Military Sexual Trauma: Treatment options

1. Military Sexual Trauma: Treatment options Lori R. Daniels, Ph.D., LCSW Military Sexual Trauma Psychotherapist Portland Vet Center, Portland, OR

2. All statements made are strictly the presenter’s and do not reflect the thoughts, opinions, nor policies of the Dept. of Veterans Affairs. • Acknowledgements: numerous researchers whose work is cited in this presentation; MST resources provided by the DVA for use in community presentations/information.

3. Gender differences – Problems post deployment MALES FEMALES • Can express anger • Are not expected to continue previous domestic duties • Have a larger support network (more men) • Are assumed to be veterans • Cannot express anger the same way – not acceptable • Are expected to return to previous domestic duties without problems • Have a very limited social support network (less women) • Are not assumed to be veterans (@ vet gatherings)

4. Military Sexual Trauma (MST) • Defined: Physical assault of a sexual nature, battery of a sexual nature, or sexual harassment….repeated, unsolicited verbal or physical contact of a sexual nature which is threatening in character… that occurred while a veteran was serving on active duty or active duty for training. - (Title 38, US Code 1720D)

5. Not in today’s military?(How common is MST?) FEMALES • Sexual harassment 54%; Sexual assault 3% • (Annual rates; DoD, 2002) • Sexual harassment 60%; Sexual assault 23% • (Anytime during service; Street et al., 2003) • Sexual harassment 55%; Sexual assault 23% • (Anytime during service; Skinner et al., 2000) MALES • Sexual harassment 23%; Sexual assault 1% • (Annual rates; DoD, 2002) • Sexual harassment 27%; Sexual assault 3% • (Anytime during service; Street et al., 2003)

6. CST and MST Civilian Sexual Trauma Military Sexual Trauma • 24% of women experience sexual trauma (13-30%) • 10% of men experience sexual trauma(3-16%) • 55-70% are sexually harassed (21 studies; Goldzweig et al., 2006) • 11-48% are assaulted • 55% of women experience sexual trauma • 14% of men experience sexual trauma

7. Why is sexual trauma higher in the military? (Katz, 2009) • Military training in aggression • High concentration of males and females ages 18-40 • High use of alcohol • Victims and perpetrators may have pre-military abuse or dysfunctional families • Victims are a “captive audience” • Therefore – it’s a pressure cooker

8. CST (Civilian) vs. MST (Military) • Military culture of camaraderie • Victims continue to live among the perpetrator within a unit or battalion or duty station • Fear of reporting (no-win) • Two methods – restricted and non-restricted

9. Victims are left feeling confused • “Was it rape?” • “Was it my fault?” • “Will anyone believe me?” • “Will I be blamed, labeled, ostracized?” • “If I report it, will it ruin my career?” • “Everyone else likes (the perpetrator), so what will they think of me?” • “I’m not sleeping at night, am constantly scared, can’t trust others, and wanting everyone to leave me alone.” (Katz, 2009)

10. Symptoms after MST • 4x more likely to develop PTSD than for those who experience combat stress only • 3x more likely to be depressed than combat stress only • 2x more likely to abuse substances than combat stress only • Assoc with obesity, eating disorders, heart attacks, chronic pain and increased medical conditions across all systems • Diffic keeping jobs; involvement with abusive relationships - homelessness

11. MST survivors with PTSD: • Obsessive thinking about how it should have been (incident) • Self-blame and/or elevated level of responsibility • Fixation on controlling environment and symptoms • Lack of trust in self/others • Victim paradigm • Nightmares (threatening)

12. MST survivors with PTSD: • Waiting for next bad thing • Interpersonal conflicts • Difficulties communicating • Problems with intimacy & attachment • High tolerance for dysfunctional relationships • Hyper sexual (men: to prove masculinity) or non sexual (too many associations with trauma)

13. Male mst: Contributing issueS

14. MST+ Masculinity = HUGE Conflict • Sexual Trauma evokes everything that masculinity rejects: • Fear • Shame • Vulnerability • Helplessness/submission • Intense, inescapable emotions

15. Gender Identity Concerns • Rape Myth: Real Men Don’t Get Raped So, if a male is raped, normal male gender identity is no longer an option ...Conclusion: “If I was raped, I can’t be a real man”

16. Male Attributions of Self-Blame It happened because… I gave off some gay signal I was too effeminate I was too trusting/eager to make friends I was being punished for being gay I was physically weak-- I should have been heavier, stronger, bigger, etc.

17. Sexual Identity Concerns • Rape Myth: Male Rape is Homosexual Sex So if I was raped… • “Am I gay?” • “I must be gay.” • “I am gay and I can’t face it.”

18. Barriers to Help Seeking • Little public awareness • Stigma • Male identity/values: Weak and unmanly to… • Be victimized • Need help • Seek help • Talk about victimization • Share vulnerable feelings

19. Male survivors do take risks, but often…. (common Responses to disclosure to non-MST therapists) • “Are you gay?” • “Why didn’t you fight him off?” • “You’re not a real man.” • “I don’t want to have anything to do with you.” • “Don’t tell anyone, and it will eventually disappear.” • Silence, denial

20. Treatment • Individual psychotherapy focusing using a mixture of client-centered, insight-oriented, emotion-focused,interventions: Integrative Therapy • Including: therapeutic processing of traumatic memories; • Psychoeducation: sleep hygiene; relationship counseling; substance abuse treatment; • group psychotherapy; • medications

21. But, evidence-based psychotherapy treatments; where do they fit? Evidence exists in many forms.

22. Given the issues presented by an MST client… Betrayal, mistrust, difficulty with relationships, fear of disclosure, shame/guilt, detachment from full range of emotions, low self-esteem… Are technique-focused psychotherapy interventions the best choices for complex issues?

23. Integrative Psychotherapy • Converges different solutions with evid-based with different problems requirements; • Consistently identifies new ways of conceptualizing and conducting psychotherapy that go beyond confines of a single school of intervention/theoretical orientation; • “meta-psychology”: does not offer ONE model of psychopathology or theory of personality, therefore does not limit mechanisms through which psychotherapy works • Embraces therapeutic value of many systems of psychotherapy • Posits that many tx methods have valuable place in repertoire

24. GESTALT THERAPY • CLIENT-CENTERED THERAPY • EXISTENTIAL THERAPY • EXPOSURE TECHNIQUES • EMOTION-FOCUSED THERAPY • Trauma focus • Responsibility (Scurfield; Kubany) • PSYCHOEDUCATION: Relationships, sleep/nightmares, communication • SOCIAL SUPPORT • ETC.

25. Common factors in therapy • Outcome in psychotherapy might be due to factors that all therapies have in common, i.e., characteristics of therapists, resources of the client, potency of therapeutic relationship (versus techniques specific to theoretical orientation. (Rosenzweig, 1936); Dodo Bird conjecture • Even therapies based on radically different values show similar affect sizes in terms of successful outcome, in studies utilizing varying outcome measures. • Variance in outcome is attributed to therapeutic factors = 30%; variance attributed to techniques = 15%; expectancy fracture (placebo) = 15%. (Lambert, 1992) • Evidence strongly supports a contextual versus a medical model of therapy in which specific ingredients are important only as aspects of the entire healing context (Wampold, 2001, p. 217).

26. “Common factors research”: • Upholds RELATIONSHIP, as opposed to techniques, as the core facilitative agent of change. (Wampold, 2001) • Therapeutic alliance support (Hovarth, 1995) • Rapport and empathy (Bohart & Greenberg, 1997) • Client’s capacity for self-healing (Bohart & Tallman, 1999) • Expressed emotion (Gendlin, 1996; Greenberg, Rice, & Elliott, 1993)

27. Integrating: Gestalt • Gestalt: manner of relating and the execution of techniques must be tailored to each patient’s needs, not to diagnostic categories… Therapy will be ineffective if the patient is made to conform to the system rather than the system adjust to the patient… • Mechanisms of gestalt include: • Focusing techniques that allow attention to be on the experience of the client and therapist; here and now; key moments: interruptions of process, build pt’s capacity to work through emotions. • Enactment via role-playing, psychodrama, empty-chair • Body Awareness, breathing; • Loosening thinking – alternative possibilities; putting words to sensations.

28. Evidence: • Gestalt: randomized-control studies not necessarily fit for measuring gestalt techniques; • Experiential therapies which overlap with gestalt, process-experiential (directive): more effective than either pure client-centered approach or cognitive and behavioral treatments. (Greenberg, Elliott, and Lietaer, 1994); empty-chair technique effective in resolving unfinished emotional issues with signif others (Greenberg, 1982; Greenberg & Dompierre, 1981; Greenberg & Higgins, 1980, Paivio & Greenberg, 1992). • Research relevant for gestalt needs to account for importance of therapeutic relationship • Gestalt has wide range of interventions, therefore more diff to study quantitatively in terms of clinical practice.

29. Review of data from 74 published research studies on tx process and outcome; tests of efficacy on data for approx 4500 patients treated in clinical practice; 3000 treated with gestalt, 1500 control Ss; multiple dx; • Discusses comparisons conducted by Elliott (2001; 2004) and suggests that relative to # of measurements used, signif results were found more freq for humanistic therapies than behavioral and psychodynamic. Effects largest for gestalt therapy with symptoms of depression, anxiety and phobias (Strumpfel, 2006); • Effectiveness of gestalt in areas of social /relations/interpersonal functions; marked improvement in establishing personal contact, sustaining relationships, and managing aggression/conflicts (Strumpfel, 2004, 2006); • Meta-analysis, experiential confrontation (focus) process in session is strong predictor for positive therapeutic outcome (Orlinsky, Grawe, and Parks, 1994).

30. Integrating: Client-centered • Therapist provides unconditional positive regard and empathic understanding of client’s expressions from viewpoint of the internal frame of reference of the client (Rogers, 1957, 1959b); opposite: un-genuine; client’s perception of therapist’s congruence = effective or ineffective therapy; • Non-directiveness: Tx recognizes client’s presentation, accepts this, does not provide answers ore reassurance; client is regarded as the best ‘expert’ • By attending to and understanding a client’s narrative, it validates the subjective context – which can strengthen this context and allow future access (Zimring, 2000).

31. Treatment Foci • Creating a space • to build trust • Where survivor can be ‘safe’ • To disclose and process changes since traumatic event • To feel comfortable and not judged

32. Treatment Foci • Educating about sexual assault responses that are to be expected (PTSD sx) • Process underlying “stuck” issues • Issues of self-blame • Staying in reality • Addressing distorted schemas of “I could have stopped this from happening (to me)”