OIF/OEF WomenOIF/OEF Women

Darrah Westrup, Ph.D.Darrah Westrup, Ph.D.Women’s Mental Health CenterWomen’s Mental Health Center

Women’s Trauma Recovery ProgramWomen’s Trauma Recovery ProgramNational Center for PTSDNational Center for PTSD

VA Palo Alto Health Care SystemVA Palo Alto Health Care SystemwomenvetsPTSD.va.govwomenvetsPTSD.va.govdarrah.westrup@va.govdarrah.westrup@va.gov

OIF/OEF WomenOIF/OEF Women

What do we need to know about What do we need to know about OIF/OEF women?OIF/OEF women?How are they different?How are they different?What are their particular treatment needs?What are their particular treatment needs?

How can we best serve OIF/OEF How can we best serve OIF/OEF women?women?What services are needed?What services are needed?What are the effective treatments?What are the effective treatments?

Women VeteransWomen Veterans

Women are one of the fastest growing segments Women are one of the fastest growing segments of the veteran population. They comprise:of the veteran population. They comprise: 15% of active military15% of active military 20% of new recruits20% of new recruits 17% of reserve and National Guard17% of reserve and National Guard 13% of OIF/OEF troops (59 casualties as of April ’06)13% of OIF/OEF troops (59 casualties as of April ’06)

5% of 27 million veterans are women and this 5% of 27 million veterans are women and this number is expected to increase to 10% by 2010number is expected to increase to 10% by 2010

Women veterans have greater health problems Women veterans have greater health problems than their nonveteran female counterpartsthan their nonveteran female counterparts

87% of women veterans do not use VA care87% of women veterans do not use VA care

Specific Needs of OIF/OEF Specific Needs of OIF/OEF WomenWomen

Less in-service social support

Different determinants of social support

Role transition

Intimate partner violence

Behavioral health29% of OEF/OIF women veterans who use VA are diagnosed with mental health disorders

PTSD – SUD comorbidity

OIF/OEF and FamilyOIF/OEF and Family

Family issues are paramountFamily issues are paramount Often in caregiver roleOften in caregiver role Partner conflictPartner conflict Parenting skillsParenting skills Domestic violenceDomestic violence Young childrenYoung children Individuation from family of originIndividuation from family of origin

OIF/OEF Women: Presenting OIF/OEF Women: Presenting ProblemsProblems

Comorbid DifficultiesComorbid Difficulties DepressionDepression Anxiety/panicAnxiety/panic Substance useSubstance use Personality disorders Personality disorders SomatizationSomatization Sexual dysfunctionSexual dysfunction Eating disordersEating disorders Self-injurious behaviorSelf-injurious behavior

Military Sexual AssaultMilitary Sexual Assault

Higher rates of Military Sexual Trauma

Physical attacks and sexual assaults of Physical attacks and sexual assaults of women by comrades exceed casualties women by comrades exceed casualties by enemy actions.by enemy actions.

As many as 25% of military women As many as 25% of military women have been sexually assaulted.have been sexually assaulted.

Sexual assaults and harassment that Sexual assaults and harassment that occur in military may be more occur in military may be more damaging than other work settings. damaging than other work settings.

MST is associated withMST is associated with

Increased suicide riskIncreased suicide risk Major depressionMajor depression PTSDPTSD Alcohol/drug abuseAlcohol/drug abuse Long-term sexual dysfunctionLong-term sexual dysfunction Disrupted social networksDisrupted social networks Occupational difficultiesOccupational difficulties AsthmaAsthma Breast cancerBreast cancer Heart attacksHeart attacks ObesityObesity

Combat-related ExposureCombat-related Exposure

Problems similar to those for sexual Problems similar to those for sexual assaultassault

Drug-related disordersDrug-related disorders Accidental deathsAccidental deaths Higher level of general psychiatric Higher level of general psychiatric

distressdistress More frequent somatic complaintsMore frequent somatic complaints Anxiety/panicAnxiety/panic PTSDPTSD

Service ModelService Model

Designated women’s clinicDesignated women’s clinic Gender specific servicesGender specific services Prevention and educational servicesPrevention and educational services Mental health presence in primary careMental health presence in primary care Couples and parent-child therapiesCouples and parent-child therapies Drop-in groups with childcareDrop-in groups with childcare Evening hoursEvening hours Evidence-based treatmentsEvidence-based treatments

VA Services for WomenVA 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 TreatmentResponse to Treatment

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

Pre-treatment

Post-treatment

Follow-up

Eff

ect

Siz

e

MenWomen

Cason, et al., 2002

Evidence-Based PTSD TreatmentsEvidence-Based PTSD Treatments

Clinical Practice Guidelines Clinical Practice Guidelines (ISTSS)(ISTSS) Cognitive behavioral therapyCognitive behavioral therapy PharmacotherapyPharmacotherapy Group therapyGroup therapy

Cochrane Review Cochrane Review (Bisson & Andrew, 2005)(Bisson & Andrew, 2005) Trauma focused cognitive behavioral (TFCBT) Trauma focused cognitive behavioral (TFCBT)

group and individual therapy, and stress group and individual therapy, and stress management are effective treatments for PTSDmanagement are effective treatments for PTSD

TFCBT is superior to stress management between 2 TFCBT is superior to stress management between 2 and 5 months following treatmentand 5 months following treatment

TFCBT is more effective than other therapiesTFCBT is more effective than other therapies

Empirically-Supported Empirically-Supported Treatments for Women with Treatments for Women with PTSDPTSD

Seeking Safety Seeking Safety (Najavitz et al., 1996)(Najavitz et al., 1996)

For women with PTSD and substance For women with PTSD and substance disordersdisorders

Fits Herman’s “first stage” of treatmentFits Herman’s “first stage” of treatment No exposure workNo exposure work 24 weekly sessions for 90 minutes24 weekly sessions for 90 minutes Group formatGroup format ManualizedManualized Easily transferableEasily transferable

Empirically-Supported Empirically-Supported Treatments for Women with Treatments for Women with PTSD (cont.)PTSD (cont.)

Cognitive-Processing Therapy Cognitive-Processing Therapy (Resick & (Resick & Schnicke, 1992, 1993)Schnicke, 1992, 1993)

Based on Information Processing TheoryBased on Information Processing Theory

12 sessions12 sessions Education about trauma meaningEducation about trauma meaning Cognitive therapy – challenging beliefsCognitive therapy – challenging beliefs Disclosure about the trauma (written)Disclosure about the trauma (written) Skills building – safety, trust, power, self-Skills building – safety, trust, power, self- esteem, and intimacyesteem, and intimacy

Empirically-Supported Empirically-Supported TreatmentsTreatments

Acceptance and Commitment Therapy Acceptance and Commitment Therapy (Hayes, Strosahl, & Wilson, 1999)(Hayes, Strosahl, & Wilson, 1999)

12 sessions in “building block” format12 sessions in “building block” format

Control of private events as the problemControl of private events as the problem

Self as context rather than contentSelf as context rather than content

Letting go of the struggleLetting go of the struggle

Commitment and behavior changeCommitment and behavior change

Clinical PresentationClinical Presentation

Interpersonal problems Interpersonal problems Social isolationSocial isolation Identity disturbanceIdentity disturbance ImpulsivityImpulsivity Emotion dysregulationEmotion dysregulation Numbing/dissociationNumbing/dissociation Problematic thinkingProblematic thinking

Clinical Presentation (cont.)Clinical Presentation (cont.)

They are in despairThey are in despair

They want better livesThey want better lives

They deserve our best effortThey deserve our best effort

““Coping” strategies impede therapeutic Coping” strategies impede therapeutic growthgrowth

Difficulties can be longstanding and Difficulties can be longstanding and entrenchedentrenched

Providers are necessarily impacted by the Providers are necessarily impacted by the workwork

Clinical Factors that Affect Clinical Factors that Affect TreatmentTreatment

Difficulty establishing the Difficulty establishing the therapeutic alliancetherapeutic alliance Approach based on relationship Approach based on relationship

history history Blended with familial and military Blended with familial and military

dynamicsdynamics Situation evokes vulnerabilitySituation evokes vulnerability Evokes issues with “control”Evokes issues with “control”

Providers’ Challenge - Providers’ Challenge - Maintaining a Therapeutic Maintaining a Therapeutic StanceStance

Caring for those who can make it Caring for those who can make it difficult difficult

Managing the negative impactManaging the negative impact On oneselfOn oneself On the patient or clientOn the patient or client On other patients/clientsOn other patients/clients

Strategies to Help Maintain a Strategies to Help Maintain a Therapeutic StanceTherapeutic Stance

Protect your compassion Protect your compassion Language mattersLanguage mattersNo need to be “above it all”, get supportNo need to be “above it all”, get supportExpect to fall from graceExpect to fall from grace

Be rigorousBe rigorousBe intentional vs. reactiveBe intentional vs. reactiveBe aware of your limitsBe aware of your limits

Human behavior is purposefulHuman behavior is purposefulEven illogical behavior has a functionEven illogical behavior has a functionFocus on the behaviors vs. labelingFocus on the behaviors vs. labeling

Never forget people can and do get betterNever forget people can and do get better

Program Planning Program Planning ResourcesResources

Women Veterans Health Program Women Veterans Health Program HandbookHandbook

Women Veterans Health Program Plan Women Veterans Health Program Plan of Careof Care

VA DirectivesVA Directives

Mental Health Strategic PlanMental Health Strategic Plan

Women’s Mental Health CommitteeWomen’s Mental Health Committee

Suggested References Suggested References

Kimerling, R., Ouimette, P., Wolfe, J. (2002). Kimerling, R., Ouimette, P., Wolfe, J. (2002). Gender and PTSD.Gender and PTSD. New York: New York: Guilford Press.Guilford Press.

WashingtonWashington, D. L., Yano, E. M., & Horner, R. D. (Eds.). (2006). VA , D. L., Yano, E. M., & Horner, R. D. (Eds.). (2006). VA Research on Women’s Health [Special issue]. Research on Women’s Health [Special issue]. Journal of General Internal Journal of General Internal Medicine, 21Medicine, 21 (3). (3).

http://siadapp.dior.whs.mil/index.htmlhttp://siadapp.dior.whs.mil/index.html (DoD Personnel and Procurement (DoD Personnel and Procurement Statistics)Statistics)

http://www.defenselink.mil/news/Mar2006/d20060316SexualAssaultReporthttp://www.defenselink.mil/news/Mar2006/d20060316SexualAssaultReport.pdf.pdf (DoD Sexual Assault Report for 2005 with 06 Summary) (DoD Sexual Assault Report for 2005 with 06 Summary)

http://www1.va.gov/VHI/page.cfm?pg=32http://www1.va.gov/VHI/page.cfm?pg=32 -- -- https://www.ees-learning.net/librix/loginhtml.asp?v=librixhttps://www.ees-learning.net/librix/loginhtml.asp?v=librix ( (Military Military Sexual Trauma Veterans Health Initiative) Sexual Trauma Veterans Health Initiative)

http://www.ncptsd.va.gov/index.htmlhttp://www.ncptsd.va.gov/index.html (National Center for PTSD). (National Center for PTSD).