Roksana Korchynsky PhD VA Pittsburgh Healthcare System RoksanaKorchynskvagov PA Women Veterans Symposium June 7 2014 Who Am I Licensed clinical psychologist with VAPHS with 10 years experience in the assessment amp treatment of sexual trauma ID: 693370
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Military Sexual Trauma (MST): Increasing Awareness & Connecting to Treatment for Recovery
Roksana Korchynsky, PhD
VA Pittsburgh Healthcare System
Roksana.Korchynsk@va.gov
PA Women Veterans Symposium, June 7, 2014 Slide2
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 & trainerSlide3
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 psychotherapiesSlide4
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 diagnosisSlide5
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” )Slide6
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 consentSlide7
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 MSTSlide8
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 AWOLSlide9
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 goalsSlide10
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.)Slide11
Context: ST in Military Setting(cont.)
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 reformsSlide12
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 traumaSlide13
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 traumaSlide14
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 PsychosesSlide15
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)Slide16
One Reaction to Trauma: PTSD
Symptoms (per
DSM5):
Intrusion
s
x’s
(intrusive
thoughts;
nightmares; flashbacks; strong emotional and physiological reactions to reminders)
Avoidance
s
x’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
s
x’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 functioningSlide17
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
HomelessnessSlide18
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 strategiesSlide19
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…Slide20
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
MSTSlide21
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 approvalSlide22
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 counselorsSlide23
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 ProgramsSlide24
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 StudiesSlide25
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.Slide26
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)Slide27
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) Slide28
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.” Slide29
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.”Slide30
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.’”Slide31
Questions?