Counseling Practice with Aging Female Veterans: The Impact of Military History Lynette Adams, Ph.D. Women Veterans Program Manager VA Connecticut Healthcare System 1
Purpose Today To discuss some of the background, history, and statistics on women Veterans that may help inform you in your work with older women Veterans. 2
Objectives for Today 1. Overview of the history of women in the military 2. Discuss differences between women Veterans and civilian women and men Veterans 3. Identify challenges with and barriers to receiving care in women Veterans 4. Identify resources for women Veterans through the VHA, the state department of Veterans Affairs, and other community agencies 3
Question for Discussion What comes to mind when you hear the word Veteran? 4
Who is in our Veteran population?
Women in the USA Military http://www.womensmemorial.org/index.html Women served since the American revolution Common roles in early conflicts caretakers, phone operators, stenographers 1775 First woman to be killed in action 1865 First woman to be awarded Medal of Honor, Mary Walker 1917 Women could enlist Navy and Coast Guard 1942 Women s specific military branches established in WWII era 1967 Policy on % women allowed into military 2013 Ban on women officially serving in combat lifted 2015 First servicewomen to pass through Ranger School 2016 Ban on integrating into front line combat roles lifted 6
What Do Women in the Military D0? Combat Specialists Aircraft Loadmaster Combat Arms Generalist Combat Engineer Communications/Intelligence Security Forces Intelligence Analyst Interrogator Electrical/Mechanical Repair Ammunition Specialist Cable Systems Installer Helicopter Repair LW Vehicle Mechanic Healthcare Flight Nurse Combat Medic Veterinarian Physician Functional Support Airfield Management Chaplain Human Resources Other Allied Specialists Explosive Ord Disposal Mortuary Affairs Weather Forecaster Craftworkers Carpentry/Masonry Crane Operator Water Treatment Specialist Service and Supply Foodservice Military Police Motor Transport Operator 7
Commonalities Across Conflicts Most common conditions for all conflicts: Musculo-skeletal injuries with pain Diagnosable mental health conditions Unexplained symptoms Dental Hearing Stressors of War: Physical, Psychological, and Psychosocial Women Veteran s Health Strategic Healthcare Group (2011) 8
Unique to Conflict WW I: poison gas; trench warfare with artillery blast exposure WW II: Cold injury (European); Peptic Ulcer Disease and GI complaints Korea: Cold injury Vietnam: Agent Orange Persian Gulf War I: Unexplained Medical Symptoms OEF/OIF/OND eras: TBI/Polytrauma Women Veteran s Health Strategic Healthcare Group (2011) 9
Within Conflict Differences: Vietnam as Example, (Kaiser, 2017) Wide range of differences in experiences in any given conflict Career Military Women (20+ years) compared to women who served <20 years or deployed in civilian roles (Red Cross), reported 25 years after Vietnam Had least severe PTSD symptoms Better average mental and physical health Less overall and work-related stress while serving in Vietnam Highest levels of perceived community support 10
Voice of Women Veterans Stories from the Veterans History Project Joan Furey - War: Vietnam War, 1961-1975 Service Location: San Francisco, California; Fort Meade, Maryland; Pleiku, Vietnam Rank: First Lieutenant A year out of nursing school, Joan Furey was working an Intensive Care Unit in a hospital in the Central Highlands of Vietnam. Her year there was an accelerated course in applied nursing techniques. Both the intensity of her daily shifts and the democratic nature of her unit, where nurses were given decision-making latitude by the doctors in the interests of serving the patients, spoiled her for civilian nursing in more relaxed and structured surroundings. She came to discover a delayed reaction to the stress of her wartime experiences and gained a better understanding of postwar trauma suffered by the soldiers she had treated. Taken From: http://memory.loc.gov/diglib/vhp-stories/loc.natlib.afc2001001.19249/#vhp:clip 11
Voice of Women Veterans Stories from the Veterans History Project Cookie Avvampato: War: Iraq War, 2003-2011; Persian Gulf War, 1991 Branch: Air Force; Air Force Unit: 752nd ASES; 944th Aeromedical Staging Squadron (ASTS) Service Location: Kuwait; Iraq; also: March Air Force Base, California; Carswell Air Force Base, Texas; Luke Air Force Base, Arizona; Kuwait Rank: Lieutenant Colonel; Major Three months after Cookie Avvampato, a professional nurse with two late-teen children, joined the Air Force Reserves, she was called into active duty to serve in Desert Storm as a backfill medical specialist in Kuwait. Having grown up a selfdescribed military brat, with her father an Air Force enlisted man she had little trouble adapting to life in the military. Some fourteen years later, she volunteered to go to Iraq to serve in that conflict. Daily life in the two wars was a study in contrasts; her medical facility in Kuwait had many amenities, with little sense of danger, while conditions as her base in Balad, Iraq, were very confining Taken From http://memory.loc.gov/diglib/vhp-stories/loc.natlib.afc2001001.39017/#vhp:clip 12
Voice of Women Veterans Stories from the Veterans History Project Brenda Vosbein War: Cold War; Persian Gulf War Era, 1990-2001 Branch: Army Rank: Lieutenant Colonel When Brenda Vosbein joined the Army in 1970, she was a WAC with the Women s Army Corps. She overcame her disappointment that women could not serve in combat and became a nurse. In her 29 year career, Brenda experienced--and quickly adapted to--the massive sea change in the military as women s roles expanded. However, when the military s "Don't Ask Don't Tell" policy regarding gay military service became a legal issue, Brenda volunteered to be one of the plaintiffs. As the only lesbian plaintiff, and the only plaintiff still on active duty, her pseudonym of "Jane Able" was chosen for the title of the suit Able vs. The United States of America. Taken From: http://memory.loc.gov/diglib/vhp-stories/loc.natlib.afc2001001.39017/#vhp:clip 13
Question for Discussion How many have worked with female Veterans? How did you know they were a Veteran? Practice Consideration: Include a question about service history in your intake. Consider the language did you serve in the military instead of Are you a Veteran? Ask about branch, rank, station, deployments, injuries or illnesses sustained, reason for separation 14
Current Data from the Dept of Defense More women are entering the military (Department of Defense, 2011) Active Duty = 14.6% Reserves = 19.5% National Guard = 15.5% As of 2015, there are 201,413 female active duty service members. (source defense.gov) 15
What We Know about Women Veterans in Connecticut According to Vet Pop va.gov/vetdata 21.7 Million Veterans More than 2 Million are women Connecticut: 16,545 women (about 8%) http://www.va.gov/vetdata/veteran_population.asp VA Connecticut 4,155 enrolled 3,160 uniques About 5.5% of Veterans using VACHS are women Only 25% of women Vet population enrolled at VA 16
Women Veterans by Age Attendees at VA Connecticut in FY16 17
Relative to Men Veterans... Across all age groups, Women Veterans utilizing VHA care are: Younger More highly educated Less likely to be married Less likely to have someone who could take them to the doctor if ill More likely to experience physical/sexual abuse More likely to be service connected (rating more likely to be > 50%) Likely to utilize more outpatient services and non-va care Similar with regard to physical/emotional functioning Among recent service Veterans, Women Veterans utilizing VHA care are More likely to be single parents More likely to be homeless/unemployed More likely to be non-white More likely to report musculoskeletal injuries More likely to be depressed Frayne, et al, 2006; Women Veteran s Health Sourcebook Vol 2 18
Gender Specific Mental Health Care for Women Veterans Knowledge base is growing Few studies have focused specifically on older women Veterans, even fewer on mental health Most of the data on women Veterans is collected from women getting services at the VHA, which might represent a different population Will summarize some a few studies on gender specific data on women Veterans pertaining to mental health and/or aging 19
Mental Health Considerations: Treatment Preferences 484 Veteran stakeholders surveyed about priorities for mental health care (Kimerling, et al, 2015) Key priorities included targeted mental health treatment to address: Depression Pain Coping with general medical conditions Sleep problems Weight management PTSD **Substantial proportions of women endorsed need for specialized, gender specific services for each** 20
Gender Specific Barriers to Care Potential barriers to care participation (Washington et al., 2011): Inability to take off from work Transportation difficulties Knowledge gaps about VA care Perception that VA providers are not gender-sensitive Military sexual assault history Childcare Other areas I ve noticed: Understanding about eligibility Effectiveness of outreach Location/hours 21
Special Considerations for Women Veterans: Military Sexual Trauma Military Sexual Trauma all Veterans are screened in 1 st visit for MST at VA Connecticut 1 out of 4 women screen positive compared to 1 out of 100 men Sexual minority women, about 1 out of 3 (Booth et al., 2012) VA MST Support Team estimates 55-79% female Veterans and active duty experience sexual harassment (2012) MST has been associated with (Klingensmith et al, 2014) Major Depressive Disorder, PTSD, Generalized Anxiety Disorder Past history of suicide attempt Current suicidal ideation Decreased functioning and quality of life Increased utilization of medication and therapy/counseling 22
Military Sexual Trauma cont. MST may affect therapeutic rapport, relationship to the VA versus military, experience of the milieu and environment, trust of other Veterans Practice Consideration: Screen Veterans for history of military sexual trauma I m going to ask about some things that may have happened to you while you were in the military. We ask all Veterans these questions because VA offers free care related to these experiences. You can choose not to answer these questions or you can simply respond with a yes or no 1. When you were in the military, did you ever receive unwanted, threatening, or repeated sexual attention? 2. When you were in the military, did you have sexual contact against your will or when you were unable to say no? 23
Special Considerations for Women Veterans: Other Types of Trauma 13% women reported sexual assault before the military vs. 6% men (Bryan et al., 2015) Homeless women veterans assessed in specialized residential care: 41% reported military sexual assault and were more likely to report childhood sexual abuse and reported greater PTSD symptom severity (Decker, Rosenheck, Tsai, Hoff, & Harpaz- Rotem, 2013) Domestic Violence/Intimate Partner Violence (for a review, see Gerber et al., 2014) 37% of women screened for positive for IPV (Iverson et al, 2015) Women Veterans identified the following as important: options for how/when discussed, follow-up support, transparent documentation, community resources (Iverson et al., 2014) Practice Consideration: Screening includes questions about intimate partner violence or other trauma 24
Suicide among Women Veterans (VHA Office of Suicide Prevention, 2014) After adjusting for differences in age, risk for suicide was 2.4 times higher among female Veterans when compared with U.S. civilian adult females. Rates of suicide have remained relatively stable among male patients between 2001 and 2014 and increased among female VHA patients during that same time period. Observed gender-based difference in changes in rates of suicide among female VHA patients between 2001 and 2014 is consistent with comparatively greater increase in rates of suicide among females in the U.S. general population, as reported by CDC. 25
Risk Assessments Practice Considerations ASK about suicidal ideation, history of attempt, and preparatory behavior ASK about nonsuicidal self-injury (doing other things to harm your body without the intent to kill yourself) ASK about firearms, med stashes, and other suicide/nssi means Free online training courses via Suicide Prevention Resource Center http://training.sprc.org Use MH Safety Plan update as needed Stanley et al 2016: after ED : 61% reported using safety plan to reduce suicide risk Best practice in the Suicide Prevention Resource Center Am. Foundation for Suicide Prevention Best Practices Registry http://www.suicidesafetyplan.com/uploads/safety_planning_-_cog Beh_Practice.pdf Data from this slide compiled by Suzanne Decker, 2016 26
Healthy Aging in Women (LaCroix et al, 2016) Large longitudinal study looked at whether Veteran status influenced 1. Survival to age 80 without disease or disability 2. Indicators of successful aging at 80 years and older Prior military service was associated with older age, higher education, higher levels of physical activity, alcohol consumption Lower likelihood of marrying or currently living with spouse/partner This study suggests prior military service may help identify a sub-group of older women with certain risk factors 27
Healthy Aging in Women (LaCroix et al, 2016) cont Women Veterans age 80 and older compared to non-veteran women Lower perceived health, physical functioning, life satisfaction, social support, quality of life, purpose in life Women Veterans more likely to die prior to age 80 than non-veteran women, no difference in development of non-fatal disease or disabilities Across all women, healthy survival was associated with Not smoking, higher physical activity, healthy body weight, and fewer depressive symptoms, married, using HT Possible theoretical explanations for these findings: Women who join the military may be different from those who don t Exposure to experiences in the military When/where they receive their healthcare Practice Considerations target the protective factor, ask about risk factors 28
Case Discussion *(fictitious identity based on common presenting problems) Your current intake is with Ms. J*, a 70 year old woman who presents with complaints of overwhelming anxiety. On her demographics form, she has checked the Veteran box and also lists that she is the sole caretaker for her adult daughter with special needs. When you meet with her, she asks if you ve ever worked with women Veterans before and whether you can handle all the things that have happened to me back when I was in the service. As you think about what you can do to create the best therapeutic relationship with her, what questions do you think are important to ask of her regarding her past military experience considering any of the factors discussed in the presentation today? 29
Case Discussion Considerations Factors to consider: Age: Overall health Caretaker status: will this be a barrier to getting to appointments, who is helping Social support: partner status, friends, family who can help? Reference to military: MST? Lack of support? Overwhelming anxiety and risk for suicide How can you best understand her military experience Building trust and an alliance may be particularly important with this Veteran 30
Resources at VHA Women s Comprehensive Health Primary Care Maternity Care Coverage Specialty care, mental health, inpatient, residential Women s Specific Groups depends on specific needs Healthcare for Homeless Veterans Vet Centers for combat Veterans or those who experienced MST Women Veterans Program Manager Lynette Adams, Ph.D. 203-932-5711x5402 31
Women Veterans Call Center
Veterans Crisis Line 33
Other Resources Veterans Eligibility - https://www.va.gov/healthbenefits/apply/veterans.asp Women Veterans Health Care: http://www.womenshealth.va.gov/womenshealth/index.asp VA Connecticut Women s Health Page: http://www.connecticut.va.gov/services/women/index.asp Connecticut State Department of Veterans Affairs: http://www.ct.gov/ctva/site/default.asp 34
Thank you, Questions? Please contact me at Lynette Adams, Ph.D. (203) 932-5711x5402 Lynette.Adams@va.gov 35