Lori R. Daniels, Ph.D., LCSW

Military Sexual Trauma Psychotherapist

Portland Vet Center, Portland, OR

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.

Can express angerAre 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)

FEMALES

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)

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)

MALESSexual harassment

23%; Sexual assault 1%◦ (Annual rates; DoD,

2002)

Sexual harassment 27%; Sexual assault 3% ◦ (Anytime during service;

Street et al., 2003)

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

Military Sexual Trauma

Military training in aggressionHigh concentration of males and

females ages 18-40High use of alcoholVictims and perpetrators may have

pre-military abuse or dysfunctional families

Victims are a “captive audience”Therefore – it’s a pressure cooker

Military culture of camaraderieVictims 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

◦ “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)

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

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/othersVictim paradigmNightmares (threatening)

Waiting for next bad thingInterpersonal conflicts

Difficulties communicatingProblems with intimacy & attachment

High tolerance for dysfunctional relationships

Hyper sexual (men: to prove masculinity) or non sexual (too many associations with trauma)

Sexual Trauma evokes everything that masculinity rejects:FearShameVulnerabilityHelplessness/submissionIntense, inescapable emotions

Rape Myth: Real Men Don’t Get RapedSo, 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”

It happened because…

I gave off some gay signalI was too effeminateI was too trusting/eager to make friendsI was being punished for being gayI was physically weak-- I should have been heavier, stronger, bigger, etc.

Rape Myth: Male Rape is Homosexual Sex

So if I was raped… o “Am I gay?”o “I must be gay.”o “I am gay and I can’t face it.”

• Little public awareness• Stigma • Male identity/values: Weak and unmanly

to…• Be victimized• Need help• Seek help• Talk about victimization• Share vulnerable feelings

(common Responses to disclosure to non-MST therapists)

o “Are you gay?” o “Why didn’t you fight him off?”o “You’re not a real man.” o “I don’t want to have anything to do with

you.”o “Don’t tell anyone, and it will eventually

disappear.”o Silence, denial

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

Evidence exists in many forms.

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?

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 worksEmbraces therapeutic value of many systems of

psychotherapyPosits that many tx methods have valuable place in

repertoire

GESTALT THERAPYCLIENT-CENTERED THERAPYEXISTENTIAL THERAPYEXPOSURE TECHNIQUESEMOTION-FOCUSED THERAPY

Trauma focusResponsibility (Scurfield; Kubany)

PSYCHOEDUCATION: Relationships, sleep/nightmares, communication

SOCIAL SUPPORTETC.

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 conjectureEven 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).

“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)

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.

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.

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).

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).

Creating a space to build trustWhere survivor can be ‘safe’

To disclose and process changes since traumatic event

To feel comfortable and not judged

Educating about sexual assault responses that are to be expected (PTSD sx)

Process underlying “stuck” issuesIssues of self-blameStaying in reality

Addressing distorted schemas of “I could have stopped this from happening (to me)”