Psychiatric Annals

CME Article 

Treatment of Posttraumatic Stress Disorder Related to Military Sexual Trauma

Lindsey Matt, PhD; Kaitlin Thompson, LCSW; Ashton M. Lofgreen, PhD; Rebecca Van Horn, MD

Abstract

The experience of military sexual trauma (MST), including harassment and assault, is a reality for hundreds of thousands of active duty service members and veterans. Those who have experienced MST are at risk for the development of posttraumatic stress disorder (PTSD) and often require comprehensive care to facilitate recovery. This article describes evidence-based approaches for the treatment of PTSD related to MST, the settings in which such care is most effective, and the supplementation of evidence-based treatment for PTSD with skills-based approaches for managing emotional distress and improving relationships (eg, dialectical-behavior therapy, skills training for affect and interpersonal regulation). Pharmacologic treatment and holistic modalities (eg, mindfulness, yoga, art therapy) are also discussed. [Psychiatr Ann. 2020;50(10):432–436.]

Abstract

The experience of military sexual trauma (MST), including harassment and assault, is a reality for hundreds of thousands of active duty service members and veterans. Those who have experienced MST are at risk for the development of posttraumatic stress disorder (PTSD) and often require comprehensive care to facilitate recovery. This article describes evidence-based approaches for the treatment of PTSD related to MST, the settings in which such care is most effective, and the supplementation of evidence-based treatment for PTSD with skills-based approaches for managing emotional distress and improving relationships (eg, dialectical-behavior therapy, skills training for affect and interpersonal regulation). Pharmacologic treatment and holistic modalities (eg, mindfulness, yoga, art therapy) are also discussed. [Psychiatr Ann. 2020;50(10):432–436.]

Military sexual trauma (MST) refers to assault or battery of a sexual nature or sexual harassment that occurred while a service member or veteran was on active duty or training for active duty.1 A 2018 meta-analysis of military personnel and veterans found that 8.9% of men and 52.5% of women reported sexual harassment, and 1.9% of men and 23.6% of women reported sexual assault.2 Although these reported rates are only slightly higher than those experienced by the general population (1.4% of men and 18.5% of women), they suggest service members are at unique risk as MST events only occur within the timeframe of military service, whereas civilian measures assess lifetime prevalence.2

MST has been shown to place people at higher risk for posttraumatic stress disorder (PTSD) relative to civilian sexual trauma.3 This increased risk may be due in part to higher rates of trauma exposure. Many service members contend with trauma sequelae from combat in addition to MST, leading to more severe PTSD than combat exposure alone.4 Additionally, MST survivors are more likely than their civilian counterparts to have experienced interpersonal trauma, including childhood sexual abuse (CSA).5 Cumulative trauma, particularly CSA, often disrupts the development of skill sets crucial in emotion regulation and relational domains that can make coping with the experience of MST particularly challenging.

Aspects of the military context may also play a role in increased risk of MST-related PTSD. Survivors of MST are likely to have been close to their perpetrator(s). Assault by someone the veteran previously trusted or relied on for survival can create conflict between a need to maintain the relationship versus responding to feelings of betrayal.6 Betrayal can be particularly salient within the military context, in which unquestioning trust is fostered through military training. Finally, survivors may fear that their experience will impact unit cohesion, that they will be ostracized or retaliated against, or that those in power will not believe them if they report.6 When such negative responses occur, survivors report strong feelings of “institutional betrayal,” which have been associated with higher odds of attempting suicide.7

Taken together, MST survivors face a complex scenario in which they must deal with not only their military trauma, but often the cumulative effects of past trauma and betrayal. These aggregate experiences may erode survivors' coping abilities, leading to further difficulties managing strong emotions and engaging successfully in important relationships. Treatment of MST-related PTSD may include psychotherapy, pharmacotherapy, or a combination thereof and should be driven by patient symptom presentation, preferences, and motivation. It has also been suggested that the approach to successful treatment for MST-related PTSD is likely to be multipronged, focusing not only on trauma-focused, evidence-based psychotherapies but also present-focused coping skills for managing strong emotions and improving interpersonal relationships.8

Trauma-Focused, Evidence-Based Psychotherapies for MST-Related PTSD

Psychotherapies with the most empirical support for the treatment of MST-related PTSD use cognitive-behavioral strategies and involve processing memories of the most salient traumatic experience. Two such psychotherapies are cognitive-processing therapy (CPT) and prolonged exposure (PE).9 CPT is a manualized approach entailing 12, 50-minute sessions. CPT focuses initially on providing psychoeducation to increase recognition of symptoms and the relationship between thoughts and feelings. The primary mechanism of change in CPT is cognitive restructuring of unhelpful beliefs about why the trauma happened as well as rigid beliefs about how life must now be lived because of the trauma. The patient's unhelpful beliefs are referred to as “stuck points,” and often include distorted perceptions of the self (eg, “I'm a bad person”), the world (eg, “The world is dangerous everywhere”), and other people (eg, “Nobody can be trusted”).9 Research with MST survivors indicates that beliefs related to self-blame about the trauma are particularly prominent.10 One study showed that reductions in self-blame–related cognitions predicted greater PTSD improvements, which is one reason CPT may be so effective with this population.11 Indeed, CPT has been shown to effectively decrease PTSD symptoms for both men and women who have experienced MST.12 Additionally, CPT is effective for people with complex trauma histories. A 2018 study found that having a history of CSA did not significantly affect CPT treatment response.13

PE is an additional modality with numerous studies supporting its efficacy with this population.9,14 Also a manualized approach, it involves 8 to 15, 90-minute sessions and focuses on psychoeducation about trauma symptoms (with emphasis on avoidance behaviors) and breathing retraining. The primary mechanism for change in PE is habituation to trauma-related reminders and memories through exposure to environmental reminders related to the trauma (ie, in vivo exposure), and to one's own trauma memories (ie, imaginal exposure). PE has been shown to increase survivors' confidence in their ability to manage distress.9,14 Like CPT, PE has demonstrated effectiveness for women veterans with extensive interpersonal trauma histories15 and is among treatments that demonstrate effectiveness for men who have survived MST.9

Beyond CPT and PE, there are several other treatment approaches with preliminary evidence illustrating utility with MST survivors. Eye movement desensitization and reprocessing (EMDR) combines exposure to a traumatic memory with focus on an external stimulus such as lateral eye movement and has been used with sexual trauma survivors more generally.16 Holographic Reprocessing focuses on identifying patterns of re-enactment, cognitive reappraisals, and experiential techniques using imagery and has demonstrated effectiveness with MST survivors.14 Additionally, Warrior Renew is a treatment based on Holographic Reprocessing that was developed specifically for MST survivors and addresses the culturally specific needs of this population through processing of experiences such as betrayal, injustice, and lack of closure.17

Treatment Settings for MST

Both CPT and PE for the treatment of MST-related PTSD have been studied in various settings including outpatient clinics, residential treatment facilities, and intensive treatment programs (ITPs). Outpatient delivery of CPT and PE typically spans 3 to 4 months of weekly sessions. In one study, nearly 20% of veterans offered weekly treatment in Veterans Affairs outpatient clinics setting did not initiate care.18 Moreover, many veterans find these therapies emotionally challenging, and drop-out rates are consistently between 30% and 50% with about one-quarter of those occurring before the third therapy session.18

Residential treatment programs, usually spanning 10 to 12 weeks, may offer more frequent CPT sessions (often twice weekly) in conjunction with other services such as psychoeducation, medication management, and wellness interventions.19,20 The residential level of care promotes completion of a full course of CPT or PE, and such programs have been shown to be effective for reducing symptoms of depression and PTSD across MST survivors.12 Additionally, the comprehensive care offered appears to be beneficial for people with comorbidities such as traumatic brain injury and substance use disorders.19,20 However, for many veterans, committing to 10 to 12 weeks away from home may make such programs infeasible.

A relatively novel approach of delivering “massed” trauma-focused treatment uses an intensive format in which an individual and/or group trauma-focused evidence-based psychotherapy (TF-EBP) is delivered on a daily basis across 2 to 3 weeks. Like residential care, veterans may be offered other comprehensive services such as mindfulness, yoga, medication management, art therapy, and biofeedback.21,22 Massed treatment delivery has demonstrated effectiveness for treating MST-related PTSD specifically, with many survivors experiencing significant symptom remission21 up to 6-months posttreatment.22 Importantly, massed treatment has lower dropout rates than those seen in outpatient TF-EBPs, with one study showing nearly 92% of some 648 veterans completing a full course of treatment.23 The additional support of daily trauma-focused treatment in conjunction with daily peer and provider support in ITPs may help veterans counter PTSD-related avoidance and manage the life stressors that often interfere with outpatient care. Further, 2 to 3 weeks is a much more practical amount of time to spend away from day-to-day responsibilities for many veterans.

Skills-Based Therapies: Stage-Based and Integrated Treatments

MST has been associated with difficulties characteristic of people with cumulative interpersonal trauma histories such as relational difficulties, emotion dysregulation, dissociative symptoms, somatic symptoms, and nonsuicidal self-injury.8 As such, it is commonly recommended that treatment for MST-related PTSD involve present-focused coping skills with an emphasis on establishing safety and stability and preparing patients for engagement in TF-EBPs. Treatments that are particularly suitable for meeting these goals include dialectical-behavior therapy (DBT)24 and skills training in affective and interpersonal regulation (STAIR).25 STAIR is a trauma-informed therapy that focuses on emotion management and interpersonal skills and is offered in an individual or group format. DBT is a treatment widely used for borderline personality disorder but with demonstrated effectiveness for a wide range of diagnoses. DBT focuses on helping clients meet goals through use of mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness skills. Additionally, Seeking Safety is a skills-based curriculum used widely with veterans including MST survivors and is designed for those with co-occurring PTSD and substance use disorders.26

A primary question in using skills-based interventions for PTSD is whether they should be offered in a sequential (ie, stage-based) or an integrated manner (ie, concurrently with the TF-EBP). Traditionally, treatment for cumulative trauma presentations has used a stage-based approach, where skill-work precedes trauma-processing.8 However, there is limited research directly comparing stage-based versus integrated approaches and at least one study to indicate that the integration of skills-based treatment with CPT in an intensive treatment modality improves PTSD treatment outcomes and provides rapid relief for many survivors of MST.27 This finding is promising, as integrated approaches may be more efficient than stage-based approaches and provide relief more quickly. More research is needed to determine the relative merit of stage-based versus integrated approaches for MST-related PTSD and if there are survivors who may benefit from one approach over another.

Pharmacologic Treatment for MST-Related PTSD

Although psychotherapeutic interventions provide the foundation for treatment of PTSD, pharmacotherapies also play an important role in care. Several studies have suggested MST is associated with numerous poor clinical outcomes, including both physical and mental health conditions.28 Therefore, evaluation of people presenting for medication management of PTSD resulting from MST should include a thorough history to assess for co-occurring psychiatric and medical disorders. To date, the US Food and Drug Administration29 has approved only two medications for the treatment of PTSD, sertraline and paroxetine. Both medications belong to the same class of medication, selective serotonin reuptake inhibitors (SSRIs),30 and have been shown to reduce mood and anxiety symptoms in patients with PTSD. Given the dearth of approved treatments for PTSD, off-label use of medications is not uncommon. A systematic review and meta-analysis by Hoskins et al.31 indicated three medications, fluoxetine, paroxetine, and venlafaxine, showed some efficacy versus placebo against PTSD, although effect sizes were modest. Importantly, SSRIs are often accompanied by sexual side effects that should be considered and discussed with patients, as they are a common reason for treatment discontinuation. Given the association of MST with chronic pain conditions (eg, fibromyalgia, chronic pelvic pain) prescribers may also consider the use of tricyclic medications to address both mood and pain symptoms.32 However, given the toxicity and potential lethality of tricyclic medications, the use of these medications should be carefully weighed with suicide risk.33

Holistic Care

Holistic therapy approaches to treat PTSD have been increasing among military and veteran populations.34 There are many complementary treatments that address the mind, body, and spirit that may bolster the results of traditional TF-EBPs, address overall well-being, and offer strategies for coping. Adjunctive treatments that have been studied in PTSD include mindfulness-based psychotherapies, exercise, nutrition and healthy diet, yoga, art therapy, acupuncture, Tai Chi, and Qigong.35 Although current evidence is limited, preliminary findings suggest that some of these approaches may help reduce the arousal symptoms that often make PTSD treatment less tolerable. Although these modalities should not be offered as first-line treatments for MST-related PTSD, they are often welcomed complementary treatments when used concurrently with more verbal, logic-based TF-EBPs.

Conclusion

Although challenges persist for survivors of MST, treatment approaches continue to evolve to best meet the needs of this population. Although TF-EBPs continue to offer benefit when delivered in outpatient clinics, current research suggests these approaches may be most effective when delivered in mass formats over weeks rather than months, allowing veterans to receive a full dose of treatment while still limiting time away from home. Moreover, embedding such modalities in a comprehensive model of care, including skills-based training, medication management, and holistic techniques, appears to boost symptom reduction even in those with multiple and often complex comorbidities. Last, promising work continues to explore novel approaches to trauma treatment including EMDR, Holographic Reprocessing, and Warrior Renew. Future research should continue to assess the feasibility and efficacy of both current and novel trauma treatments in condensed format and in conjunction with supplemental care, as well as use dismantling approaches to determine which facets of such care offer the most benefit to survivors.

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Authors

Lindsey Matt, PhD, is a Psychologist, Department of Psychiatry, University of California, Los Angeles (UCLA). Kaitlin Thompson, LCSW, is a Licensed Clinical Social Worker, Department of Psychiatry and Behavioral Sciences, Rush University Medical Center. Ashton M. Lofgreen, PhD, is an Assistant Professor, Department of Psychiatry and Behavioral Sciences, Rush University Medical Center. Rebecca Van Horn, MD, is the Medical Director, Department of Psychiatry and Behavioral Sciences, Rush University Medical Center.

Address correspondence to Lindsey Matt, PhD, UCLA, 924 Westwood Boulevard, #1040, Los Angeles, CA 90095; email: lmatt@mednet.ucla.edu.

Disclosure: The authors have no relevant financial relationships to disclose.

10.3928/00485713-20200916-01

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