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OIF/OEF Women. Darrah Westrup, Ph.D. Women’s Mental Health Center Women’s Trauma Recovery Program National Center for PTSD VA Palo Alto Health Care System womenvetsPTSD.va.gov [email protected] OIF/OEF Women. What do we need to know about OIF/OEF women? How are they different?

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Darrah Westrup, Ph.D.

Women’s Mental Health Center

Women’s Trauma Recovery Program

National Center for PTSD

VA Palo Alto Health Care System


[email protected]

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  • 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?

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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

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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

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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

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OIF/OEF Women: Presenting Problems

Comorbid Difficulties

  • Depression

  • Anxiety/panic

  • Substance use

  • Personality disorders

  • Somatization

  • Sexual dysfunction

  • Eating disorders

  • Self-injurious behavior

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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.

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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

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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

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Service Model

  • Designated women’s 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

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VA 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

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Response to Treatment

Cason, et al., 2002

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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

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Empirically-Supported Treatments for Women with PTSD

  • Seeking Safety (Najavitz et al., 1996)

    • For women with PTSD and substance disorders

    • Fits Herman’s “first stage” of treatment

    • No exposure work

    • 24 weekly sessions for 90 minutes

    • Group format

    • Manualized

    • Easily transferable

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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

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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

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Clinical Presentation

  • Interpersonal problems

  • Social isolation

  • Identity disturbance

  • Impulsivity

  • Emotion dysregulation

  • Numbing/dissociation

  • Problematic thinking

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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

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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”

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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

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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

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Program Planning Resources

  • Women Veterans Health Program Handbook

  • Women Veterans Health Program Plan of Care

  • VA Directives

  • Mental Health Strategic Plan

  • Women’s Mental Health Committee

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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 Women’s 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/d20060316SexualAssaultReport.pdf (DoD Sexual Assault Report for 2005 with 06 Summary)

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

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