Transcript Military Sexual Trauma

MILITARY SEXUAL TRAUMA
Susan Knoedel, LCSW
MST Coordinator
William S. Middleton VA Hospital
Today’s Agenda
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VA definition of MST
Incidence of MST
Barriers to reporting
Types of reporting in military
What affects survivors’ reactions to MST
 Event
characteristics
 Individual characteristics
 Environmental characteristics
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Treatments that work
Accessing VA services
What is Military Sexual Trauma
(MST)?
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VA term for sexual assault or sexual harassment
occurring during military service
Definition in Public Law:
 “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”.
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US P.L. 102-585, 1992; 108-422, 2004
How Common is MST?
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Rates of MST among veteran users of VA healthcare are
higher than in the general military populations.
Based on a 2000 national survey of 3,632 women veterans
using VA healthcare, 23% reported at least one sexual assault
while on active duty.
Reported rates of sexual assault while in the military are
higher than lifetime rates among women in the general
population.
How Common is MST? (cont.)
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Based on VA’s 2002 national MST surveillance data
from approx. 1.7 million VA patients, 22% of
women and 1% of men have experienced MST.
Even though MST is far more common in women,
54% of all VA patients who screen positive for MST
are men.
National totals of veterans in VA care endorsing
having experienced MST are nearly 60,000 men
and 60,000 women.
Barriers to reporting
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Fear of harm/retribution
Embarassment
Denial
Co-occuring offenses (drug/alcohol/fraternization)
Reputation
Lack of knowledge
Fear for career
Fear of being blamed
Fear of not being believed
Reporting a Sexual Trauma
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Two methods
 Restricted
 Unrestricted
Restricted Reporting
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Allows victim to confidentially disclose details to
specific individuals without triggering the
investigative process
Gives victim access to medical care, counseling and
support without pressure of others finding out
Commander will be notified of an assault and any
other non-identifying information
Specified Individuals (Restricted
Reporting)
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Individual who are NOT required to report
 SARC
(Sexual Assault Response Coordinator)
 VA (Victim Adocate)
 Chaplains
 Medical Personnel
 Military OneSource
Unrestricted Reporting
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Allows the Service Member who is sexually
assaulted to report the assault and permits the
commencement of an official investigation of his or
her allegations using the current reporting channels.
The victim will still receive prompt sensitive support,
medical treatment and counseling.
What Affects Survivors’ Reactions?
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Characteristics of the experience(s):
 Single event vs. ongoing set of events
 Rape vs. sexual harassment
 Single perpetrator vs. multiple perpetrators
Characteristics of the individual:
 Gender
 Developmental level at time of the event
 Prior trauma experiences
 Available coping strategies
Characteristics of the environment:
 Response of others at the time
 Need to keep seeing/working with the perpetrator
 Military culture
Characteristics of the Individual:
Childhood or Other Prior Trauma
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High rates of childhood trauma among veterans,
particularly those who experience MST (Merrill et al., 2001;
Rosen & Martin, 1996; Sadler et al., 2003)
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Later traumas seen as confirmation that the world is a bad and
dangerous place
Aftereffects of earlier trauma (e.g., poor social support; self-blame)
may impair ability to cope with later trauma
Effects of trauma appear to be dose-specific—the more traumas or the
worse the trauma, the worse the outcome
Childhood Trauma Can Leave
People Particularly Vulnerable
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Typically more “complex traumas”
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Ongoing over a period of time
Interpersonal victimization by a known perpetrator
Occur early in development
Experiences that are even more psychologically destructive than
“simple” traumas
Given rates of childhood and post-military trauma among
veterans, working with survivors of MST often means working
with multiply traumatized individuals
(Merrill et al., 2001; Rosen & Martin, 1996; Sadler et al., 2003)
Revictimization /
Insufficient Self-Protection
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Relationships with abusive partners, unsafe sex, prostitution,
poor boundaries with others / trusting too easily, putting self in
dangerous situations…
Rates of revictimization are high
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16% - 72% of female childhood sexual abuse survivors experience
sexual or physical revictimization as adults (Messman & Long, 1996)
Sadler and colleagues (2003) found that 37% of women reporting a
history of MST had been raped at least twice during their military
service
Few studies exist for men, but some suggest sexual revictimization rates
comparable to those for women
Characteristics of the Individual:
Gender – Impact on male victims
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Men may be taught that being victimized implies
they are weak, and thus, not a man.
Shame, stigmatization, and negative reactions from
others may also result from the social taboos.
Resulting confusion about their sexuality and their
gender role (their role as men).
Overcompensating through hypermasculinity.
Guilt and shame if they experienced physical
arousal.
Gender Identity Concerns of male victims
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Calls into question unexamined assumptions about
male gender in the culture at large
o heterosexual
o physically strong
o unemotional
o in control
.......Conclusion: “I am no longer a real man”
Sexual Identity Concerns (of male victims)
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Confusion over sexual identity
 “Am
I gay?”
 “I must be gay.”
 “I am gay and I can’t face it.”
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Result: Attempts to “prove” their heterosexuality
 Multiple
“conquests” of women/promiscuity
 Early or impulsive marriage
Characteristics of the Individual:
Tendency towards Self-Blame
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“I must have done something to provoke the attack”
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“I must have wanted it”
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“ What did I expect when I …. (joined the military, hung
out with male soldiers…)”
“It happened because I am gay, as punishment” (gay
patient)
“It happened because I am weak”
“I should have been able to fight him off?””
“I am damaged, there is something about me that
perpetrators can identify”
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(esp. if child trauma)
Characteristics of the Environment: Military Context
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In the military…
 The
victim typically knows the perpetrator
 The victim is typically chronologically and
developmentally young
 Can’t just quit, AWOL
 Perception that career goals will be jeopardized by
disclosing MST
 Risk is typically ongoing
 Repeated,
continuing exposure to the perpetrator
 Given military hierarchy, victim may be dependent upon the
perpetrator and/or his/her friends in many areas of life
Characteristics of the Environment: Role of
Military Culture
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Implicit message in Basic Training is that a good
soldier:
o Does not question authority
o Subsumes his/her emotional needs to the mission
o Is loyal and focused on teamwork, unit cohesion
o Ignores the physical needs/messages of his/her body
o Is strong and self sufficient
o Does not divulge negative information about peer
o Maintains Esprit de Corps
o Is “owned” by the military
Characteristics of the Environment: Substance
Abuse
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“Gender-acceptable” & military-condoned way to manage/numb
intrusive thoughts, feelings, & images of rape
 Creates
appearance of being “just like all the other guys”
 PTSD symptoms may go undetected by veteran himself
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Facilitates aggression, re-enactment and re-victimization
May be the “identified problem” unless MST is identified during
screening
Sexual Trauma Is A
Particularly Toxic Stressor
Probability of Developing PTSD
Molest- Physical
ation
Abuse
Rape
Combat
Women
45.9%
--
26.5%
48.5%
Men
65.0%
38.8%
22.2%
22.3%
(Kessler et al, 1995)
Sexual Trauma Is A
Particularly Toxic Stressor
(cont.)
Study of Gulf War Veterans
Probability of Developing PTSD
Women
Men
(Kang et al., 2005)
MST
Combat
5x higher
rates
6x higher
rates
4x higher
rates
4x higher
rates
Multiple impacts of MST
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Physiologically
 Body sensitized to threat
 Prone to all-or-nothing reactions
 Disrupted memory / cognitive processing
Emotionally
 Intense feelings that are difficult to contain
 Normal regulatory systems that promote homeostasis are
overwhelmed
 Tendency towards all-or-nothing reactions
Cognitively
 Affects how we view the world
 Disrupts sense of power and control, beliefs about
trustworthiness of others, sense of self…
 Tendency towards all-or-nothing thinking
Diagnoses Associated with MST
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PTSD is the formal diagnostic category most frequently
associated with sexual assault.
Other diagnoses often associated with MST:
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Depression
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Suicidal thoughts and/or suicide attempts
Substance abuse/dependence
Other anxiety disorders
Dissociative disorders
Somatization disorders
Eating disorders
Borderline personality disorder
Physical health problems (e.g., lower back pain; headaches; pelvic pain;
GI pain/symptoms; sexual dysfunction; gynecological symptoms; chronic
fatigue)
Themes/Issues Common in
Working with MST Survivors
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MST (as opposed to other types of trauma) is particularly
associated with:
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Feelings of self-blame
Difficulties trusting self and others – especially formal authorities
Difficulties with hierarchies, sensitivity to issues of justice
Boundary issues
Concerns about sexual identity / sexuality / sexual orientation
Revictimization
Multiply traumatized individuals are particularly likely to
evidence these types of difficulties
Treatments that Work: EvidenceBased Practices
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Therapies tested with randomized controlled trials (RCTs) and found to
be effective are referred to as Evidence-Based Practices (EBP’s)
Examples of widely-used EBPs appropriate for treating the aftereffects
of MST:
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Cognitive Processing Therapy (CPT)
Prolonged Exposure (PE)
Seeking Safety
Dialectical Behavior Therapy (DBT)
Acceptance & Commitment Therapy (ACT)
Recovery
Overarching framework provided by Judith
Lewis Herman’s Trauma and Recovery:
The fundamental stages of recovery are…
1. Establishing safety
2. Remembering and mourning
3. Reconnection and meaning-making
Not necessarily a linear progression through
these stages
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A Loose Categorization of Some Commonly Used
Protocols
Establish
safety
Seeking Safety
Dialectical Behavior Therapy
(DBT)
Cognitive Processing
Therapy (CPT)
Prolonged Exposure (PE)
Acceptance & Commitment
Therapy (ACT)
Remember
and mourn
Reconnect and
make meaning
Treatment issues that arise in working with MST:
Keeping the Secret
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Expectation of stigma in treatment settings
 Concerns
 Lack
about MST designation in medical records
of control over which providers have access to this
information
What Do We Know About MST
Among OEF/OIF Veterans?
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Still learning
Issues to consider:
 Trauma
is recent, reactions are acute
 Interaction between combat exposure and MST is
unclear
 How TBI may affect treatment is unclear
 Issue of compounding factors of being away from
home, usual support systems
Improving Our Sensitivity:
Reconceptualizing Symptoms
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Underlying logic to many ‘symptoms’ if you look more closely
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Allowed the victim to survive the event at the time, but have persisted
into different, inappropriate contexts
and/or
Represent best efforts to deal with (overwhelming) uncharted territory
Particularly true in the case of early or complex trauma (and thus often
MST) – the trauma occurred before the victim had developed more
sophisticated coping strategies
Examples of
Looking for the Underlying Logic
Problem
Underlying Logic
Self-blame
Way to avoid confronting helplessness/
vulnerability – allows to believe that have
control over what happens to him/her.
Allows to avoid confronting idea that the
perpetrator had intent.
Emotional constriction
Allows to experience only a limited, lessthreatening range of emotions
All-or-nothing thinking
Over-generalization / over-protectiveness
more likely to ensure safety than underreaction
Difficulties trusting self or
others
Way to prevent it from happening again
Examples of
Looking For the Underlying Logic (cont.)
Problem
Underlying Logic
Preoccupation with justice
issues / sensitivity to
power & control dynamics
Way to prevent it from happening again to
self or anyone else. Way to express
outrage at own perpetrator’s behavior.
Substance use / abuse
Helps calm physiology, tolerate social
situations, and gives the illusion of aiding sleep
Boundary issues
Profound violation of own boundaries makes it
hard to know what is okay and what is not okay.
May be related to trusting too easily, to avoid
acknowledging vulnerability.
Examples of
Looking For the Underlying Logic (cont.)
Problem
Dissociation
Underlying Logic
In situations where there is nothing you can do
to avoid the inevitable, allows escape from
chronic feelings of terror, hypervigilance, and
impending doom
Starving oneself or overeating Makes self undesirable (believing this may
prevent future attack) and gives sense of
control over something. Way to self-soothe
Self-harm behaviors
(e.g., cutting)
Way to distract from overwhelming feelings, to
experience more controllable pain, or to avoid
feelings of numbness
What’s the logic?
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Trusting too easily as a way to deny prior trauma
and/or avoid facing one’s vulnerability
Intoxication (for self-medication) reduces sensitivity to
/ awareness of danger
Lack of self-trust leads to discounting internal alarms
Remaining with an abuser as a way to maintain hope
about others and/or reflects reluctance to see self as
a victim
Helpful general principles
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Adopt a strengths-based approach
Empathy goes a long, long way
Provide ongoing normalization / validation
Be transparent and genuine
Offer choice, restore control
Help the veteran balance the big and little picture
Don’t assume you know what the worst part of the
veteran’s experience was (and is)
Prioritize self-care, so that you can remain
engaged
VA Resources: MST Coordinators
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Chicago (Jesse Brown VAMC): Megan Null (312)
569-7209
Hines: Kris Lopez (708)202-8387 x24718
Iron Mountain: Julie Gendron (906) 774-3300
x32388
Madison: Susan Knoedel (608) 280-7084
Milwaukee: Mitzi Dearborn (414) 384-2000
x41674
North Chicago: Julianne Hish (224) 610-5798
Tomah: Catherine Routh (608) 372-3971 x61757
Thanks!
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To SAPRC’s
To MST Support Team for resources for this
presentation