OIF/OEF Women

1
OIF/OEF Women

• Darrah Westrup, Ph.D.
• Womens Mental Health Center
• Womens Trauma Recovery Program
• National Center for PTSD
• VA Palo Alto Health Care System
• womenvetsPTSD.va.gov
• darrah.westrup_at_va.gov

2
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?

3
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

4
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

5
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

6
OIF/OEF Women Presenting Problems

• Comorbid Difficulties
• Depression
• Anxiety/panic
• Substance use
• Personality disorders
• Somatization
• Sexual dysfunction
• Eating disorders
• Self-injurious behavior

7
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.

8
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

9
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

10
Service Model

• Designated womens 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

11
VA Services for Women
Only 19 of VA facilities provide any MH services
in a Womens Health Center Space Only 7 of
facilities provide any services by a specialized
womens MH team
These services will be especially important for
the younger, less chronic, women OEF/OIF veterans
12
Response to Treatment
Cason, et al., 2002
13
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

14
Empirically-Supported Treatments for Women with
PTSD

• Seeking Safety (Najavitz et al., 1996)
• For women with PTSD and substance disorders
• Fits Hermans first stage of treatment
• No exposure work
• 24 weekly sessions for 90 minutes
• Group format
• Manualized
• Easily transferable

15
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

16
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

17
Clinical Presentation

• Interpersonal problems
• Social isolation
• Identity disturbance
• Impulsivity
• Emotion dysregulation
• Numbing/dissociation
• Problematic thinking

18
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

19
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

20
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

21
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

22
Program Planning Resources

• Women Veterans Health Program Handbook
• Women Veterans Health Program Plan of Care
• VA Directives
• Mental Health Strategic Plan
• Womens Mental Health Committee

23
Suggested References

• 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 Womens Health
  Special issue. Journal of General Internal
  Medicine, 21 (3).
• http//siadapp.dior.whs.mil/index.html (DoD
  Personnel and Procurement Statistics)
• http//www.defenselink.mil/news/Mar2006/d20060316S
  exualAssaultReport.pdf (DoD Sexual Assault Report
  for 2005 with 06 Summary)
• http//www1.va.gov/VHI/page.cfm?pg32 --
  https//www.ees-learning.net/librix/loginhtml.asp?
  vlibrix (Military Sexual Trauma Veterans Health
  Initiative)
• http//www.ncptsd.va.gov/index.html (National
  Center for PTSD).