Trauma-focused therapy retention among military sexual trauma survivors: relationship with veterans' sexual or gender minority identification.

Military servicemembers identifying as sexual and gender minorities (SGM) are at increased risk for military sexual trauma (MST) exposure and Post-traumatic Stress Disorder (PTSD). Although evidence-based treatments can reduce symptoms of PTSD, treatment attrition is concerning. Unfortunately, evaluations of such approaches with veterans identifying as SGM are currently restricted to case studies offering limited information regarding treatment completion. Both historic and current contextual factors related to military and mental health practices may uniquely influence minority veterans' treatment engagement in veteran healthcare settings. We explored associations between SGM identification and treatment of MST-focused therapy completion patterns (finishing the full protocol [FP] or receiving minimally adequate care [MAC; defined as attending eight or more sessions]). Veterans (N = 271, 12.5% SGM) enrolled in individual Prolonged Exposure or Cognitive Processing Therapies at a Midwestern veterans hospital system. Those identifying as SGM were more likely than non-identifying peers to complete FP treatment and, even when attrition occurred, they were retained longer. For MAC, the SGM group was as likely as non-SGM peers to be retained. This research suggests SGM veterans represent a notable minority of those seeking treatment in association with MST and do not appear at greater risk for discontinuation from trauma-focused treatment.

Therapeutic Dance for the Healing of Sexual Trauma: A Systematic Review.

Therapeutic dance has been increasingly used as a treatment modality for sexual trauma, yet its evidence-based efficacy has not yet been catalogued. We therefore conducted a systematic review to summarize the existing evidence for therapeutic dance as an intervention for healing after sexual trauma. We searched 5 major databases to identify intervention studies on the use of therapeutic dance for individuals with histories of sexual trauma. Studies were included based on the following criteria: 1) the study involves individuals who have been exposed to sexual trauma; 2) the study reports on any form of dance as a therapeutic intervention; and 3) the study reports on dance intervention outcomes. A total of 1,686 sources were identified. Of these, 11 articles met eligibility criteria and were assessed. Reported outcomes were extracted and organized into emergent domains. We found that therapeutic dance acts upon three broad domains-affect, self, and interpersonal relationships - and can be delivered in diverse settings. Across the studies, dance showed benefits on outcomes. However, a significant weakness of the current peer-reviewed literature is the lack of robust empirical intervention research on dance therapy. Overall, the emerging literature suggests that therapeutic dance is a potential intervention for those who have experienced sexual trauma. The review findings presented here can be used to inform practitioners and systems of care targeted for those who have been subject to sexual trauma.

State of the Knowledge of VA Military Sexual Trauma Research.

Despite substantial efforts to counter sexual assault and harassment in the military, both remain persistent in the Armed Services. In February 2021, President Biden directed the U.S. Department of Defense to establish a 90-day Independent Review Commission on Sexual Assault in the Military (IRC) to assess the department's efforts and make actionable recommendations. As servicemembers discharge from the military, effects of military sexual trauma (MST) are often seen in the Veterans Health Administration (VA). In response to an IRC inquiry about VA MST research, we organized an overview on prevalence, adverse consequences, and evidence-based treatments targeting the sequelae of MST. Women are significantly more likely to experience MST than their male counterparts. Other groups with low societal and institutional power (e.g., lower rank) are also at increased risk. Although not all MST survivors experience long-term adverse consequences, for many, they can be significant, chronic, and enduring and span mental and physical health outcomes, as well as cumulative impairments in functioning. Adverse consequences of MST come with commonalities shared with sexual trauma in other settings (e.g., interpersonal betrayal, victim-blaming) as well as unique aspects of the military context, where experiences of interpersonal betrayal may be compounded by perceptions of institutional betrayal (e.g., fear of reprisal or ostracism, having to work/live alongside a perpetrator). MST's most common mental health impact is posttraumatic stress disorder, which rarely occurs in isolation, and may coincide with major depression, anxiety, eating disorders, substance use disorders, and increased suicidality. Physical health impacts include greater chronic disease burden (e.g., hypertension), and impaired reproductive health and sexual functioning. Advances in treatment include evidence-based psychotherapies and novel approaches relying on mind-body interventions and peer support. Nonetheless, much work is needed to enhance detection, access, care, and support or even the best interventions will not be effective.

Effects of Emotion Dysregulation on Post-treatment Post-traumatic Stress Disorder and Depressive Symptoms Among Women Veterans With Military Sexual Trauma.

Military sexual trauma (MST), defined as sexual assault or repeated, threatening sexual harassment while in the military, is associated with increased risk of long-term mental and physical health problems, with the most common being symptoms of post-traumatic stress disorder (PTSD) and depression. In addition to PTSD and depression, MST is linked to difficulties in emotion regulation as well as poor treatment engagement. Thus, it is important to examine these correlates, and how they affect postintervention symptom reduction in this vulnerable population. The current study presents secondary data analyses from a randomized clinical trial comparing the efficacy of in-person versus telemedicine delivery of prolonged exposure therapy for female veterans with MST-related PTSD (n = 151). Results of the study found that changes in difficulties with emotion regulation predicted postintervention depressive symptoms but not postintervention PTSD symptoms. Neither postintervention depressive nor PTSD symptoms were affected by treatment dosing (i.e., number of sessions attended) nor treatment condition (i.e., in-person vs. telemedicine). Findings from the current study provide preliminary evidence that decreases in difficulties with emotion regulation during PTSD treatment are associated with decreases in depressive symptom severity.

Comparing Veterans with Posttraumatic Stress Disorder Related to Military Sexual Trauma or Other Trauma Types: Baseline Characteristics and Residential Cognitive Processing Therapy Outcomes.

The Veterans Health Administration (VHA) has called for improved assessment and intervention for survivors of military sexual trauma (MST) to mitigate deleterious sequalae, including posttraumatic stress disorder (PTSD). Research on the impact of MST-related PTSD (MST-IT) on men is limited, and few studies have examined the differential effects of treatment across genders and MST-IT. Additionally, studies have utilized varying definitions of MST (e.g., sexual assault only vs. including sexual harassment), contributing to disparate outcomes across studies. Utilizing data from 343 veterans seeking residential cognitive processing therapy (CPT) for PTSD in VHA, this study examined the impact of MST-IT and gender on differences in demographic characteristics; pre-treatment severity of PTSD (overall and clusters), depression, and negative posttraumatic cognitions (NPCs); and post-treatment severity of these variables after accounting for pre-treatment severity. Results from 2x2 factorial ANOVAs found no differences in pre-treatment depression or overall PTSD by MST-IT, gender, or their interaction; however, MST-IT survivors presented with greater pre-treatment avoidance, global NPCs, and self-blame. Results from hierarchical linear regression models found only pre-treatment symptom severity significantly predicted post-treatment severity for overall PTSD and all NPCs. These findings suggest veteran survivors of MST-IT appear to benefit similarly from CPT delivered in a VHA residential PTSD program compared to veterans with other index traumas, regardless of gender. Although there were minimal post-treatment differences in PTSD and NPCs by MST-IT status and gender, residual symptoms related to negative cognitions and mood appear to differ across gender and MST-IT status. Specifically, in individuals without MST-IT, post-treatment PTSD symptoms of negative alterations in cognition and mood were higher in men than women. Moreover, women with MST-IT reported more symptoms of depression than both men with MST-IT and women without MST-IT. These findings suggest depressive symptoms decrease through residential PTSD treatment differentially by MST-IT status and gender and warrant further examination.

Barriers to PTSD treatment-seeking by women veterans who experienced military sexual trauma decades ago: The role of institutional betrayal.

BACKGROUND: While some barriers to PTSD treatment engagement among veterans are well-identified, e.g., stigma, little is known about the barriers to VA PTSD treatment-seeking among women veterans who experienced military sexual trauma (MST) decades ago. PURPOSE: To explore the barriers to PTSD treatment-seeking of women veterans with PTSD related to MST experienced prior to 2000. METHOD: Data were collected from women veterans (n = 14) who had experienced MST and sought VA PTSD treatment. Data analyses utilized a constructivist grounded theory approach. FINDINGS: The context of the MST experience, including the military environment at the time, the era in which they experienced MST and the response of others to their reporting or disclosure of MST created decades-long barriers to PTSD treatment-seeking. DISCUSSION: Understanding institutional betrayal as a barrier to PTSD treatment-seeking among women veterans who experienced MST decades ago is necessary to develop effective targeted outreach and programs for this population.

Trauma-Sensitive Yoga for Post-Traumatic Stress Disorder in Women Veterans who Experienced Military Sexual Trauma: Interim Results from a Randomized Controlled Trial.

Objective: To conduct an interim analysis of data collected from an ongoing multisite randomized clinical trial (RCT) assessing the effectiveness of Trauma Center Trauma-Sensitive Yoga (TCTSY) for post-traumatic stress disorder (PTSD) among women veterans with PTSD related to military sexual trauma (MST). The purpose of the interim analysis was to assess outcomes from the primary site, which is geographically, demographically, culturally, and procedurally distinct from the second site. Design: RCT was conducted within a Veterans Administration Health Care System. Data collection included preintervention through 3 months postintervention. Participants: Enrollment for the main site was 152 women. The sample size for the intent-to-treat analysis was 104. The majority were African American (91.3%) with a mean age of 48.46 years. Intervention: The TCTSY intervention (n = 58) was conducted by TCTSY-certified yoga facilitators and consisted of 10 weekly 60-min group sessions. The control intervention, cognitive processing therapy (CPT; n = 46), consisted of 12 90-min weekly group sessions conducted per Veterans Administration protocol by clinicians in the PTSD Clinic. Outcome measures: The Clinician Administered PTSD Scale for DSM-5 (CAPS-5) was used to assess current PTSD diagnosis and symptom severity, including overall PTSD and four symptom clusters. The PTSD checklist for DSM-5 (PCL-5) was used to obtain self-report of PTSD symptom severity, including total score and four symptom clusters. Results: The findings reported here are interim results from one clinical site. For both the CAPS-5 and PCL-5, total scores and all four criterion scores decreased significantly (p < 0.01) over time in all five multilevel linear models within both TCTSY and CPT groups, without significant differences between groups. There were clinically meaningful improvements seen for both TCTSY and CPT with 51.1%-64.3% of TCTSY subjects and 43.5%-73.7% of CPT decreasing their CAPS-5 scores by 10 points or more. Effect sizes for total symptom severity were large for TCTSY (Cohen's d = 1.10-1.18) and CPT (Cohen's d = 0.90-1.40). Intervention completion was higher in TCTSY (60.3%) than in CPT (34.8%). Symptom improvement occurred earlier for TCTSY (midintervention) than for CPT (2 weeks postintervention). Safety: There were no unanticipated adverse events in this study. Conclusion: The results of this study demonstrate that TCTSY may be an effective treatment for PTSD that yields symptom improvement more quickly, has higher retention than CPT, and has a sustained effect. TCTSY may be an effective alternative to trauma-focused therapy for women veterans with PTSD related to MST. The study is registered in ClinicalTrials.gov (CTR no.: NCT02640690).

A Latent Class Analysis of Mental Health Beliefs Related to Military Sexual Trauma.

Military veterans with histories of military sexual trauma (MST) are at risk for several negative mental health outcomes and report perceived barriers to treatment engagement. To inform interventions to promote gender-sensitive access to MST-related care, we conducted an exploratory, multiple-group latent class analysis of negative beliefs about MST-related care. Participants were U.S. veterans (N = 1,185) who screened positive for MST within the last 2 months and reported a perceived need for MST-related treatment. Associations between class membership, mental health screenings, logistical barriers, difficulty accessing care, and unmet need for MST-related care were also examined. Results indicated a four-class solution, with classes categorized as (a) low barrier, with few negative beliefs; (b) high barrier, with pervasive negative beliefs; (c) stigma-related beliefs; and (d) negative perceptions of care (NPC). Men were significantly less likely than women to fall into the low barrier class (27.9% vs. 34.5%). Relative to participants in the low barrier class, individuals in all other classes reported more scheduling, ps < .001; transportation, p < .001 to p = .014; and work-related barriers, p < .001 to p = .031. Participants in the NPC class reported the most difficulty with access, p < .001, and those in the NPC and high barrier classes were more likely to report unmet needs compared to other classes, ps < .001. Brief cognitive and behavioral interventions, delivered in primary care settings and via telehealth, tailored to address veterans' negative mental health beliefs may increase the utilization of mental health treatment related to MST.

Cognitive behavioral therapy for the treatment of chronic pelvic pain.

Chronic pelvic pain (CPP) in women is defined as noncyclical and persistent pain lasting more than six months perceived to be related to the pelvis. There are many etiologies that can cause CPP, including gynecologic, urologic, gastrointestinal, musculoskeletal, neurologic, and psychosocial. There is a strong association between psychological factors and CPP. It has been noted that almost half of women being treated for CPP report a history of sexual, physical, or emotional trauma. Women with CPP have been noted to have higher rates of psychological disorders in comparison to their peers. For men, the most common etiology for CPP is chronic prostatitis and there are also correlations with psychological disorders. There are many different treatment options for CPP: surgical, pharmacological, and non-pharmacological (alternative therapies). Cognitive-behavioral therapy may be another option when treating chronic pelvic pain syndrome and should be considered.

Sexual Behavior Problems and Premature Termination From Pediatric Trauma-Focused Treatment Among Sexually Abused Children.

Premature termination from child trauma-focused treatment is common; however, the role of children's level of symptoms as a risk factor for attrition remains uncertain. In particular, children's sexual behavior problems (SBPs) have received scant attention in the prior attrition literature, and no known studies to date have thoroughly examined SBPs in relation to premature treatment termination. The current study investigated whether higher levels of children's SBPs were associated with increased risk for attrition from trauma-focused treatment in a sample of 242 sexually abused children aged 2-12 years (M = 7.48 years, SD = 2.68; 64.5% female, 54.1% White). To assess the potential associations between SBPs and treatment dropout more thoroughly, two definitions of attrition were utilized: (a) clinician-rated dropout and (b) whether the child received an adequate dose of treatment (i.e., 12 or more sessions). Whereas only 34.3% of the children completed treatment per their clinician, 69.4% received an adequate dose of treatment. In contrast to the study hypotheses, neither development-related nor sexual abuse-specific SBPs were associated with either clinician-rated dropout or adequate dose status, ORs = 0.99-1.00. Sexual acting-out behaviors in sexually abused children may not correspond with attrition from trauma-focused treatment at multiple points of treatment. Given the heterogeneity of SBPs, further assessment of whether attrition patterns differ across subgroups of children who exhibit SBPs is needed.

Barriers in seeking support: Perspectives of service providers who are survivors of sexual violence.

Research with survivors of sexual violence suggests that most do not seek supportive services from community organizations. The purpose of this study is to understand the unique barriers that service providers, who are also survivors of sexual violence, may experience and how it informs their work with survivors. We conducted semi-structured interviews with 19 female, trans, and nonbinary survivors of sexual violence who are also employed as domestic violence or sexual assault advocates, community organizers, therapists, health care providers, educators, or substance abuse counselors, and had worked with survivors of sexual violence in their current positions. We coded the data using a multistep strategy derived from grounded theory. Participants indicated sensitivity to community-level barriers including where services are offered, perceived cost of services, and taking time off of work. Internalized blame, shame, minimization of their experiences, and trauma were also mentioned as significant barriers for themselves and impacted their work with survivors. Our findings suggest a need for trauma-informed intervention in community practice and policy.

Facilitating Erotic Connection: The Relationship Shared Values Primer (RSVP) to Sex and Relationship Therapy in the Context of Sexual Trauma History.

There are few models of sex therapy designed specifically for working with relationships in which one or more partners have a history of sexual trauma. The Relationship Shared Values Primer (RSVP) to sex and relationship therapies is a pre-sex therapy psychoeducation with the goal of promoting buy-in and reducing attrition by fostering safety and connection prior to beginning the therapeutic work through a dialogue of four key values: (1) Intimate Justice, (2) Non-linear Healing, (3) Mindful Acceptance, and (4) Erotic Empathy. We discuss research support for the rationale of the RSVP, how the RSVP can mitigate current obstacles to working with this population, and present a case study of the RSVP application.

Featured counter-trafficking program: H.E.A.L.T.H. Clinic of Ottawa.

This invited article is one of several comprising part of a special issue of Child Abuse and Neglect focused on child trafficking and health. The purpose of each invited article is to describe a specific program serving trafficked youth. Featuring these programs is intended to raise awareness of innovative counter-trafficking strategies emerging worldwide and facilitates collaboration on program development and outcomes research. This article describes the H.E.A.L.T.H. Clinic of Ottawa, Ontario, Canada, a primary health care clinic designed specifically for those who have experienced, are currently experiencing, or are at risk for sexual exploitation, coercion, or human trafficking.

Military sexual trauma survivors' perceptions of veterans health administration care: A qualitative examination.

Although the Veterans Health Administration (VHA) provides free health care related to military sexual trauma (MST), many veterans forgo or delay such care, underscoring the need for research aimed at understanding MST survivors' perceptions and concerns regarding VHA care. This study employed a qualitative phenomenological approach to describe MST survivors': (a) perceptions of VHA care, (b) concerns about VHA care, and (c) suggestions for how VHA can facilitate recovery from MST. Fifty veterans (32 women, 18 men) with histories of MST participated in semistructured interviews. Transcripts were analyzed using thematic analysis. The pattern of themes was examined by gender and MST type. The majority of participants described neutral or positive perceptions of VHA care; however, a subset of participants described negative perceptions and reservations about using VHA care. Participants expressed concerns regarding distrust, provider compassion, privacy, stigma, shame, and continuity of care. Some women, particularly those who experienced military sexual assault, also described gender-related distress (e.g., feeling anxious or out of place, desire for separate facilities). Both men and women described wanting nonspecific support, improved continuity of care, and the ability to choose from a variety of treatment options (e.g., holistic, gender-specific). Further research is needed to examine if these findings are replicated in other samples. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Featured counter-trafficking program: Trauma recovery for victims of sex trafficking.

This invited article is one of several comprising part of a special issue of Child Abuse and Neglect focused on child trafficking and health. The purpose of each invited article is to describe a specific program serving trafficked children. Featuring these programs is intended to raise awareness of innovative counter-trafficking strategies emerging worldwide and facilitate collaboration on program development and outcomes research. This article describes a mental health program within Agape Restoration Center (ARC), a residential treatment center in Phnom Penh, Cambodia. Development of the mental health services program was based on a modified version of an evidence-based trauma-focused cognitive behavioral therapeutic modality developed in the U.S (Cohen, Mannarino, & Deblinger, 2006, 2012).

Pragmatic trial of brief warrior renew group therapy for military sexual trauma in VA primary care.

This is a pragmatic trial of a brief version of Warrior Renew, an emerging evidence-based treatment for military sexual trauma (MST) delivered in a Department of Veterans Affairs women's health clinic primary care setting. The full protocol meets twice a week for 12 weeks (24 sessions); however, Brief Warrior Renew meets for 8 sessions. Brief Warrior Renew is a manualized protocol addressing coping skills for affect management (e.g., triggers and anxiety) and unique aspects of MST including anger-resentments due to injustice-betrayal, and self-blame. It also addresses interpersonal factors such as relationship patterns. In this evaluation, 39 female veterans enrolled, 38 started, and 30 completed Brief Warrior Renew treatment (21% attrition). Participant scores reflected significant decreases of anxiety, depression, posttraumatic stress disorder, and negative thinking with large to very large effect sizes. Of the sample, 73.3% had reliable clinical change in their reports of negative thinking. This brief treatment appears to be feasible and well tolerated by veterans in a primary care setting. Results suggest formal investigation of this brief protocol is warranted. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Comparing PTSD treatment retention among survivors of military sexual trauma utilizing clinical video technology and in-person approaches.

INTRODUCTION: Interventions such as Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT) have demonstrated efficacy for the treatment of post-traumatic stress disorder (PTSD) following military sexual trauma (MST). However, MST survivors report a number of logistical and social barriers that impede treatment engagement. In an effort to address these barriers, the Veterans Health Administration offers remote delivery of services using clinical video technology (CVT). Evidence suggests PE and CPT can be delivered effectively via CVT. However, it is unclear whether rates of veteran retention in PTSD treatment for MST delivered remotely is comparable to in-person delivery in standard care. METHODS: Data were drawn from veterans (N = 171, 18.1% CVT-enrolled) with PTSD following MST who were engaged in either PE or CPT delivered either via CVT or in person. Veterans chose their preferred treatment modality and delivery format in collaboration with providers. Data were analysed to evaluate full completion (FP) of the protocol and completion of a minimally adequate care (MAC) number of sessions. RESULTS: FP treatment completion rates did not differ significantly by treatment delivery format. When evaluating receipt of MAC care, CVT utilizers were significantly less likely to complete. Kaplan-Meier analyses of both survival periods detected significant differences in attrition speed, with the CVT group having higher per-session attrition earlier in treatment. DISCUSSION: Disengagement from CVT-delivered treatment generally coincided with early imaginal exposures and writing of trauma narratives. CVT providers may have to take special care to develop rapport and problem-solve anticipated barriers to completion to retain survivors in effective trauma-focused interventions.

Featured Counter-Trafficking Program: The Minnesota Runaway Intervention Program.

This invited article is one of several comprising part of a special issue of Child Abuse and Neglect focused on child trafficking and health. The purpose of each invited article is to describe a specific program serving trafficked children. Featuring these programs is intended to raise awareness of innovative counter-trafficking strategies emerging worldwide and facilitate collaboration on program development and outcomes research. This article describes the Minnesota Runaway Intervention Program (RIP), a Minneapolis-St. Paul based program dedicated to supporting youth aged 12-17 who have run away and experienced sexual violence, including sexual assault and exploitation. It is a comprehensive, health care focused intervention, embedded within a hospital-based Child Advocacy Center. RIP is developed and led by nurse practitioners who provide services tailored to participants' diverse needs, including health care, case management services, and a therapeutic empowerment group.

"I cannot change what happened to me, but I can learn to change how I feel": A case study from ImpACT, an intervention for women with a history of sexual trauma who are living with HIV in Cape Town, South Africa.

Sexual trauma is highly prevalent among women living with HIV in South Africa, and there is a great need for psychotherapeutic interventions to address these concerns. Improving AIDS Care After Trauma (ImpACT) is a manualized intervention, based on stress and coping theories, that builds skills for coping with sexual trauma and HIV to promote long-term HIV care engagement. Using qualitative case study methodology, we report the case of Xoliswa, a 34-year-old woman with a complex history of sexual trauma and alcohol use who was diagnosed with HIV 1 year prior to enrollment in ImpACT. The interventionist, a lay counselor, worked with Xoliswa in a primary care clinic to address her concerns by exploring personal values, managing barriers to HIV care, and teaching active coping. Xoliswa's drinking reduced, symptoms of trauma and depression improved, and she maintained strong HIV care engagement. The interventionist experienced stress and emotional challenges in delivering ImpACT to Xoliswa and other highly traumatized women, and the interventionist's skill development and support received through training and supervision are briefly discussed. The case demonstrates the feasibility of ImpACT in a resource-limited setting and highlights themes and barriers in therapy, which can inform future interventions for women living with HIV. (PsycINFO Database Record (c) 2020 APA, all rights reserved).