1. Advocacy Project for Change and Improvement:Women Veterans, PTSD & Practice Standards Dr. Joann Regan, PhD, LMSW Ashley J. Slagel, MSW Student University of South Carolina March 15th, 2011

2. Abstract This advocacy project and presentation seeks to accomplish the following: 1.) Review the current literature and research on female veterans and PTSD from a multi-systemic perspective. 2. ) Assess and review what is considered best practice for working with this population through literature, research and review of DoD Directives & policies 3. ) Advocate for changes that will increase the knowledge base of the social work profession in order to more fully serve female veterans

3. Community Need & Targeted Problem 8% of U.S. Veterans are women The largest group of women veterans today served in the OEF/OIF operations Women make up 11% of all OEF/OIF veterans. This number is estimated to almost double 10% by 2020 60% of veterans who are receiving MH treatment are NOT coming to the VA

4. Lioness http://www.youtube.com/watch?v=QBViJOYILyM

6. Community Need & Targeted Problem Traditional PTSD and female veterans: Misunderstanding of combat exposure “Burden of Proof” Trauma Variables influence the affects of trauma: Trauma History Demographics

7. Military Sexual Trauma = Rape & Sexual Assault http://www.youtube.com/watch?v=9k_0b9hvIjc

8. Community Need & Targeted Problem Military Sexual Trauma (MST) Definition of MST Unique characteristics of MST Military Sexual Trauma is prevalent among OEF/IOF female veterans 15%-27% or 1 in 5 women compared to 1 in 100 men

9. Military Sexual Trauma

10. On receiving help… 1. I would be seen as weak, 65% 2. Unit leaders would treat me differently, 63% 3. Other unit members would have less confidence in me, 59% 4. Leaders would blame me for the problems, 51% 5. It would harm my career, 50% 6. It’s too embarrassing, 41% 7. I don’t trust Mental Health professionals, 38% 8. Mental Health Care doesn't work, 25% 9. I do not know where to get help, 22% 10. I don’t have adequate transportation, 18%

11. In Their Boots Part I: http://www.youtube.com/watch?v=dtyCMdoJ4Xg Part II: http://www.youtube.com/watch?v=fuXyZYIYGIc&NR=1

12. Community Need & Targeted Problem The VA health has been systematically difficult to navigate for female veterans due to: Fragmented delivery of care Idea of who veterans are “men who served” Undeserving women veterans Insufficient clinicians with training in women’s health Inconsistent policy for women’s health (DoD, 2008)

13. Current Regulations, Directives & Policies DoD Recommendations: Deliver coordinated, comprehensive primary women’s health care at every VA facility. Recognizing models of best practice, develop systems and structures for care delivery that ensure that every woman veteran has access to a VA primary care provider who can meet all her primary care needs, including gender-specific, acute and chronic illness, preventive, and mental health care. (DoD, 2008)

14. Current Regulations, Directives & Policies DoD Recommendations: 2. Ensure integration of women’s mental health care as part of primary care, including co-locating mental health providers. (DoD, 2008)

15. Current Regulations, Directives & Policies DoD Recommendations: 3. Promote and incentivize innovation in care delivery by supporting local best practices fitted to the particular configuration and women veteran population. (DoD, 2008) Shawna Kimbrell

16. Current Regulations, Directives & Policies DoD Recommendations: 4. Cultivate and enhance capabilities of all VA staff—medical providers, clinical support, non-clinical, and administrative—to meet the comprehensive health care needs of women veterans. (DoD, 2008)

17. Current Regulations, Directives & Policies Dod Recommendations: 5. Achieve gender equity in provision of clinical care. (DoD, 2008)

18. Best Practice Approaches According to the DoD recommendations, what is considered “best practice” for treating female veterans is currently being created. “VA facilities are the best positioned to develop innovative programs to meet the needs of women veterans” (DoD, 2008)

19. Building a Therapeutic Alliance Assessing through the framework of: ->Military Culture ->Deployment Cycle ->Nature of Deployment ->Stages of Change Model

20. Deployment Cycle

21. Nature of Deployment

22. Evidenced Based Treatments for PTSD Cognitive Behavioral Therapy (CBT) Exposure Based Therapy (ET) Stress inoculation Training (SIT) Eye Movement Desensitiviation Reprocessing (EMDR) Seeking Safety

23. Changed Proposed & Feasibility

24. Changed Proposed & Feasibility Social workers in the VA must follow best practice considerations from the DoD. Social workers who work in community based organizations do not. 60% of military personnel receiving MH services do so in the community.

26. Clients with Substance Use Disorders

27. Palliative & End of Life Care

28. Adolescents

29. SW Practice in School Setting

30. SW Practice in Health Care Setting

31. Clinical SW in SW practice

32. SW Practice in Long Term Facilities

33. SW Practice in Child Welfare “I stay because the NASW helps me be a better Social Worker”

34. Poll 1. How many students have taken HBSI I & HBSI II? 2. How many students have taken or are taking Advanced Practice with Individuals & Groups? 3. Prior to taking this course, has your course material covered cultural considerations and best practice considerations with military individuals & families?

35. Changed Proposed & Feasibility Creating a practice standard for this population would be provide an endorsement from the NASW that the unique needs and strengths of individuals in the military are important to research and review.

36. Who would resist change?

37. Evaluation of the Efficacy of Proposed Standards

39. REFERENCES American Psychological Association (APA). Treatment for Patients with Acute Stress Disorder and Post Traumatic Stress Disorder. Retrieved on March 8th from: http://www.psychiatryonline.com/pracGuide/pracGuideTopic_11.aspx Arbanas, G. (2010). Patients with Combat-related and War-related Posttraumatic Stress Disorder 10 Years After Diagnosis. Clinical Sciences , 209-213. Department of Defense. Retrieved November 3, 2010 , from: http://www.publichealth.va.gov/womenshealth/facts.asp Department of Defense. Military Sexual Trauma . Retrieved November 3, 2010, from: http://www.publichealth.va.gov/womenshealth/facts.asp Fontana, A., Rosenheck, R., & Desai, R. (November, 2010). Female Veterans of Iraq and Afghanistan Seeking Care from VA Specialized PTSD Programs: Comparison with Male Veterans and Female War Zone Veterans of Previous Eras. Journal of Women's Health, Volume 19 , 751-757. Freedy, J., Magruder, K., Mainous, A., Frueh, C., Geesey, M., & Carnemolla, M. (2010). Gender Difference in Traumatic Event Exposure and Mental Health Among Veteran Primary Care Patients. Military Medicine, Vol. 175 , 750-758.

40. Haskell, S., Gordon, K., Mattocks, K., Duggal, M., Erdos, J., Justice, A., et al. (November 2010). Gender Difference in Rates of Depression, PTSD, Pain, Obesity, and Military Sexual Trauma Among Connecticut War Veterans of Iraq and A fghanistan. Journal of Women's Health, Vol. 19 , 267-271. Kimerling, R., Gima, K., Smith, M., Street, A., & Frayne, S. (December 2007). The Veterans Health Administration and Military Sexual Trauma. American Journal of Public Health, Vol. 97, No. 12 , 2160-2166. Kimerling, R., Street, A., Pavao, J., Smith, M., Cronkite, R., Holmes, T., et al. (August 2010). Military-Related Sexual Trauma Among Veterans Heath Administration Patients Returning from Afghanistan and Iraq. American Journal of Public Health, Vol. 100, No. 8 , 1409-1412. Lang, A., Aarons, G., Gearity, J., Laffaye, C., Satz, L., Dresselhaus, T., et al. (Winter 2008). Direct and Indirect Links Between Childhood Maltreatment, Posttraumatic Stress Disorder and Women's Health. Behavioral Medicine, Vol. 33 , 125-135. Milliken, G., Auchterlonie, J., Hoge, C. (2007). Longitudinal Assessment of Mental Health Problems Among Active and Reserve Component Soldiers Returning From the Iraq War. Retrieved on March 8th from: http://jama.ama- assn.org/content/298/18/2141.full

41. Murdoch, M., Hodges, J., Hunt, C., Cowper, D., Kressin, N., & O'Brien, N. (August 2003). Gender Differences in Service Connection for PTSD. Medical Care, Volume 41, No. 8 , 950-961. Office of Public Health and Environmental Hazards, W. V. (November 2008). Report of the Under Secretary for Health Workgroup Provision of Primary Care for Women Veterans. Department of Veterans Affairs. Ozer, E., & Weiss, D. (August 2004). Who Develops Posttraumatic Stress Disorder? Current Direction in Psychological Science, Vol. 13., No. 4 , 169-172. Van Wormer, K. (2011). Veterans Affairs Current Trends - About Post Traumatic Stress Disorder (PTSD) and Brain Injury in Iraq's War Veterans. Retrieved from NASW: http://www.helpstartshere.org/issues-and-answers/issues-answers- %e2%80%93-veterans-affairs-about-post-traumatic-stress-disorder-ptsd- and-brain-injury-in-iraq%e2%80%99s-war-veterans.html Wells, T., LeardMann, C., Fortuna, C., Smith, B., Smith, T., Ryan, M., et al. (January 2010). A Prospective Study of Depression Following Combat Deployment in Support of the Wards in Iraq and Afghanistan. American Journal of Public Health, Vol. 100, No. 1 , 90-99.