Intimate Partner Violence (IPV): Mental Health Services within the
Veterans Affairs (VA) Healthcare SystemSusan McCutcheon, RN, EdD
Director for Family Services, Women's Mental Health and Military Sexual Trauma, Office of Mental Health Services, VA Central Office, Department of Veterans Affairs
Katherine M. Iverson, PhDClinical Research Psychologist, Women's Health Sciences Division of the National
Center for PTSD, VA Boston Healthcare System and Office of Mental Health Services, VA Central Office, Department of Veterans Affairs & Boston University
&Roger Casey, PhD, LCSW
Director of VA's National Homeless Providers Grant and Per Diem Program, VHA Homeless Programs Office, VA Central Office, Department of Veterans Affairs.
1
Topics to be Covered• Overview of the Department of Veterans Affairs (VA)• Intimate Partner Violence (IPV)• VA Treatments: Evidence-Based Practices• Women Veterans Program Managers• Homelessness Programs
2
OVERVIEW OF THE DEPARTMENT OF VETERANS AFFAIRS (VA)
3
Department of Veterans AffairsVA established in 1930 - Cabinet rank in 1989
Consists of 3 Administrations:
4
Current Estimate of US Veteran Population
5
Population of Women Veterans
Source data supplied 7/9/10 by the Office of the Actuary, Office of Policy and Planning, Department of Veterans Affairs
VHA Health Care UtilizationIn FY 2010 there were:
– 8.3 million unique Veterans enrolled in VHA1
– 6 million unique patients treated in VHA2
• Approximately 30% had a mental health diagnosis– 75.6 million outpatient visits1
– 679.6 thousand inpatient admissions1
Source: 1Department of Veterans Affairs, Veterans Health Administration, Office of Assistant Deputy Under Secretary for Health; 2DVA Information Technology Center, Health Services Training Report, VBA Education Service, VBA Office of Performance Analysis & Integrity
7
VHA Facilities at a Glance
Source: National Center for Veterans Analysis and Statistics, February 2, 2011
VA Mental Health
• Mission of VA’s Office of Mental Health Services– To maintain and improve the health and well-being of
Veterans through excellence in health care, social services, education, and research
• The VA supports a recovery model– Enable individuals with mental health problems to live
a meaningful life in their community and achieve their full potential
9
VA’s Mental Health System• Vet Centers
– Provide readjustment counseling– Located in community settings– Mobile vans to take care to rural areas
• Medical Centers & Community Based Outpatient Clinics (CBOCs) have multiple ways of delivering mental health care– Specialty Mental Health and Substance Use Services– MH Integrated with Primary Care, Geriatrics,
Rehabilitation, …– Direct staffing and/or telemental health in Community
Based Outpatient Clinics– Fee basis and contract care as needed10
INTIMATE PARTNER VIOLENCE
11
Intimate Partner Violence (IPV) Defined
Veterans can be:•Perpetrators•Victims •Perpetrator & Victims
IPV can occur in:•Heterosexual relationships•Same-sex relationships
IPV is actual or threatened physical or sexual violence or psychological/emotional abuse directed toward a
former or current intimate partner (CDC, 2011)
A Complex Public Health Issue
• VA recognizes that IPV is an important health issue faced by male and female Veterans
• Appropriate health care response requires collaboration between many programs and agencies both within and outside of VA to address: – Prevention– Provision of safety supports– Advocacy– Treatment– Legal consequences
13
A Complex Public Health Issue
• This presentation focuses primarily on mental health and homelessness services for Veterans who are victims and/or perpetrators of IPV
14
General Resources for IPV in VA
• Common to all VA facilities:– Directives according to JCAHO standards for
identification, evaluation and treatment– Adherence to state reporting requirements – Lists and contacts for local community resources for
perpetrators and victims– Staff training regarding IPV– VA clinicians experienced in treating trauma
• Individual VA facilities determine and implement the specifics of IPV-related care and education
15
Mental Health Consequences of IPV: Evidence-Based Psychotherapies within the
VA for IPV Survivors
16
IPV Victimization in Male Veterans
• Men are victims of IPV too- Female-to-male IPV- Male-to-male IPV
• Men experience mental health consequences from IPV
17
IPV Victimization in Women Veterans
• Current and comprehensive data is lacking
• 19-30% report IPV prior to enlistment– Millner et al., 2000; 2006; Sadler et al., 2004
• 22-44% report IPV during active duty– Campbell et al., 2003; Rosen et al. 2002
• VA Primary Care (Veteran status)– 46% reported IPV during their lifetime– Latta/Ngo unpublished
18
Mental Health Conditions Related to IPV in Male and Female Veterans
• Posttraumatic stress disorder (PTSD)• Depression• Anxiety• Substance abuse• Suicidal ideation/attempts and self-harm• Low self-esteem, guilt and shame
19
VA TREATMENTS: EVIDENCE BASED PRACTICES
20
VA Treatments:Evidenced Based Practices
• Multiple levels of care determined by the individual’s clinical needs― Inpatient and residential treatment programs―Outpatient services
21
PTSD
• PTSD is common among IPV survivors (31%-84%; Golding, 1999)
• PTSD does not go away on its own (Campbell & Soeken, 1999; Zlotnick, Johnson & Kohn, 2006)
• PTSD symptoms may increase risk for revictimization among interpersonal trauma survivors (Iverson et al., 2011a; Krause et al., 2006)
22
What are the Symptoms of PTSD?
• Re-experiencing symptoms―e.g., repeated unpleasant memories, unwanted
thoughts, nightmares, and “flashbacks”
• Avoidance symptoms―e.g., avoidance of people or places, shutting down,
feeling numb or “cut-off” from others
• Arousal symptoms―e.g., increased arousal, difficulty sleeping, difficulties
concentrating, hyper-vigilance, startle response
23
Evidence Based Therapies for PTSD Widely Available within the VA
• Cognitive Processing Therapy (CPT)– A type of cognitive-behavioral therapy– Delivered in individual or group formats for 12 weekly
sessions– Provide education about PTSD, thoughts, emotions,
and behaviors– Explore the “meaning” of the IPV and modify
unhelpful beliefs associated with the event– Emotionally process and accept the painful IPV
experiences in the service of reducing symptoms24
Evidence Based Therapies for PTSD
• Cognitive Processing Therapy (CPT)– Effective for past and recent IPV survivors in terms of
reducing PTSD and depression symptoms (Iverson et al., 2011b)
– Women who recover from PTSD during CPT are significantly less likely to experience future IPV (Iverson et al., 2011a)
25
Evidence Based Therapies for PTSD
• Prolonged Exposure (PE)– A type of cognitive-behavioral therapy– Individually-based 90 minute treatment session for 8
to 15 weeks– Provide education about common reactions to trauma– Repeated exposure to traumatic memories and
situations they have been avoiding with the goal of reducing fear and anxiety
– Safety should be established prior to beginning PE– PE is very efficacious for the treatment of PTSD
26
Depression and Anxiety• Both depression and anxiety are common
(30% - 48%; Campbell, 2002; Golding, 1999)– low self-esteem/sense of worth– insecurities– hopelessness– sadness– sleep disturbances– chronic worry– guilt and self-blame– suicidal thoughts and suicide attempts
27
Evidence Based Therapies for Depression and Anxiety
• Cognitive Behavioral Therapy (CBT)– Delivered in individual or group format– Consists of 12 to 16 weekly or bi-weekly 50-minute
sessions– Present-focused approach– Helps patients develop strategies to change
problematic thinking and behaviors using both cognitive restructuring and behavioral activation
– Very effective treatment for anxiety and depression symptoms
28
• Acceptance and Commitment Therapy (ACT)– A type of cognitive-behavioral therapy– Delivered in individual or group formats– Typically 12 sessions, but ranges from 11 to 16– ACT promotes acceptance of uncomfortable private
events (thoughts, emotions, memories, and sensations) in order to promote behavioral commitments that are in line with their personal values
29
Evidence Based Therapies for Depression and Anxiety
Substance Use Disorders
• Substance use disorders are common (Golding, 1999)– Alcohol use disorder – 20%– Drug use disorder – 10%– Rates are even higher in treatment settings
• IPV and substance use frequently occur together
30
Treatments for Substance Use Problems in VA
• Multiple levels of care determined by the individual’s risk and clinical needs
• Range from standard outpatient care to more intensive inpatient programs
• Includes:– 12-step facilitation– motivational enhancement– cognitive-behavior therapy
31
Treatments for Substance Use Problems in VA
• Seeking Safety for substance use disorders and co-occurring PTSD– Individual or group formats– Works on both disorders at the same time– Initiate/maintain the recovery process– Teach and reinforce skills needed to stay sober and
abstinent and safe from dangerous relationships
32
•Mandated (2008) as a full-time, program-managementposition in response to:
– More women Veterans using VA health care – Demand for expanded services to meet their needs– Located at VA facilities throughout the nation
33
The Role of the Women Veterans Program Manager (WVPM)
Advocates for Women Veterans • WVPMs serve as a linchpin for Women’s Health:
– Coordinate care across disciplines– Facilitate referral to appropriate VA services:
• Mental health, Social work, Primary care, etc. • WVPMs:
– Provide support and information for women who are victims of trauma or IPV
– Liaise with community to connect patients with appropriate resources:• e.g., counselors, safe houses,
legal and financial services, etc.– Assist with local provider training and
development of screening tools34
Mental Health Correlates of IPV Perpetration Among Veterans: Implications for Mental Health
Treatments
35
What Do We Know About IPV Perpetration Among Veterans
• IPV perpetration among Veterans varies widely, but tends to be higher among Veterans than non-Veterans (Marshall, Panuzio, & Taft, 2005)―13.5% to 58% (lifetime)― Rates are higher in treatment-seeking samples,
particularly Veterans with PTSD
36
Jakupack et al., 2007; King & King, 2004; Orcutt, King, & King, 2003; Rosenbaum & Leisring, 2004; Taft et al., 2008; Taft et al., 2007; Taft et al., 2010; Taft et al., 2011
PTSD & IPV • Male Veterans with greater PTSD symptoms report
higher levels of:– Anger– Hostility– General aggressiveness– Physiological anger reactivity– Physical, sexual and psychological IPV perpetration
• Many Veterans with PTSD do not perpetrate IPV, but the link is well established
Other Mental Health Factors Contributing to IPV Perpetration
• Depression ― e.g., Erikson et al., 2001; Suvarese et al., 2001;
Taft et al., 2005
• Alcohol use problems ― e.g., Suvarese et al., 2001; Taft et al., 2010
38
Mental Health Treatment Implications• Referral for evidence-based treatment for mental health
conditions (see descriptions on earlier slides):―PTSD
• Cognitive Processing Therapy (CPT)• Prolonged Exposure (PE)
―Depression and Anxiety• Cognitive-behavioral Therapy (CBT)• Acceptance and Commitment Therapy (ACT)
―Substance Use Disorders• Seeking Safety• Behavioral Couples Therapy (coming soon)
39
Mental Health Treatment Implications• Anger management treatments are effective in reducing
general anger and physical aggression in Veterans (e.g., Marshall et al., 2010)
• Anger management may be an important treatment target for IPV perpetrators because of the strong associations between anger and IPV perpetration (e.g., Taft et al., 2007; Shorey et al., 2010)
• Caveats:– Anger management interventions do not typically
focus on reducing IPV– Anger management interventions do not address the
important dynamics of power and control40
Mental Health Treatment Implications
• Psychoeducation about IPV, anger management, and safety planning can be woven into all of these treatments while maintaining fidelity to the treatment models
• Several VA facilities have IPV programs for perpetrators, but most do not
• Referrals to domestic violence intervention programs in the community
41
HOMELESSNESS PROGRAMS
42
Homelessness Programs
• Roger Casey for approximately 15 minutes
43
Current VA Research and Educational Projects Relevant to IPV
44
IPV Programming at the Bedford VAMC• Evaluation of recovery-oriented therapy for both
Veterans who are victims and perpetrators of IPV• Treatment focuses on:
― exploration of both parties’ understanding of IPV ― employing an empathic approach ― using strength-based approaches (Lehman &
Simmons, 2009)― attending to the experience of trauma― helping the provider to be aware of his/her own
biases and assumption about IPV• Contact: Rachel Latta, Ph.D. at
Strength At Home
• Couples Program to Prevent IPV (funded by CDC)―Goal is to prevent conflict and IPV in returning
Veterans with PTSD • Relationship distress but no current violence
―Couples-based group format (10 sessions)―3-5 couples per group; male and female co-therapist― Intervention focuses on psychoeducation about PTSD
and relationship distress, conflict management, and communication skills
46
Strength At Home
• Veterans Program to Reduce IPV (funded by VA and DOD)―Goal is to prevent/reduce conflict and IPV in returning
Veterans with PTSD• Veterans have engaged in recent IPV
― Individual (non-couple) group format (12 sessions)―6-10 Veterans per group; male and female co-therapists― Intervention focuses on psychoeducation, anger
management skills, and emphasizes personal responsibility and accountability
• Principal Investigator (PI): Casey Taft, Ph.D. • www.StrengthAtHome.com
47
Modification of the Duluth Model in Milwaukee
48
• Training staff to provide IPV services to Veterans following a modified Duluth model (funded by National Center for Homelessness)―Modifications focus on the unique needs of Veterans
• Incorporates a focus on trauma and PTSD• Improved detection of IPV among Veterans with
PTSD• Enhanced coordination of response between VA
and the community, particularly the Criminal Justice System
• Contact person: Dennis Thompson, LCSW, MSSW at [email protected]
Treating Violence-Prone Substance Use Disorder Patients
49
• Evaluation of an Interpersonal Violence Prevention intervention among VA patients with a substance use disorder (SUD) and a history of violence perpetration against adults (including IPV) (funded by VA HSR&D)
• Vets were randomly assigned to SUD + violence prevention intervention or SUD review only– Violence prevention intervention is cognitive-
behavioral • Results are currently being analyzed• PI/Contact: Dr. Christine Timko at
Improving Care for Women Veterans
• Forthcoming projects– Evaluations of tools and programs to better detect
and respond to IPV
50
Examples of VA Education Efforts
• Mini-residency trainings focusing on IPV detection, assessment, and responding
• Half-day workshops on IPV detection and management in couples therapy roll out
• National satellite broadcast and DVDs to increase VA providers’ awareness, sensitivity and competency in terms of IPV detection, assessment, responding and treatment
• An IPV Fact Sheet for patients developed by the National Center for PTSD– http://www.ptsd.va.gov/public/pages/domestic-
violence.asp
51
Outreach/Awareness
http://www.publichealth.va.gov/womenshealth/campaigns.asp
Thank you for listening and caring for our Veterans!
Presenter contact information:
Dr. Susan McCutcheon: [email protected]. Katherine Iverson: [email protected]
Dr. Roger Casey: [email protected]
53