Context: Previous Trauma History High rates of childhood trauma among veterans, particularly those who experience MST (Merrill et al., 2001; Rosen & Martin, 1996; Sadler et al., 2003) Can greatly impact how later traumas are experienced Later traumas confirm 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 Childhood traumas are typically more “complex” traumas

27. One Other Factor To Consider: MST is an Interpersonal Trauma Perpetrated by another human being Often by a close friend/intimate partner Involves a profound violation of boundaries and personal integrity Sends confusing messages about what relationships involve, what is acceptable and expected behavior from a trusted other, what rights/needs the victim has, what is “theirs” versus publicly accessible…  Has significant implications for survivors’ subsequent relationships and understanding of self Particularly true when victim is young and trauma is chronic and/or repeated

28. MST Survivors Often Present With… Extremes of emotion (flooding and constriction) Feelings of self-blame Difficulties trusting self and others and/or trusting too easily Particular wariness with authorities and institutions Strong reaction to justice issues and power & control dynamics Sensitivity to and 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

29. What Do We Know About MST Among OEF/OIF Veterans? Not a lot Particular 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 compounded stressors, particularly while away from home and support network DoD’s new policies and programs are an improvement, but are still new/untested

30. All this being said, many victims of MST, even those seeking treatment, cope quite well and evidence few, if any, of these difficulties. For other victims of MST, particularly those multiply traumatized, these difficulties may be more severe.

31. Reconceptualizing Symptoms Even seemingly purposeless or self-destructive behaviors often turn out to be serving a self-protective function 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

32. 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

33. 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.

34. 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

35. 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

36. What’s the Logic? Childhood abuse may mean a survivor never learned self-protection was an option / how to protect self Negative self-image may lead to believe that he/she doesn’t deserve safety and/or make it difficult to do things to take care of self Tendency to dissociate in the presence of danger cues adaptive as a child when there was little to do to protect oneself, but leaves vulnerable as an adult

37. What’s the Logic? (cont.) 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 discount internal alarms Remaining with an abuser as a way to maintain hope about others and/or reflects reluctance to see self as a victim

38. In Sum… A sexual trauma history creates dilemmas for survivors Whether to trust others, when you know that even friends and family may prove untrustworthy Whether to trust yourself, when you know the consequences of being wrong Whether to form relationships and get your needs for connection and affiliation met, when you know how profoundly others could hurt you Whether to prioritize safety or freedom “Crazy” interpersonal behavior can result from trying to manage these dilemmas Helps to assume that there’s a healthy need being met Part of our job is to clarify that these are not either-or choices Part of our job is to be honest that there aren’t always clear answers, and to help veterans examine the trade-offs of different choices

39. RESOURCES TO HELP YOU IN YOUR WORK WITH VETERANS WHO EXPERIENCED MST We’re Talking…Now What?

40. MST Resource Homepage VA Intranet webpage that serves as a repository of resources for MST-related training and education, monitoring, and treatment http://vaww.mst.va.gov

41. MST Resource Homepage Discussion forums Description and copies of MST-related laws and policies National/facility MST screening and treatment data Resources to assist in interpreting and using these data Educational materials, training opportunities, and handouts Outreach materials for Veterans Materials to assist in raising the visibility of MST List of residential programs able to provide specialized care

42. MST Teleconference Training Series Monthly training calls held on the first Thursday of the month from noon to 1 PM (ET) Anyone interested in learning more about MST-related issues is welcome to attend CEUs available Calls are recorded and posted on our website for download on demand Information about how to participate is distributed via the MST Resource Homepage

43. How Might This Knowledge Affect Your Work?

44. 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 Counseling usually involves some amount of skills- building/stabilization – may also potentially include trauma processing (exposure) work

45. Across Stages, Across Treatment Approaches… Top 10 Things I’ve Found Helpful (in no particular order) 1. Adopt a strengths-based approach Likely a novel, validating idea for the veteran; will help you maintain an empathic, patient stance 2. Empathy goes a long, long way 3. Provide ongoing psychoeducation / normalization / validation 4. Be transparent and genuine 5. Offer choice, restore control 6. Help the veteran balance the big and little picture, the long- and short-term perspective Hold the hope

46. Across Stages, Across Treatment Approaches… Top 10 Things I’ve Found Helpful (cont.) 7. Figure out what need is being met by a behavior Engage in a discussion of the pros and cons of meeting it in this way versus some other way 8. Don’t assume you know what the worst part of the veteran’s experience was (and is) 9. Attend to parallel process and other dynamics Be present, be a witness, and be a secure base 10. Prioritize self-care, so that you can remain engaged Monitor your own reactions Remind yourself that recovery can be a long-term process Seek out support from others