Not All Traumas Are Created Equal:

1. Not All Traumas Are Created Equal: BarbaraSchmidlapp, L.I.S.W. MST Coordinator, Huntington VISN 9 V.A. Point of Contact

2. What Is Military Sexual Trauma (MST)? • Definition in US Code (federal law): “Psychological trauma, which in the judgment of a mental health professional employed by the Department, resulted from a 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

3. 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

4. As a result of national policies and programs • All Veterans seen in VA healthcare are screened whether they experienced MST • All treatment for physical and mental health conditions related to experiences of MST is free for both men and women (this includes pharmacological services.)

5. As a result of national policies and programs • Every VA healthcare facility has a designated MST Coordinator who serves as a contact person for MST–related issues.

6. Because of the high ratio of men to women in the military, there are about comparable numbers of men and women seen in VA who have experienced MST with only slightly fewer men than women. • 22% women and 1%men

7. Eligibility for Care • They do not need to have reported the incident(s) when they happened or have other documentation that they occurred.

8. Eligibility for Care • Veterans may be able to receive this benefit even if they are not eligible for other VA care. • It’s important to know that Veterans do not need to be service connected to receive free, confidential treatment for mental and physical health conditions related to MST.

9. Eligibility for Care • Incidents occurred while on active duty or active duty for training • Includes Reservists and members of the National Guard • Independent of VBA claims process • Eligibility accrues as a result of events incurred in service • No length of service requirements • No income requirements • Veterans who received an other than honorable discharge may be able to receive care with VBA Regional Office approval

10. MST and Medical Comorbidity • Mary Koss’s (1992) research found that women with sexual trauma histories had more physical symptoms across nearly all body systems than women without histories of sexual trauma. • Women with sexual trauma histories make twice as many physician visits as women without histories of sexual trauma.

11. SARA • http://www.ptsd.va.gov/apps/AboutFace/veterans/cpt-sarah-c-humphries/who-i-am.html

12. Sexual Trauma and Healthcare Utilization • Typically, patients with a sexual trauma history present to medical providers, not mental health providers.

13. Medical Exams • Medical examinations that are most likely to trigger strong reactions in sexual trauma survivors include: • Pelvic (gynecological) exams, pap smears • Rectal exams • Vaginal ultrasound • Breast exams/mammograms • Colonoscopies • Endoscopies • Urological examinations

14. Managing the Disclosure Process • It is important that providers respond to disclosures in a nonjudgmental, affirming manner.

15. Therapeutic Responses Respect Empathy Support Patient Perceptions accepted Education Clinician Competence Triage – assess safety Harmful Responses Disbelief Distancing Attributing assault to victim behavior Trivializing emotional reactions Encouraging forgetting Ridicule or harassment Prejudicial assumptions “First, Do No Harm”Response of Others to Sexual Assault

16. Managing the Disclosure Process • Patients show a range of disclosure styles. • Flat affect • Nervous laughter • Disclosing full details

17. Managing the Disclosure Process LIMIT the DISCLOSURE PROCESS

18. Steps after disclosure • Validation and empathy • Education • Assessment of current status and safety • Assessment of support • Check in with him and how he/she is feeling. Offer to have him/her call if he/she feels the need after disclosure.

19. Validation and empathy • Validation and Empathy "I’m sorry that you experienced sexual trauma while in the military."

20. Education • "Many Veterans have experienced sexual trauma while serving in the military. We have staff who specialize in MST and would be able to help you.”

21. Assessment of Support Level • "Have you been able to discuss this with anyone previously

22. Elements of Sexual Trauma Psychotherapy

23. 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 is acceptable and expected behavior from a trusted other, what rights/needs the victim has, and what is “theirs” versus publicly available • May be particularly confusing in the military context • May have expected others to be “soldiers in arms” • Has significant implications for survivors’ subsequent relationships and understanding of themselves

24. MST May Be Ongoing Over Time • In the military, there are often few boundaries between work and home life and in both spheres individuals may interact with the same group of people • Survivors may continue to have interactions with their perpetrator • May be ongoing potential for revictimization • Can increase feelings of helplessness and of being trapped • Parallels with childhood abuse

25. Sexual Trauma That Occurs in Military Settings Unique due to: • MST occurs in a setting where the victim lives and works • Increased feelings of entrapment, powerlessness, & risk of revictimization • Need to rely on perpetrators for basic needs • Disruption of career goals • Particular aspects of military culture compound feelings of helplessness and betrayal • Typically considered to be a complex trauma  Experiences that are even more psychologically destructive than “simple” traumas

26. Social Support May Be Limited • At the time of experiences, may be far from friends and family • May be reluctant to report experiences to authorities • Experience of OEF/OIF Veterans may be different due to DoD reforms • At homecoming or discharge, may believe or be told by others that their experiences are not as “legitimate” as combat trauma experiences

27. Social Support May Be Limited • May be reluctant to disclose experiences to loved ones or healthcare providers, limiting important opportunities to receive support • May believe that treatment programs targeted at returning veterans will not welcome them • Problematic given research identifying social support as the most consistent and best predictor of recovery after trauma

28. How is Sexual Trauma that Occurs in Military Settings Unique? • Survivors are particularly vulnerable • Young in age (increased risk factor for MST if 19 or younger at time of enlistment) • May be away from home and support network for the first time

29. Additional Complicating Factors:Age / Developmental Level • Leaves vulnerable to developing mental health and other difficulties • May draw on less developmentally advanced coping strategies such as dissociation, behavioral acting out, or cutting or other forms of self-harm that themselves impair functioning and health

30. How is Sexual Trauma that Occurs in Military Settings Unique? • Particular aspects of military culture compound feelings of helplessness and betrayal • Power differential due to frequency of higher rank in perpetrator compared to victim • Victim cannot escape by choosing to leave or change jobs • Difficulty reporting if perpetrator is in chain of command

31. How is Sexual Trauma that Occurs in Military Settings Unique? • Violation of sense of trust • Command supposed to take care of troops-violated if perpetrator is in chain of command or if chain of command does not respond • Expectation of respect and trust for those of higher rank violated if perpetrator is of higher rank • Violation of sense of safety-military base as high security and safe

32. How is Sexual Trauma that Occurs in Military Settings Unique? • High value on loyalty and teamwork • Taboo to divulge negative info about peers • MST is that much more incomprehensible to victim • High value placed on strength and self-sufficiency reduces social support available and increases likelihood of invalidating responses being a victim conflicts with desired identity-”Army Strong” Threat of death if report is real-peers trained to kill in combat, threat of “accidents” on firing range

33. How is Sexual Trauma that Occurs in Military Settings Unique? • Response is often minimal or punitive to victim • 90% of rapists never court-martialed • Victim who reports is accused of breaking up their unit or hurting esprit de corps • Victim may be the one transferred, may be branded as “trouble-maker”

34. MICHELLE • http://www.ptsd.va.gov/apps/AboutFace/veterans/michelle-rentas/who-i-am.html

35. Continuum of Severity • Anything in the trauma, the person or the context that: makes the emotions more intense • makes the meanings more confusing or upsetting • will make the trauma more severe or “complex”

36. Why Look At Complex Trauma? • Complex trauma is associated with a more confusing array of responses • Military Sexual Trauma (MST) is often a complex trauma • Understanding complex trauma sheds light on confusing behaviors

37. Additional Complicating Factors: Other Experiences of Trauma • High rates of childhood and premilitary trauma among MST survivors and military personnel more generally • Concurrent exposure to combat among OEF/OIF Veterans • 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 (e.g., poor social support; self-blame) may impair ability to cope with later trauma

38. Complex Trauma vs. PTSD • •Complex Trauma refers to multiple and on-going stress, originally ,primarily experienced in childhood and adolescence but now MST is being viewed as a complex trauma. • •The impact of complex trauma may not mirror the symptoms of PTSD,

39. Complex Trauma • “Complex trauma generally refers to traumatic stressors that are interpersonal, that is, they are premeditated, planned, and caused by other humans, such as violating and/or exploitation of another person.” (Christine A. Courtois, PhD)

40. What makes trauma ‘worse’? • Interpersonal • Age (early or late in development) • Repetition • Violence (subjective life threat)

41. Entrapment Creates • An ongoing traumatic situation • Repeated exposure to trauma • An inability to get safe • Intense, chronic helplessness, terror, and dread • Unrelenting physiological arousal • Dependency upon the perpetrator • Increased risk of internalizing the perpetrators views • The necessity of not knowing what you know Intolerable meanings Dissociation is inevitable • 14

42. PTSD • •A diagnosis of PTSD may result from a single event at anytime in the lifecycle. • •A diagnosis PTSD is limited to specific symptom criteria, including re-experiencing, avoidance, and increased arousal.

43. Definition of Complex Trauma • Prolonged exposure to repeated or multiple traumatic events • From which escape is not possible due to environmental, social, psychological, maturational forces • Typically of an interpersonal nature • Often reported about but does not necessarily only occur in early life

44. Examples Complex Trauma • childhood abuse • domestic violence • prisoners of war/MST • slave-trade • sex trafficking • torture • exposure to genocide or other forms of organized violence

45. Core Characteristics of Complex Trauma: Impact on Self Concept • Repeated violations of the body is often accompanied by a dehumanization of the person • CPA – “I was a punching bag” • CSA - “I was a sexual object “ • Torture - ”I was no longer human” • Genocide – “I, my people, were vermin to be eradicated” • Repeated bodily violations in the context of abrogated personhood leads to the degeneration of the capacity for self-organization (or in the case of children, disturbs the development of these capacities)

46. The ISTSS ( International Society of Traumatic Stress Studies) task force definition of Complex PTSD included the core symptoms of PTSD (re-experiencing, avoidance/numbing, and hyper-arousal) in conjunction with a range of ISTSS Expert Consensus Guidelines for Complex PTSD November 2012

47. ICD-11 Complex PTSD • PTSD • Disturbances in Emotions: Affect Dysregulation - heightened emotional reactivity, violent outbursts, impulsive or reckless behaviors • Disturbances in Self: “Defeated/Diminished” Self - marked by feeling diminished, defeated and worthless, feelings of shame, guilt, or despair (extends despair) • Disturbances in Relationships - marked by difficulties in feeling close to others, having little interest in relationships or social engagement more generally. There may be occasional relationships but the person has difficulty sustaining them. (combines and extends detachment and social withdrawal) Van der Kolk, Roth, Pelcovitz et al (2005) Journal of Traumatic Stress Cloitre, Courtois, Charuvastra et al (2011) Journal of Traumatic Stress

48. Relevance to Women Veterans with MST

49. Concept applicable to Women with MST? • Frequently have experience chronic early life or premilitary trauma (Kelly et al, 2011; Suris & Lind, 2008) • Typical symptom profile is complex PTSD or PTSD plus multiple comorbid symptoms (Allard et al, 2011; Kimerling et al, 2007, Kimerling et al,2010; Luterek et al, 2011; Suris et al, 2004; Suris et al, 2007) • Commonly worry about social and role functioning, including coping with re-integration (Mattocks et al, 2012; Street et al, 2009)

50. Elements of Sexual Trauma Psychotherapy • Addressing immediate health and safety concerns • Normalizing post–trauma reactions by providing education about trauma and psychological reactions to traumatic events • Providing the Veteran with validation