Pearl Fernandes & Yvette Aiello Clinical Psychologists

1. Pearl Fernandes & Yvette Aiello Clinical Psychologists

2. Context • Seldom disclosed • "Female rape is significantly underreported and male rape almost never" (Dolan, 2014) • Male victims are let down • Not routinely assessed/ don’t ask right questions • Few services available

3. Myths • “a man who is raped becomes a woman” • “only gay men are victims of rape” • “men cannot be raped” • “male victims are to blame because real men should be able to protect themselves from any form of abuse” • “male rape does not affect men as badly as it does to the women (men are emotionally strong)” (Arnold Kwesiga, 2013) •  Possibility of criminalisation if men report being raped!

4. Combination of individual & group sessions Why Groups? • Less power imbalance • Instil courage to revisit past horror • Share experiences mutual support • Trauma isolates; groups break isolation • Tackle stigma and sense of shame

5. Initial Assessment • To identify appropriate participants • Inform about ‘MANTRA’ • Commitment to 10 sessions • Consent form • Psychometric assessment tools: MultiCASI Acknowledging sexual violence more important than willingness to share in group

6. Integrated culturally appropriate trauma informed approaches • Psycho-education • Culturally appropriate metaphors • Remembered heroes (cultural icons) • ‘Parables’ (“elephant in the dark”, “vignettes from Mahabharata and Puranas”) • Established a place of strength & calmness • Yoga: “asana & pranayama” to facilitate grounding, affect regulation & mind body connection • Mantra’s; prayers, music • Narrative Exposure Therapy (NET)

7. Timelines

8. SAM & VAM SAM (Hot): Situationally Accessible Memories VAM (Cold): Verbal Accessible Memories • Facilitated connections between “Hot and Cold memories” • A majority had survived multiple traumas since early childhood

9. “Even though we were civilians they were shooting at us from the helicopters and planes. Everyone was screaming and there was a lot of noise. I looked back and saw my mum. She had her arm stretched out. Her eyes were open The bullet fired from the helicopter had gone through her left shoulder and come out though her right breast on the other side. We tied her saree around her chest to stop the bleeding but she was dead. ”

10. “After being hung up I then had a nylon thread tied to my penis with a weight on the other end which would be brought down during interrogation causing unbearable pain. They would also beat me from behind (did whipping motion on his buttock). I am finding it hard to find the words to describe this experience.”

11. Identifying fear networks • Actual act of sexual violence and rape • Aftermath & Consequences of rape • Fear of not being believed; Male rape a culturally kept secret • Anticipatory fear • (Not mutually exclusive)

12. Rape & sexual violence Details of the actual act • Intense vulnerability • Unable to fight back • No access to medical treatment • Physical scars untreated • Shattering sense of self – emotional scars more difficult and long lasting

13. Consequences of Sexual Violence & Rape(PTSD, Depression & Anxiety) Intrusions: • “All the time the past comes up in my mind” Avoidance/ Numbing: • Dissociation, memory deficits (amnesia) • “We do not talk about our internal injuries” Alteration in arousal and reactivity: • Anger • Suicidal thoughts • Sleep difficulties Affect regulation • “Our Thinking Brain is not working. ..Every day we have a power cut. A short circuit when the body shuts down.” • Self perception: • Helplessness • Shame & Guilt • Loss of manhood • Loss of self esteem • Relationships: • Loss of trust • System of meaning & beliefs: • Hopelessness (man in the rain) • Alteration in religious beliefs • “God got the earlier boat”

14. Disbelief, Ridicule • Male rape -a culturally kept secret • Rejections from Department of Immigration • Difficulty constructing narrative in coherent manner “It is hard to explain the true situation, if people are creating a story then they can just create more details” “Having to talk about my story is terrifying. I do not know what to tell. We were not normal at that time. Are they going to believe us?” “They would look at the person in a funny way, laugh at the person. His wife or children may leave him as they will believe that he can’t protect himself so he can’t protect his family”

15. Anticipatory Fear • Fear of repatriation & imprisonment • Strong belief that if returned will be shot, tortured, imprisoned • “Would rather die than go through the same tortures” • Intense fear of rape/ torture worse than actual act • “the torture was O.K. but the fear of the next time they would take me was worse”

16. Helplessness, hopelessness & lack of control… • Suicidality • “When think of this (being returned and torture) then I think of ways to suicide” • “Can’t get any solution and always more problems; it is hard to untangle like this” • “everyone has the same problems and what is the use of talking. DIPB have not believed my case” • Anger: “When I get angry I cannot control my anger. I break anything next to me. I have broken 4 mobile phones already”

17. Group Processes • Collective experiences • Understanding reasons violence perpetrated • Able to rationalise at one level that it was because of ethnicity • Distress tolerance – diminishing sense of shame

19. Instrument of the Mind • In Sanskrit MAN = mind & TRA = instrument • Introduced & created awareness of power of self talk • Identify negative self talk • Exploring underlying schema • Reconnection & Reawakening with inner self

20. Schemas identified • I have no strength • I am incapacitated • There is no meaning in life • I am at fault • Why am I living? • I am not fully responsible but… maybe I did something to bring it on • I’m lower in society • Us Tamils are not as good as someone else • We are living a life with no meaning. Why were we born?

21. GROUP “MANTRA’S” I am not alone It is not my fault I am still a man Feeling is Healing

22. Outcomes • Observable change in physical appearance • Increased confidence • Feeling more positive about the future • Some reports of reduction in nightmares • Reduction in anxiety related to interviews • Found employment • Low drop out rate

23. MultiCASI results

24. Self reports “When coming here at first we didn’t know what to do. I relieved myself by coming here. I met all these people and my behaviour changed. Some of the stories the group told I had never heard about, it helped me to understand” “You became my family” “Since coming to sessions I have become confident to talk about my problems. I can’t say I would be able to say all this to Immigration before”

25. Self reports “Now I can talk about my problems, but I didn’t know how to talk about my problems before. First I needed the opportunity and the confidence. My brain says don’t tell anything and my mind says to tell....I feel like you are teaching a small child how to speak and finally we have started to talk.” “You have helped my mind do what my brain would not let it do”

26. Therapeutic Trajectory • Comfortable to reconstruct past & share with department • Confident to share with the departmentas well as close friends and family 3. Shift from silence & secrecy to therapeutic activism “I do not want anyone else to experience what I have been through- beaten and tortured. I like to share so others can know how to be careful” MANTRA The Movie: watch this space…

27. Explanation of outcomes • Acceptance & Empathy fostered reflection and mentalization • Contributed to insight • Subsequent affect regulation & integration • A key to therapeutic change • Gradual habituation • anxiety • intensity of emotional responses • The onset of a recovery process

28. Brain based interpretation “Your brain controls and coordinates each and every function of the body” Grey’s Anatomy • Exposure, reorganisation and integration of traumatic memories results in changes in the brain • Every breath we take corresponds to a brain wave • Focus on breath (slow breathing) activates lower brain waves and makes the brain resilient and adaptive

29. Implications To maximise Healing and Recovery from sexual violence there is a need for multilevel interventions that target: • Individual • Family • Refugee community • National & international community

30. Impact on us • Participants reported that we gave them a “voice” and “taught” them to talk about themselves • But….they often left us “speechless” as we became more aware of the brutality and cruelty of human nature –darkest side of human nature • Our ability to witness & tolerate their conflicts, distress and ambivalence was internalised by clients. • This ability is more than just validating their horrific experiences & it assisted with affect regulation • –Interpreters too requested debriefing

31. Impact on us • Feel privileged to have witnessed the courage and resilience • The awe and admiration transcends the psychological realm into a more spiritual domain • Transforms the therapeutic space by what Christians, Muslims and Sufis call God’s Love, and Hindus refer to as Shakti - the special power in the Universe - the triumph of the human spirit to survive...

32. How did we cope with the challenge of witnessing trauma so graphic and horrific? • Being “present” to listen, hold and balance perceptions and pain • Being realistic about what we could offer and clear about what we could not • Setting limits/boundaries and clearly explaining our role as therapists not ‘advocates’ • Trusting the process, ourselves and each other • Requesting trauma-sensitive consultation

33. Thank You • Clients -honesty and trust • Interpreters • Mrs. Gordana Hol Radicic • Mr. Mariano Coello

35. References • Kwesiga, Arnold (2013). Hiding my shame: the rape of men as a weapon of war in the democratic republic of Congo. East Africa Journal of Peace and Human Rights, 19(2), • Nguyen, Katie (2004). Powerful myths silence male victims of rape in war. Thomson Reuters Foundation. http://news.trust.org//item/20140515154437-het27/ • Refugee Law Project Working Paper No. 24 (2013). Promoting accountability for conflict related sexual violence against men: a comparative legal analysis of international and domestic laws relating to IDP and Refugee men in Uganda. • Dolan, Chris (2014). Into the mainstream: addressing sexual violence against men and boys in conflict. https://www.warchild.org.uk/sites/default/files/Into-the-Mainstream.pdf • Sivakumaran, Sandesh (2005). Male/male rape and the “taint” of homosexuality. Human Rights Quarterly (27); 1274-1306. • International Truth & Justice Project Sri Lanka (2016). Silenced: survivors of torture and sexual violence in 2015. https://www.tamilnet.com/img/publish/2016/01/STOP_report_3_v5.1-2.pdf