Roksana Korchynsky, PhD
VA Pittsburgh Healthcare System
Roksana.Korchynsk@va.gov
PA Women Veterans Symposium, June 7, 2014
Who Am I?
 Licensed clinical psychologist with VAPHS with 10+ years
experience in the assessment & treatment of sexual trauma
 VAPHS’s Military Sexual Trauma Coordinator – provide
education and training to providers caring for Veterans who have
experienced sexual trauma; monitor screening and referral
process; provide treatment
 VAPHS’s Evidence Based Psychotherapy Coordinator – promote
best practices for the treatment of PTSD and other mental health
disorders
 Cognitive Processing Therapy (CPT) provider & trainer
Roadmap for today…
 Overview of MST (definitions, prevalence, sexual
trauma in context: military setting & culture)
 Diagnoses/problems/treatment themes commonly
associated with MST
 Accessing care through VHA
 Recovering from sexual trauma
 Evidence-based psychotherapies
What is MST?
 VA’s definition of MST comes from federal law but in
general is sexual assault or repeated, threatening
sexual harassment that occurred during a Veteran’s
military service
 Can occur on or off base, while a Veteran was on or
off duty
 Perpetrator identity does not matter
 Both men and women can experience MST
 Era of service does not matter
 MST is an experience, not a diagnosis
What is MST (cont.)
 Any sort of sexual activity in which someone is
involved against his or her will
 Someone may be:
 Physically forced into participation
 Unable to consent to sexual activities (e.g.,
intoxicated, drugged)
 Pressured into sexual activities (e.g., with threats of
consequences or promises of rewards – “command
rape” )
What is MST (cont.)?
 Can involve things such as:
 Threatening, offensive remarks about a person’s
body or sexual activities
 Threatening and unwelcome sexual advances
 Unwanted touching or grabbing
 Oral sex, anal sex, sexual penetration with an object
and/or sexual intercourse
 Compliance does not mean consent
How common is MST?
 Difficult to know, as sexual trauma is frequently
underreported
 About 1 in 5 women and 1 in 100 men have told their VHA
healthcare provider that they experienced sexual trauma in
the military
• These data speak only to the rate among Veterans who
have chosen to seek VA healthcare
• Because MST is an experience, not a diagnosis, these
data cannot address what percent of those who screened
positive need or want treatment
 Although women experience MST in higher proportions
than do men, because of the large number of men in the
military there are significant numbers of men and
women seen in VA who have experienced MST
Context: ST in Military Setting
In the military…
 Victim typically knows the perpetrator
 Victim is typically chronologically & developmentally
younger
 Risk is typically on-going because:
 Victim & perpetrator live & work together
 Victim may be dependent upon perpetrator and/or
perpetrator’s associates for basic necessities (food,
shelter, protection, medical care)
 No way to leave – leaving means going AWOL
Context: ST in Military Setting
(cont.)
In the military…
 High value placed upon loyalty & teamwork
 Taboo to divulge negative information about peers
 MST is that much more incomprehensible to victims
 High value placed upon strength & self-sufficiency
 Reduces social support available, increases likelihood of
invalidating response
 Being a “victim” conflicts with desired identity
 Disruption of career goals
Context: ST in Military Setting
(cont.)
In the military…
 The same institution is responsible for the care of the
victim & the adjudication of the perpetrator
 Increased sense of betrayal, being alone, helplessness,
& entrapment
 Parallels with childhood abuse
Context: ST in Military Setting
(cont.)
 At the time of assault, may be far from friends and family
 Availability of social support is also impacted by societal
messages, especially to the extent they are internalized
 At homecoming or discharge, may believe or be told by others
that their experiences are not as “legitimate” as combat
trauma experiences
 May not disclose to providers or seek out help
 May not report experiences to authorities
 Experience of OEF/OIF/OND Veterans may be different due
to Department of Defense reforms
Other Complicating Factors…
 Rates of childhood and pre-military trauma are high
among MST survivors and military personnel more
generally
 OEF/OIF/OND Veterans in particular face concurrent
exposure to combat and a generalized decreased sense of
safety
 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 may impair ability to cope with
later trauma
Not All Traumas Are Equal
 Research has shown that sexual assault is more likely
to result in symptoms of PTSD than are most other
types of trauma, including combat
 Research also suggests that sexual assault in the
military may be more strongly associated with PTSD
and other health consequences than is civilian sexual
trauma
Diagnoses Commonly Associated
with MST
 Among users of VA health care, the mental health
diagnoses most commonly associated with MST are:
 PTSD
 Depressive Disorders
 Anxiety Disorders
 Bipolar Disorders
 Drug and Alcohol Disorders
 Schizophrenia and Psychoses
Diagnoses Commonly Associated
with MST (cont.)
 Other mental health diagnoses common among sexual
trauma survivors include:
 Eating disorders
 Dissociative disorders
 Somatization disorders
 A range of physical health conditions are also associated
with sexual trauma (e.g., gynecological sx’s or sexual
dysfunction, chronic fatigue, chronic pain, GI problems,
fibromyalgia)
One Reaction to Trauma: PTSD
Symptoms (per DSM5):
 Intrusion sx’s (intrusive thoughts; nightmares; flashbacks;
strong emotional and physiological reactions to reminders)
 Avoidance sx’s (avoiding distressing thoughts or feelings;
avoiding external reminders)
 Negative alterations in cognitions & mood (“I’m bad, dirty”;
anger/guilt/shame; diminished interest; detachment; inability
to experience positive emotions)
 Arousal & reactivity sx’s (trouble sleeping; irritability/anger;
trouble concentrating; easily startled; on edge/ hypervigilant)
 Must last for more than one month
 Must cause distress or impairment in functioning
Other Difficulties Commonly
Associated with ST
 Difficulties that may not rise to the level of a formal
diagnosis
 Interpersonal difficulties or avoidance of relationships
 Difficulties getting & maintaining employment
 Difficulties with school
 Difficulties with parenting
 Difficulties with identify and sense of self
 Spirituality issues/crisis of faith
 Homelessness
Common Treatment Themes
 Difficulties with intimacy, trust, safety, and other core
features of relationships
 Interpersonal difficulties
 Strong reactions to situations in which one individual
has power over another
 Difficulty identifying and setting interpersonal
boundaries that are not too high or too low
 Struggles with issues related to power and control
 Self-blame and self-doubt
 Difficulties managing distress and/or limited coping
strategies
Common Treatment Themes
(cont.)
 Problems with sexual functioning and sexuality
 Problems with sexual identity and sexual orientation
 Body image and/or problematic eating patterns
 Risk of re-victimization
 Relationships with abusive partners, unsafe sex,
prostitution, poor boundaries with others / trusting too
easily, putting self in dangerous situations…
Accessing Care:
What is VA Doing?
 Universal Screening
 Recognizing that many survivors of sexual trauma do
not disclose their experiences unless asked directly, it is
VHA policy that all Veterans seen for health care are
screened for MST
Accessing Care:
What is VA Doing? (cont.)
 FREE MST-Related Care
 VA provides free care (including medications) for all physical
and mental health conditions related to MST
 Service connection is not required
 Treatment is independent of the VBA disability claims process
 Veterans do not need to have reported the MST at the time or have
other documentation
 Veterans may be able to receive free MST-related care even if
they’re not eligible for other VA care
 There are no length of service or income requirements to receive
MST-related care
 Veterans with Other Than Honorable discharges may be able to
receive MST-related care with VBA Regional Office approval
Accessing Care:
What is VA Doing? (cont.)
 Every VA Medical Center has providers knowledgeable about
MST
 Every VA Medical Center provides MST-related mental health
outpatient services
 Formal psychological assessment and evaluation, psychiatry, and
individual and group psychotherapy
 Specialty services to target problems such as posttraumatic stress
disorder, substance abuse, depression, and homelessness
 Evidenced-based therapies are available at all VA Medical Centers
 Many VHA facilities have specialized outpatient treatment teams
or clinics focusing explicitly on sexual trauma
 Vet Centers have specially trained counselors
What are Evidence Based
Psychotherapies?
 Specific psychotherapies, or “talk therapies,” that have
repeatedly been shown in clinical research (RCTs) to
be effective for a variety of mental health conditions
including PTSD, depression, couples issues, serious
mental illness, and substance abuse.
 Recovery oriented, collaborative, time limited
 Staff are specifically trained in the delivery of EBPs
through VA National Training Programs
EBPs for PTSD
 Cognitive Processing Therapy (CPT) &
Prolonged Exposure (PE)
 Both originally developed to be used to treat victims of
sexual assault
 Recommended as frontline treatment by
 VA/DoD
 Institute of Medicine
 International Society of Traumatic Stress Studies
What is Cognitive Processing
Therapy (CPT)?
 In CPT, the focus of the therapy is on how the
traumatic experience changed one’s thoughts and
beliefs (the interpretation and meaning of the event)
and how those beliefs influence current feelings and
behaviors.
 Goals of treatment:
 Accepting that the trauma has occurred.
 Allowing emotions to run their course.
 Modifying maladaptive interpretations and meanings.
What can patients expect?
 A very active, recovery-focused process
 Approximately 12 weekly sessions, lasting 50-60 minutes
 Weekly practice assignments designed to help patients
identify and change distorted beliefs that emanated from
the trauma
 Weekly monitoring of symptoms (PTSD Checklist, Beck
Depression Inventory)
Structure of CPT
 Phase 1 – Pre-treatment assessment & issues
(Patient educational video)
 Phase 2 – Education re: PTSD, thoughts & emotions
(Sessions 1 – 3 )
 Phase 3 – Processing the trauma
(Sessions 4 – 5)
 Phase 4 – Learning to challenge
(Sessions 6 – 7)
 Phase 5 – Trauma themes (Safety, Trust, Power/Control,
Esteem, Intimacy)
(Sessions 8 – 12)
Helping Patients Get “Unstuck”
 “Stuck points” that reflect self-blame, undoing
 “I should have known he would hurt me.”
 “If I had been paying attention, I would have seen it
coming.”
 “Maybe he didn’t hear me say ‘no!’”
 “If I hadn’t been drinking, it would not have happened.”
 “I must have given off some vibe that it was okay to do
that.”
 “I should have fought harder.”
Helping Patients Get “Unstuck”
(cont.)
 “Stuck points” that are extreme or overgeneralized
 “If I let other people get close to me, I’ll get hurt again.”
 “I must be on guard all the time.”
 “Men cannot be trusted.”
 “I am dirty, unlovable, damaged.”
 “I have no control over my future.”
 “I am worthless.”
 “I deserve to have bad things happen to me.”
Final thoughts from a patient…
“People that have known me for years have noticed a marked
improvement in my behavior, attitude, and way of living.
Early into my sessions, I recall telling my therapist that I spent
many years surviving, which moved into struggling to survive,
which has now become living. After more than 32 years of
being stuck and holding myself hostage, I can honestly say
that through CPT, I have learned to ‘really live.’”
Questions?