# Presentation: 371864

## Mental Health & Women in the Military: Promoting Social Acceptance and Inclusion

**www.promoteacceptance.samhsa.gov**

**Mental Health & Women in the Military: ****Promoting Social Acceptance and Inclusion**

**August 6, 2008**

## Contact Us

**www.promoteacceptance.samhsa.gov**

**SAMHSA ADS Center**11420 Rockville PikeRockville, MD  20852
*Toll free*:**  1-800-540-0320***Fax*:**  240-747-5470***Web*:**  www.promoteacceptance.samhsa.gov***E-mail*:**  promoteacceptance@samhsa.hhs.gov**

**Contact Us**

*The Moderator for this call is ****Holly Reynolds Lee****.*

## Disclaimer

**www.promoteacceptance.samhsa.gov**

**Disclaimer**

***The views expressed in this training event do not necessarily represent the views, policies, and positions of the Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, or the U.S. Department of Health and Human Services.***** **

## Questions?

**www.promoteacceptance.samhsa.gov**

**Questions?**

- At the end of the speaker presentations, you will be able to ask questions. You may submit your question by pressing ’01’ on your telephone keypad. You will enter a queue and be allowed to ask your question in the order in which it was received. On hearing the conference operator announce your name, you may proceed with your question.

## Speakers

**www.promoteacceptance.samhsa.gov**

**Speakers**

**A. Kathryn Power, M.Ed**
- A. Kathryn Power, M.Ed. is Director of the Center for Mental Health Services (CMHS), Substance Abuse and Mental Health Services Administration (SAMHSA), an operating division of the US Department of Health and Human Services (DHHS). CMHS provides national leadership in mental health promotion, mental illness prevention, and the development and dissemination of effective mental health services. Director Power leads a staff of 126 professionals in facilitating the transformation of our nation's mental health care system into one that is recovery-oriented and consumer-centered.
- Director Power served on the Department of Defense Task Force on Mental health which submitted a report to Congress on the needs and recommendations related to mental health care of services members.
- Director Power received her Bachelor’s degree in education from St. Joseph’s College in Emmitsburg, Maryland, and her Master’s degree in education and counseling from Western Maryland College. She recently retired from her position as a Captain in the U.S. Navy Reserve.

## Speakers

**www.promoteacceptance.samhsa.gov**

**Speakers**

**Bryanne Moore**
- Ms. Moore is currently assigned as an  augmentee to the US Army Reserve Command (USARC), redeploying from Baghdad, Iraq where she worked under the Multi-National Security Transition Command- Iraq (MNSTC-I) as the public affairs Non-Commissioned Officer in Charge. Her other assignments include broadcast journalist with the 356th Broadcast Operations Detachment, drill sergeant with the 80th Division’s (IT) Company D, 4th/318th MP BN and 2nd/317th REGT BCT, as well as a public affairs specialist with the 214th MPAD under the 99th RRC out of Fort Belvoir. Through her Reserve training and assignments, she has worked with her units and others at Fort A.P. Hill, Fort Belvoir, Fort Gordon, Fort Indiantown Gap, Fort Benning, McEntire Joint National Guard Station, Fort Pickett, Fort Knox, and Fort Jackson as both a drill sergeant and a public affairs specialist.
- Ms. Moore has received numerous medals and awards. She holds a Bachelor of Arts in sociology with double minors in leadership studies and political science from Mary Baldwin College. She is currently working toward her Masters of Arts in leadership studies from George Mason University.

## Speakers

**www.promoteacceptance.samhsa.gov**

**Speakers**

**Constance (Connie) Walker**
- Constance (Connie) Walker retired from the Navy in 2005 as a Captain with over 22 years of military service.  Areas of expertise in Human Resources include strategic planning, policy, budget development, and intra and interagency coordination to develop and implement personnel recruiting and retention strategy and policy and program development and implementation of Navy-wide Employee, Family Assistance, and Retiree Programs. She holds a Master of Science degree in Education from Old Dominion University and has completed graduate work in clinical psychology at the Citadel.  She has served on the Science Advisory Board for the VA’s Mental Illness Research, Education, and Clinical Center (MIRECC) in the National Capital Region (VISN-5).  In 2006 she developed support for a three county regional affiliate for the National Alliance on Mental Illness in southern Maryland, and now serves as the President of NAMI Southern Maryland with an eleven member Board of Directors. Her education, professional expertise, and experience – as a Veteran and parent of a 100% disabled Operation Iraqi Freedom Veteran – inform her advocacy for expanded access to and improved mental health treatment and rehabilitative services for veterans returning to rural areas, mental health care reform, and improved vocational rehabilitation, education, and employment services to individuals diagnosed with mental illnesses.

## Speakers

**www.promoteacceptance.samhsa.gov**

**Speakers**

**Colonel Elspeth Cameron Ritchie, MD, MPH**
- Colonel Ritchie  is the Director of the Proponency of Behavioral Health at the Office of the US Army Surgeon General. She trained at Harvard, George Washington, Walter Reed, and the Uniformed Services University of the Health Sciences. Her assignments and other missions have taken her to Korea, Somalia, Iraq, and Vietnam. An internationally recognized expert, she brings a unique public health approach to the management of disaster and combat mental health issues. She has published numerous articles on forensic, disaster, and military operational psychiatry. In 2005, Colonel Ritchie received the William Porter and Bruno Lima awards. Her textbook, "Mental Health Interventions for Mass Violence and Disaster" was recently published by Guilford Press. Military Medicine published her supplement on Humanitarian Assistance and Health Diplomacy: Military-Civilian Partnership in the 2004 Tsunami Aftermath. She is currently the senior editor on a forthcoming text on Combat and Operational Mental Health.

## 

A, Kathryn Power, M.Ed.
Director, Center for Mental Health Services

*A, Kathryn Power, M.Ed.*
*Director, Center for Mental Health Services*

## A history of women in the military

- Women were the vanguard of today’s all volunteer force.
- More than 2.5 million women have served in the U.S. military since the American Revolution.
- Roughly 400,000 women served in noncombat jobs at home and overseas during World War II.
- More than 90,000 women have served as fighter pilots, medics, military police, and in other positions since September 11, 2001.
- Women veterans are younger than their male counterparts, fairly well educated, and increasingly come from ethnic and racial minority groups.

## The changing face of the military

- More than 200,000 women are serving in the Armed Forces.
- About 11 percent of the U.S. forces currently serving in Iraq and Afghanistan are women.
- Overall, women represent:
- 15 percent of the active duty force
- 20 percent of new military recruits
- 17 percent of National Guard and Reserve forces
- By 2010, 14 percent of all veterans will be women.

## Women serve in harm’s way

- The lack of a front line means the soldiers can face dangers anywhere.
- Medical advances now allow soldiers to survive catastrophic brain injuries, spinal cords injuries, and wounds that once would have been fatal.
- “*Female service members in combatant areas have had to fight the enemy in the same manner as their male counterparts: engaging in firefights, taking prisoners, and possibly becoming causalities*.”
- 	– U.S. Department of Defense (DOD) Task Force on Mental 	Health

## Exposure to war zone trauma in Iraq

** **Seeing dead bodies or remains		94-95%
-  Handling or uncovering remains		50-57%
-  Seeing dead/seriously injured Americans	65-75%
-  Knowing someone killed/injured		86-87%
-  Seeing ill/injured women & children		69-83%
- – From Hoge et al., *New England Journal of Medicine,* 2004

**Notes:**
Mental disorders are one of the top three conditions that lead veterans to seek care from the DVA, Antonette Zeiss, Ph.D., Deputy Chief Consultant in the Office of Mental Health Services at the VA Central Office. Post Traumatic Stress Disorder (PTSD) is by far the most common diagnosis. Veterans also come in complaining of depression, anxiety, mood disorders, sexual dysfunction, and substance abuse.  [from SAMHSA News May/June 2006].

Note: 30.9% MH statistic was pulled from Returning Vets Conference presentation.

## Mental health problems are common

- Depression is one of the top three problems for women veterans treated by the U.S. Department of Veterans Affairs (VA).
- In 2007, the VA diagnosed 60,000 veterans with posttraumatic stress disorder (PTSD). Of those, 22 percent of women suffered from military sexual trauma (MST), compared with 1 percent of men.
- Among women veterans treated at the VA Women’s Comprehensive Healthcare Center in Los Angeles, *60 percent* of those who experienced MST had a diagnosis of PTSD.

## Military sexual trauma must be addressed

- The law defines sexual trauma as “sexual harassment, sexual assault, rape, and other acts of violence.”
- National surveys suggest that from 13 to 30 percent of women veterans have experienced rape during their military service.
- Only 16 percent of rapes that occur in this country are ever reported.
- Women service members may fear reporting sexual trauma for fear of retribution.

## Sexual trauma can be devastating

- According to the VA, the after affects of sexual trauma can include:
- Avoidance of places or objects that recall memories of the traumatic incident
- Feelings that something is missing or not right
- Depression, alcohol, and or substance abuse
- Suicidal thoughts
- Recurring and intrusive thoughts and dreams
- Non-specific health problems
- Relationship problems

## Service women and men fear getting help

- Only half of returning veterans with symptoms of PTSD or depression seek help (the Rand study).
- Barriers for women include:
- They feel they need to show emotional strength.
- They may not think of themselves as veterans.
- They may not associate trauma symptoms with military service.
- In the case of MST, women may not seek help because they fear embarrassment, retribution, lack of career advancement, or dishonorable discharge.

## DOD Task Force on Mental Health

- The Task Force Vision:
- A *culture of support for psychological health *will be created and fostered.
- Service members and their families will* receive a full continuum of excellent care*.
*Sufficient and appropriate resources will be allocated* to prevention, early intervention, and treatment.
- At all levels, *visible and* *empowered leaders* will advocate, monitor, plan, coordinate and integrate prevention, early intervention, and treatment.

## Building a culture of support

- Discrimination, prejudice, and fear prevent individuals from getting help for mental health problems.
- These attitudes interfere with:
**Access** **to care**, because individuals refuse to seek treatment
**Quality** **of care**, because individuals seek care that may not be evidence-based
**Continuity** **of care**, because individuals may not inform military medical personnel of prior mental health treatment

## Addressing three barriers to care

**Public** (mis)perceptions of individuals with mental illnesses
**Individuals’** perceptions of themselves
**Institutional** policies or practices that unnecessarily restrict opportunities because of psychological health issues

## Combating public perceptions

- DOD recommendation 5.1.1.1: The Department of Defense should implement [a] public education campaign, using evidence-based techniques to provide factual information about mental disorders.
- “The message must be clear to all: building and maintaining resilience through assertive, early interventions in times of stress are crucial to the health of service members and their families and to force readiness.”

## Combating individual perceptions

- Embed mental health professionals into military units to help increase familiarity with mental health professionals and offer easy access to help.
- Integrate mental health providers in primary medical care settings, where mental health issues are often first raised.
- Ensure an easily accessible, full continuum of evidence-based care.  Help must be available when service members or family members reach the point where they recognize they need help.

## Combating structural roadblocks

- The Task Force made several recommendations designed to refine the balance between the need to encourage service members to seek help and the need for command to maintain force readiness.
- “Building a first-class system for supporting psychological health is a necessary condition for change, but it will not be sufficient if [discrimination, prejudice, and fear are] allowed to persist.”

## SAMHSA activities in support of veterans

- In March 2007, SAMHSA convened a national conference on the behavioral health needs of returning veterans and their families, which was attended by more than 1,000 people.
- This year’s conference, “Paving the Road Home: The National Behavioral Health Conference and Policy Academy on Returning Veterans and Their Families,” will be held August 11-13 in Bethesda, MD.
- The August conference is co-sponsored by SAMHSA, DOD, and the VA, together with NASMHPD and NASADAD.

## Additional SAMHSA activities

- Added a feature to the National Suicide Prevention Lifeline so callers can identify themselves as veterans and be connected to VA professionals; call 1-800-273-TALK (8255) and press 1
- Established a Workgroup on Returning Veterans and Their Families to increase access to timely support and treatment
- Updated resources for Returning Veterans and their Families: _[www.samhsa.gov/vets/index.aspx](http://www.samhsa.gov/vets/index.aspx)__ _
- Identified veterans as a priority population for many SAMHSA grants

## Additional SAMHSA activities

- A previous ADS Center teleconference, “Reducing Stigma for American Military Personnel,” at _[www.promoteacceptance.samhsa.gov](http://www.promoteacceptance.samhsa.gov/)_
- A forthcoming Participatory Dialogue Meeting on the Mental Health of Veterans of Iraq and Afghanistan
- SAMHSA resources for coping with traumatic events at _[www.samhsa.gov/trauma/index.aspx](http://www.samhsa.gov/trauma/index.aspx)_
- The National Center for Trauma-Informed Care at _[http://mentalhealth.samhsa.gov/nctic](http://mentalhealth.samhsa.gov/nctic)_
- The Campaign for Mental Health Recovery at _[www.whatadifference.samsha.gov](http://www.whatadifference.samsha.gov/)_

## Our hope for the future

*“**Sometime they’ll give a war and nobody will come.”*
- – Carl Sandburg
- In the meantime, SAMHSA and its Federal partners—including  DOD and the VA—stand ready to help.

## Personal Story

**www.promoteacceptance.samhsa.gov**

**Personal Story**
**By:**
**Bryanne Moore**

## Personal Story

**www.promoteacceptance.samhsa.gov**

**Personal Story**
**By:**
**Connie Walker**

## Women Warriorsand Army Behavioral Health 2008 

** **

- COL Elspeth Cameron Ritchie, MD, MPH
- Elspeth.Ritchie@us.army.mil

- Unclassified

## The Context: A Brief History of Psychological Reactions to War

**The Context: ****A Brief History of Psychological ****Reactions to War**

- World War I--“shell shock”
- World War II-- “battle fatigue”, 3 hots and a cot
- The Korean War---
*Principles of “PIES” (proximity, immediacy, expectancy, simplicity)*
- Vietnam
- Post Traumatic Stress  Disorder
- Desert Storm/Shield
- “Persian Gulf illnesses”, medically unexplained physical symptoms
- Operations Other Than War
- Combat and Operational Stress Control
- frontline front line mental health treatment
- 9/11
- “Therapy by walking around”

## Operation Enduring Freedom/Operation Iraqi Freedom

**Operation Enduring Freedom/****Operation Iraqi Freedom**

- Numerous stressors
- Multiple and extended deployments
- Battlefield stressors:
- IEDs, bodies, killing
- Medical
- Severely wounded Soldiers, injured children, detainees
- Changing sense of mission
- Strong support of American people
- High sense of purpose for medical personnel
- Increasing isolation of career Soldiers from society

## Women at WarPast

**Women at War****Past**

- Increasing numbers of females to 15%
- Combat support, combat service support
- Past Issues:
- Reproduction
- Pregnancy
- Breast-feeding
- Gynecology
- UTIs
- Dehydration
- Mothering
- Managing children
- Mental Health

## Women at WarPresent

**Women at War****Present**

- Serve in all locations
- Heavily deployed
- Present Issues:
- Reproduction
- Pregnancy
- Breast-feeding
- Gynecology;
- The theater is clean!
- Hand washing stations
- Portopotties
- Mothering
- Mental Health
- Wounded Soldiers

## Mental Health Advisory Teams 

**Mental Health Advisory Teams **

- MHATs have consistently shown that 15-20% of Soldiers from BCTs in Iraq are experiencing mental health symptoms.
- Key Findings from annual data collection:
- 2003:  Identified problems with distribution of behavioral health resources
- 2004:  Many of the recommended  changes had been implemented
- 2005:  Identified that longer deployments and repeated deployments were associated with higher rates of mental health symptoms
- 2006:  Repeated deployments and longer deployments again confirmed to be associated with higher rates of mental health symptoms

## Data relatively consistent from OIF I to OIF 05-07.
Findings from the WRAIR Land Combat Study indicate that these rates may increase further at 6 and 12 months post-deployment. 

- Data relatively consistent from OIF I to OIF 05-07.
- Findings from the WRAIR Land Combat Study indicate that these rates may increase further at 6 and 12 months post-deployment.

**Mental Health Status of Soldiers**** and Marines**

## Soldier Multiple Deployments

- Findings from the WRAIR Land Combat Study indicate that Soldiers’ mental health status does not “re-set” prior to deploying to Iraq a second time.
- Soldiers deployed to Iraq more than once were more likely to screen positive for a mental health problem than first-time deployers.

## Stigma Toward Mental Health Care

-   Stigma among Soldiers towards using behavioral health care is relatively stable over time.

**Stigma prevents Soldiers from Using Mental Health **
**13% of ALL Soldiers and 7% of ALL Marines reported being interested  in receiving help for a stress, emotional, alcohol or family problem.**
**Only 42% of Soldiers who screened positive for a mental health problem sought help from a behavioral health provider, primary care provider or chaplain. **

**I would be seen as weak**

**My unit leadership might treat me differently**

**It would harm my career**

**Members of my unit might have less confidence in me**

## Mental Health Issues for Women 

**Mental Health Issues for Women **

- Rates of anxiety and depression comparable between men and women on MHATs
- 13% in men, 12% in women
- Women have less combat exposure but still very high rates of exposure to traumatic events
- Increasing rates of divorce in enlisted women
- Numbers who suicide are increasing
- Firearm proximity
- Changing roles
- Mothers
- Grandmothers
- Care givers and receivers

## Prevention/Treatment in Theater

**Prevention/Treatment in Theater**

- Combat stress control
- Over 200 mental health providers in Iraq
- Prevention
- Restoration
- Medication
- Clarity of use of psychiatric medications for deployment
- Health Affairs  Policy Nov 06
- Army guidelines Apr 07
- SSRIs
- Psychotherapy
- Cognitive-behavioral therapy (CBT)
- Virtual reality therapy
- Exposure therapy
- Battlemind training modules
- www.Battlemind.org
- www.behavioralhealth.army.mil

## Pre and Post Deployment Programs 

**Pre and Post Deployment Programs **

- Deployment Cycle Support
- Pre, during, post
- Post Deployment Health Assessments
- Education, training for Soldiers, leaders, Families
- Battlemind training modules
- www.Battlemind.org
- www.behavioralhealth.army.mil
- www.pdhealth.org
- Military One Source
- Integration of Counseling Activities
- Behavioral Health, Chaplains, Installation
- Behavioral Health Clinics
- Strained, especially at Ft. Hood, Alaska, Ft. Drum, Europe

## Other Issues  

**Other Issues  **

- Treatment
- Many effective treatments for PTSD, anxiety, depression
- Liaison with the VA
- Numerous collaborative activities in education and patient care
- Transition to care principal focus of DoD-VA Mental Health Work Group
- Community based health care organizations (CBHCOs)
- Warrior Transition Units (WTUs)
- Telepsychiatry support
- Graduate Health Education strong
- 2 Psychiatry, 4 psychology programs, Master’s Program in social work
- Traumatic Brain Injury, increased screening and education in place

## More information

**www.promoteacceptance.samhsa.gov**

**More information**

**For more information, contact: **
- A. Kathryn Power: kathryn.power@samhsa.hhs.gov
- Bryanne Moore: _bryanne.moore@us.army.mil _
- Connie Walker: walkerca@md.metrocast.net
- Colonel Elspeth Cameron Ritchie: elspeth.ritchie@us.army.mil

## Resources

**www.promoteacceptance.samhsa.gov**

**Resources**

- Center for Women Veterans: http://www1.va.gov/WOMENVET/
- “Questionnaire for Security Clearances Revised” (May 1, 2008)
- http://www.defenselink.mil/releases/release.aspx?releaseid=11886
- Half of Us: http://www.halfofus.com/
- Lioness The Film: http://www.lionessthefilm.com/
- “Report to the Appropriations Committee of the U.S. House of Representatives in response to House Appropriations Report No. 110-186, accompanying Public Law 110-161, The Consolidated Appropriations Act, 2008”** **http://www1.va.gov/health/docs/Hospital_Quality_Report.pdf

## Survey

**www.promoteacceptance.samhsa.gov**

**Survey**

- We value your suggestions. Within 24 hours of this teleconference, you will receive an e-mail request to participate in a short, anonymous online survey about today’s training material.  Survey results will be used to determine what resources and topic areas need to be addressed by future training events. The survey will take approximately five minutes to complete.
- Survey participation requests will be sent to all registered event participants who provided e-mail addresses at the time of their registration. Each request message will contain a Web link to our survey tool. Please call **1-800-540-0320** if you have any difficulties filling out the survey online. Thank you for your feedback and cooperation.
- Written comments may be sent to the Substance Abuse and Mental Health Services Administration (SAMHSA) ADS Center via e-mail at promoteacceptance@samhsa.hhs.gov.