Application of PE in Veterans with Military Sexual Trauma (MST) Breakout Session May 3, 2013 Diane T. Castillo, Ph.D. Coordinator, Women s Stress Disorder Treatment Team New Mexico VA Health Care System Albuquerque, New Mexico
Agenda Special Factors in MST/PTSD PE & CPT with MST survivors Sexual Intimacy Issues Cases
Treating MST Factors to Consider General factors with treating women Veterans Safe waiting area/location of clinic Previous treatment Eligibility only for MST Documentation in medical record Specific factors Women and Men Same/opposite gender therapist issues Impact on primary relationship may need to provide education Number of traumas
Men with MST Sexual assault & sexual harassment are sometimes thought of as only women s issues Rate of MST is higher among women Unique issues face men with MST Impact of MST is large
Emotional Processing Theory and MST Conceptual Why does MST contribute to higher rates of PTSD? Factors contributing to PTSD (Emotional Processing Theory) Avoidance Negative Cognitions Personal nature of rape = avoidance Victims of trauma are blamed = negative cognitions Shame
MST and PTSD DSM Criterion A Nature of Criterion A subjective MST broadly defined Sexual Assault Often clear, unambiguous Situations where assault is not traumatic? Sexual Harassment Most often not traumatic Situations where harassment IS traumatic?
PE & CPT PE: In-vivo exercises, selection of index trauma Imaginal exposure CPT: Context of messages Messages from trauma
Clinician Factors in PE with MST Are you ready for this? Listening to details of sexual assault Clinician s own reactions/biases careful not to blame, e.g., female psychiatrist in meeting Layers of context Society s messages about sex double standards, men can t get raped Pt s personal messages about sex (religion, childhood, family messages, ideal) Trauma sexual assault Feminist theory beyond double standard Challenge: Clinician s functioning outside specialty area
In Vivo Hierarchy & Homework Set up in-vivo in same way Remember 3 types (trauma-related, general, behavioral activation) Do you identify sexual functioning tasks as in vivo exposures? Patient s goals Primary: reduce PTSD->habituate trauma memory Secondary: improve sexual functioning
In Vivo Hierarchy & Homework (cont.) Sexual Functioning in vivos ID tasks in 40-50 range. If sex with partner is above 60, assign later Successive approximation start with sensate focusing, next masturbation, sex with partner Be aware of and check on the impact of assignments: association between sexual arousal and assault want to weaken, not strengthen On the other hand....don t collude with avoidance of sex and/or opposite sex
Identifying the Target Trauma Same as other PE cases pick the worst one What if many military AND childhood traumas? What if gang rape? e.g. Pt with childhood, military, and post. Clearly, military is worst, she picks post why go with lesser trauma?
CPT General Considerations Careful not to impose your cognitions Give examples, but let them generate their own Keep cognitions simple Catch going to opposites Identify emotion caused by distorted thoughts and diff emotions with change Group can enhance commonalities of cognitive distortions
CPT Themes 5 Themes look for dualism (life/death) in each Safety safety behaviors (isolation, guns) Trust walls (vs. boundaries) or nothing Power/control OCD-like (cleanliness, time) Esteem plays out in depression Intimacy not just sexual, but also emotional
Sexual Functioning Issues Be Prepared most with MST will have problems How to deal with: As an in vivo? During imaginal or after? Factors: severity and extent of trauma How you as a PE therapist become a sex therapist Avoidance can t because: Against my religion Immoral Stay clinical and reinforce with theoretical orientation habituation, desensitization, successive approximation
Sexual Functioning (cont.) (cont.) Better in group? Decision to include partner and when? Help patient set boundaries in giving details of trauma to partner Educate yourself Be prepared with therapist referral
Case Examples Female. Mid 40 s, divorced, lives near mom, drinks champagne daily, no dating, 100% SC mental disorder, self defines as schizophrenic, gang rape in military. Male. Mid 30 s, never married, African American, s/p self inflicted gun shot, bullet still in brain, gang raped in bunk, unknown assailants.
Conclusions PE & CPT effective for treating PTSD from MST in both males and females Clinician sensitivity and education will enhance outcomes Treatment for sexual functioning may be needed
Questions/Discussion
Patient Readings Women: 1. Reclaiming Your Life After Rape: Cognitive-Behavioral Therapy for Post-traumatic Stress Disorder. Rothbaum & Foa (1999). Graywind Publications. 2. Becoming Orgasmic: A Sexual Growth Program for Women. (1988) Heiman & LoPiccolo. Prentice Hall Press. 3. The Courage to Heal: A Guide for Women Survivors of Child Sexual Abuse. Bass & Davis (1988). Harper & Row. Men: 1. Fire in the Belly: On Being a Man. Sam Keen (1992). Bantam Books, New York. Both: 1. The Courage to Heal Workbook: For Women and Men Survivors of Child Sexual Abuse. Davis (1990). Harper & Row. 2. Passionate Marriage. David Snark
References Himmelfarb, N., Yaeger, D., & Mintz, J. (2006). Posttraumatic stress disorder in female veterans with military and civilian sexual trauma. Journal of Traumatic Stress, 19, 837-846. Kilpatrick, D. G., Resnick, H. S., Ruggiero, K. J., Conoscenti, L. M., & McCauley, J. (2007). Drug-facilitated, incapacitate forcible rape: A national study. National Crime Victims Research Center. Kimerling, R., Gima, K., Smith, M. W., Street, A., & Frayne, S. (2007). The Veterans Health Administration and military sexual trauma. American Journal of Public Health, 97, 2160-2166. Kimerling, R., Street, A., Gima, K., & Smith, M. W. (2008). Evaluation of universal screening for military-related sexual trauma. Psychiatric Services, 59, 635-640. Suris, A. & Lind, L. (2008). Military sexual trauma: A review of prevalence and associated health consequences in veterans. Trauma, Violence, & Abuse, 9, 250-269. Suris, A., Lind, L, Kashner, T. M., Borman, P. D., & Petty, F. (2004). Sexual assault in women Veterans: An examination of PTSD risk, health care utilization, and cost of care. Psychosomatic Medicine, 66, 749-756.