Intimate Partner Violence (IPV): Mental Health Services ... · Intimate Partner Violence (IPV):...

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Intimate Partner Violence (IPV): Mental Health Services within the Veterans Affairs (VA) Healthcare System Susan 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, PhD Clinical 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

Transcript of Intimate Partner Violence (IPV): Mental Health Services ... · Intimate Partner Violence (IPV):...

Page 1: Intimate Partner Violence (IPV): Mental Health Services ... · Intimate Partner Violence (IPV): Mental Health Services within the Veterans Affairs (VA) Healthcare System Susan McCutcheon,

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.

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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

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OVERVIEW OF THE DEPARTMENT OF VETERANS AFFAIRS (VA)

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Department of Veterans AffairsVA established in 1930 - Cabinet rank in 1989

Consists of 3 Administrations:

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Current Estimate of US Veteran Population

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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

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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

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VHA Facilities at a Glance

Source: National Center for Veterans Analysis and Statistics,  February 2, 2011 

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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

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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

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INTIMATE PARTNER VIOLENCE

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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)

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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

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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

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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

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Mental Health Consequences of IPV: Evidence-Based Psychotherapies within the

VA for IPV Survivors

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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

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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

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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

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VA TREATMENTS: EVIDENCE BASED PRACTICES

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VA Treatments:Evidenced Based Practices

• Multiple levels of care determined by the individual’s clinical needs― Inpatient and residential treatment programs―Outpatient services

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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)

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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

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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

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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)

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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

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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

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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

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• 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

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Evidence Based Therapies for Depression and Anxiety

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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

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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

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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

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•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

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The Role of the Women Veterans Program Manager (WVPM)

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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

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Mental Health Correlates of IPV Perpetration Among Veterans: Implications for Mental Health

Treatments

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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

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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

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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

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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)

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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

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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

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HOMELESSNESS PROGRAMS

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Homelessness Programs

• Roger Casey for approximately 15 minutes

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Current VA Research and Educational Projects Relevant to IPV

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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

[email protected]

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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

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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

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Modification of the Duluth Model in Milwaukee

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• 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]

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Treating Violence-Prone Substance Use Disorder Patients

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• 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

[email protected]

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Improving Care for Women Veterans

• Forthcoming projects– Evaluations of tools and programs to better detect

and respond to IPV

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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

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Outreach/Awareness

http://www.publichealth.va.gov/womenshealth/campaigns.asp

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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]

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