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MST: Military Sexual Trauma S Presenters Myla Haider is a former criminal investigator, counselor, advocate, writer, and survivor of Military Sexual Trauma (MST). She served in the U.S. Army and deployed to Bosnia, Afghanistan, and Iraq. As an Army CID agent she worked MST cases involving both male and female victims. She testified against her own offender in 2005 and was subsequently discharged from the military without benefits after nearly ten years of honorable service. Ms. Haider spent five years appealing her discharge and was finally medically retired in 2010. Ms. Haider has briefed members of Congress on systemic investigative deficiencies associated with MST and written articles about MST investigations published in the journal "Sexual Assault Report." She currently operates a peer counseling program for MST and combat-related PTSD through Coffee Strong, a G.I. coffee house outside of Fort Lewis, Washington, and continues to advocate and write about MST and realistic improvements to the DoD system. Elizabeth Stinson: LMFT licensed in California and Oregon, with a private practice in Portland, OR. Elizabeth has extensive experience working with survivors of abuse and torture. Elizabeth is a Marriage and Family Therapist who provides MST trainings and counseling for clinicians throughout the United States. Her extensive clinical work with trauma and sexual assault survivors includes returning veterans and military members. In her role as an advocate for human rights, civil liberties and trauma recovery, She established the military trauma committee of the Bay Military Law Panel of the National Lawyers Guild and is a clinical member of ISTSS, AAMFT & OAMFT. In January of 2011 she was invited to participate in a VA arranged think tank of MST and to present in a veterans administration workshop in Vancouver, WA on the impact of military sexual trauma on the veteran and their families and community. email@example.com & 503 327-1772 S Military Sexual Trauma (MST) • Military Sexual Trauma (MST) is sexual assault and/or harassment in a US military setting. Either the victim or the perpetrator can be a member of the military. Often, both parties are service members. MST can occur stateside or abroad. Sexual Trauma is unique in a military setting both during peacetime and war for several reasons including: • Survivors of MST commonly live and work with their perpetrators, during and after their trauma. • Many survivors are dependent on, or report to their perpetrators. This power dynamic makes it difficult to report for fear of retribution. Sexual assault by a superior is commonly called “Command Rape.” • A survivor, male or female, faces serious stigmas for reporting assault or harassment. They may not be trusted by their counterparts, and are often accused of breaking unit cohesion or are harassed by others for sexual favors. • A survivor’s military career may be extremely affected when they report harassment and/or assault. The stigmatization that happens after reporting Command Rape and other forms of MST often lowers the possibility of advancement in rank. Survivors have been encouraged to remain silent to keep their career. A Public Health Issue • Sexual assault and harassment have only been documented in the Armed Forces since 1988. • Military sexual trauma has been directly correlated to the development of PTSD and numerous mental health concerns such as anxiety, depression and substance abuse. “Violence against women choosing to serve in the Armed Forces is a public health concern. Women who are raped or assaulted while on active duty are more likely to report chronic health problems, prescription medication use for emotional problems, failure to complete college, and annual incomes of less than $25,000.” –Christine Hansen (2005) Military Sexual Trauma A Spectrum of Trauma Related Problems The psychological response to MST often includes a cluster of symptoms that interfere with function. And… • The combination of sexual assault and combat exposure greatly heighten the psychological injuries in veterans of the wars in Iraq and Afghanistan. Betrayal Trauma MST is a unique form of betrayal trauma. The person who is violated is part of the same mission as the perpetrator. Is subject to the same rules under the UCMJ: Universal Code of Military Justice You may be battle buddies In many cases the perpetrator has a higher rank Needs for Psychosocial Rehabilitation Psychological response to MST can cause significant impairment in life functioning domains such as: • Family relationships • Career & Work Relationship • Interpersonal and romantic relationships • Friendships Effect MST HAS BEEN KNOWN TO SERIOUSLY IMPAIR THE ABILITY TO SELF REGULATE. CLIENTS REPORT THAT MINOR OBSTACLES AND STRESSORS ARE OFTEN PERCEIVED AS OVERWHELMING. Anxiety and the accompanying inability to self-regulate often result in some of the following symptoms and disorders following an assault and/or prolonged sexual harassment. Within Spectrum of Trauma Related Problems • Skin Picking-repeated, touching, scratching, picking or rubbing • It is thought that we are seeing more of these symptoms as a response to MST than in the civilian sector because of the need to maintain the anxiety for longer periods of time due to length and repeated deployments. Most often the anxiety response is seen in the survivor who has had little relief or support. Body dysmorphic symptoms correlate with isolation, withdrawal and agoraphobia. Anxiety Induced Disorders • Agoraphobia is an anxiety disorder that results in fear of places, crowds and/or being in places you cannot move easily and quickly from. People with agoraphobia often struggle with being in a public or crowded place. There is fear of being in a situation in which you have less control. • Your client may have to face the door of your office or be seen in their home. Public transportation is often an issue, as are family expectations. Disorders that may be related to MST: BDD- Body Dysmorphic Trichotillomania- (trick-o-til-o- Disorder MAY-nee-ah) • False perception of all or • An impulse control part of ones body, disorder in the family of causing obsessive body-dysmorphic response ie: eating disorders causing disorder, cutting, picking obsessive hair pulling or hiding (masking) from head, eyebrows or pubic region. Symptom Clusters • Symptom clusters can include: • self-hatred, • numbing, • depression, • aggressive behavior towards self or others • dissociation and depersonalization • impairment in capacity to enjoy activities and intimacies formerly found pleasurable. VA Materials State: Some Problems Associated with MST include • Disturbing memories or nightmares • Difficulty feeling Safe • Feelings of depression or numbness • Problems with alcohol or other drugs • Feeling isolated from other people • Problems with anger or irritability • Problems with sleep & Physical health problems Impulse Control Symptoms • MST is also known to stimulate Body Focused Repetitive Behaviors: BFRB’s are considered both Impulse control disorders and affect regulation disorders. The International Society of Traumatic Stress Studies also recommends in treatment of PTSD that: “Interventions should be culturally sensitive, developmentally appropriate, and related to the local formulation of problems and ways of coping” (Level- C, pg. 540) Importance of Presence & Truth Your client has been trained to be aware of his/her surroundings and to maintain a defensive position and may maintain a highly aroused and nervous emotional state. Your client may have had to maintain this emotional state for far too long. Your client may need to learn with you how to relax their symptoms and experience that relaxation and safety with you. Things to be Mindful of from a Veteran Perspective • Are you a Veteran? • If not, are you familiar with military culture and terms? • Note your office décor: • How personal is it? • Pictures? • Are there military references? • Is your office a trigger? Treatment Recommendations • The Following are Treatment recommendations based on experience treating Military Sexual Trauma survivors. Clients were both male and female who were either active duty or post-discharge from the military. Important Therapeutic Ingredients • Alliance between client and therapist. • Your MST client will bring a unique culture and need to your practice. • It is very helpful to educate yourself about the military culture. Build Your Therapeutic Alliance With Great Care • Begin with a very thorough assessment- many who are treated for MST have not been properly assessed for PTSD, depression, as well as TBI ( Traumatic Brain Injury). It is advised that you do not order tests, evaluations etc without thoroughly discussing options/procedures and locations with your client-every step of your process must have the goal of the clients recognized needs being met willingly. Clients ability to build trust will parallel building of self empowerment- MST is not about sex MST is an abuse of power • Explore meaning of safety with your client • Explore triggers • Explore clients ability to self-resource • Involve client in development of treatment plan. Therapeutic Objectives • Establish concrete but broad goals as soon as possible in union with your client. • Explore clients awareness of emotional responses-what helps and what does more damage than good and why? Work To: • Reinforce with client value of his/her narrative • Know that your are working with a survivor not a victim. • Value ALL defense systems. • Work with client to replace destructive defenses. Treatment is counterproductive if retraumatization occurs • Systematic desensitization and exposure therapy run the risk of further traumatizing the MST survivor and should be avoided. • The purpose of systematic desensitization is to demonstrate the irrationality of a fear. • Your clients fear response is rational, although exploring their emotions around their fear response when they are feeling safe can help to defuse a destructive emotional response. Self Mastery = Self Regulation • Client will have to repeatedly reprocess trauma, how and when must be up to them. • The ability to process unexpected stimulus of traumatic memory is one of the primary goals of therapy for the military sexual assault survivor • Increase in these strengths will support client increased ability to self-regulate. Imagine a Three Legged Table • Imagine your client is the surface (what happens if a 3 legged table is missing a leg?) • One of these legs is their ability to self- resource • The second leg is their family and friends • The third leg is their community resource & that includes you. Effective Treatment • ACT is new to the psychology field and based in the belief that ongoing attempts to get rid of symptoms may create more stress as well as clinical disorders. • ACT is a mindfulness-based behavior therapy, shown to be quite effective in working with survivors of trauma. • The Traumatized client often struggles with states of hyper-arousal that interfere with executive function. Why Mindfulness as Treatment for Trauma? The timing and location of neural activation directly correlates with the timing and characteristics of mental activity. There is an interconnection between brain, mind and relationship that stimulates neural firing patterns in the brain. By practicing mindful, cognitive awareness with your client you support their growing self-management. In essence you help support “their” management of “their” neural firing. What is Mindfulness? • Mindfulness is a state of “being aware”--- • It is a process of observation and attention in the flow of changing stimuli and perceptions. • Mindfulness is ‘in the moment’, present, engaged awareness. • An important characteristic of a mindful state is that it is free of judgment. Also, mindfulness is not a passive state; we apply intention when we are mindful. Building Safety in Non-Reactivity • We know that outcome and process cannot be predicted with the use of mindfulness, because mindfulness “is” the process. • By supporting your clients ability to be “present” in the moment of now with safety as their center and its “impact on their nervous system” is the needed outcome. • One of the benefits of mindfulness is the growing ability to self-regulate. This practice supports your clients ability and sense of self-mastery. How to Practice Mindfulness in Session • There are a number of ways to practice mindfulness in the session • One way is to focus on breathing- • Ask your client to sit quietly with you and focus on their breathing • As things come to mind, ask them to name them, “simply” and then to “lay them down” with the next exhale-- psychologically putting them down and returning to focused breathing. Supporting Building of Client Self-Control • Reinforce with client the power of focus and benefit of relaxation as they slowly gain control over their thoughts and feelings. • Following breathing exercise--examine with client somatic responses- • Do a body scan- what is client feeling and where • “Pick up” or discuss what client is ready to examine that had been consciously laid down– • Honor range of feelings Mindful Breathing Exercise • Practice with them-begin by devoting 5 minutes a session to “mindful-breathing-relaxation”— • Process with your client their inner struggle to “set thoughts down”—support their growing sense of “controlled self”—the controlled self can be returned to often within session to demonstrate value of self control as mindfulness develops. • Work with your client to cultivate their own sense of well- being as they want it to develop. • . Expect Emotional Reactivity Often, when working with survivors of Abuse and Sexual harassment there is a lot of emotional reactivity to the concept and practice of “setting down” fears and pain that surface. • Your client has been spending a lot psychological energy defending themselves and has adopted a “structure”— • Initial relaxation of the structure also involves relaxation of some of the constructed defenses. In processing this-expect emotional reactivity. This is good---they are feeling something new and it is frightening--- it is the undefended self they can access to begin healing.— Mindfulness & Resilience • The work of Dr. Daniel Siegel on Mindfulness and the brain, teaches us that neuroscience studies and subjective experience of mindfulness, together demonstrate that non- reactivity and emotional balance go hand-in-hand with the fact of labeling and describing internal states. • “We learn that what before felt like an unchangeable and distressful feeling can now be observed and noted and we can come back to equilibrium more readily. This is the essence of a resilient affective style.” Tools To Explore With Your Client • Narrative Therapy: Working with the survivor’s narrative can be very effective in reframing responses to experiences when a goal is set of not feeling “defined” by the trauma. • EMDR: Eye Movement Desensitization and Reprocessing (EMDR) is effective treatment for many in reducing the “charge” felt when triggered by traumatic recall. Clinical Realities • You may hear stories about how the victim is often investigated-not the perpetrator. • Until the protocol for investigating MST is changed-this will remain an obstacle for survivors. Therapeutic Realities • Your client may be unwilling to bring charges against their perpetrator. • In military sexual trauma cases, you as the clinician cannot make any guarantees about how your client will be treated, either by the military or by either a military or civilian judicial process. Examine whether or not: • You, as their clinician can support them through their process whether they choose to report the abuse or not- Reporting Options as per DoD SAPR Restricted Unrestricted • A confidential reporting method • When a victim reports an that allows a Service Member incident of sexual assault, the disclose to specified officials that matter is referred for he or she has been the victim of a investigation and victim‘s rights sexual assault. apply. • Victim receives access to medical • Victims may receive health care, counseling, and advocacy, care, counseling, & advocacy without requiring officials to services. However, details of automatically report to law the incident are reportable to enforcement or initiate an official command and law investigation. enforcement. When working with Military clients, please keep in mind: • Communications between sexual assault victims and Victim Advocates are afforded no privilege under military law and VA’s can be expected to testify at trials. • In contrast, thirty-five states provide a privilege for communications between a victim and a Victim Advocate. • The absence of a privilege can limit the effectiveness of Victim Advocates in the military community. • In addition, privilege does not exist between medical personnel and the Chain of Command Reservists When the assaulted person is a member of a “reserve unit” local law enforcement authorities can and should be notified. Sexual Assault Response Coordinators • There is not privilege between a SARC and a victim • It is the role of the SARC to advocate on behalf of the victim; however often this position is a collateral duty • DSARC in CAI: Combat Areas of Interest Client Is a Member of a System • A client emotionally supported is less likely to self-medicate destructively. • Help your client assess their family, social and work relationships. • You may want to explore client’s function level prior to service in order to establish appropriate therapeutic goals. The Power of Resiliency • Your clinical awareness of their experience coupled with their understanding their response to their experience can help them examine their “self expectations”. • Celebrate the fact that they are resilient enough to be in front of you. They could have made different choices in their response and they may have considered many more destructive ones. You can help them recognize the power of their own responses and how healthy choices support their healing and resiliency. Expectation –vs-- Reality • Psychological distress is often the result of the experience when expectation does not match reality. • Often your client will feel defeated by the lack of understanding of their experience by friends, family and coworkers. • Support their exploration of their expectations vs. reality • By doing this often you are supporting their ability to be mindful of where they are in the “present moment.” Involuntary Flooding • MST survivors often describe experiencing ―involuntary flooding‖ -- described as a sense of overwhelm with traumatic memories accompanied by what may feel like disabling emotions • If flooding occurs in session– move into it, not away from it. • Be mindful of what the clients experience is—use guided imagery and breathing to bring your client into the present safety of the session. • Your traumatized client experiences involuntary flooding with or without you. Your Client and Medication • Often MST survivors are in need of medication in order to manage symptoms. • Know what medications your client has had and the effect • Support the transition to different medications when necessary Importance of Presence and Truth • Your client has been trained to be aware of his/her surroundings and to maintain a defensive position and may maintain a highly aroused and nervous emotional state. • Your client may have had to maintain this emotional state for far too long. • Your client may need to learn with you how to relax their symptoms and experience that relaxation and safety with you. Importance of Trust & Safety • Being a therapist does not bring automatic trust. The military is an environment in which seeking mental health is often viewed as weakness. • Pay attention to clients emotional response. • Do not pretend you know what they mean if it does not make sense to you. Ask a lot of questions. Your clients ability to answer, even the very difficult questions can help defuse the trauma. Expanding the Diagnosis & Treatment • “…over the years, it has become clear that in clinical settings the majority of traumatized treatment seeking patients suffer from a variety of psychological problems that are not included in the diagnosis of PTSD”… Bessel Van Der Kolk-The Assessment & Treatment of Complex PTSD Complex PTSD by Judith Herman-Trauma & Recovery • The main difference between • In addition to the PTSD criteria, PTSD and Complex PTSD isn’t the ‘Complex PTSD’ features many length of time the sufferer has had (but not always all) of the or symptoms, but rather the following – duration of the trauma and the difference in symptoms and their • Alterations in Affect-including: severity due to the prolonged persistent dysphoria (chronic low trauma. mood), chronic suicidal pre- occupation, self-injury, explosive • Those with Complex PTSD have or extremely inhibited anger (may usually experienced a trauma over alternate). a long term period, rather than one event or one period of time. Traumatic Spectrum Symptoms Seen In MST Survivors • Alterations in consciousness, such • Alterations in perception of as forgetting traumatic events, perpetrator, including: reliving traumatic events, or preoccupation with relationship having episodes in which one feels with perpetrator (includes detached from one's mental preoccupation with revenge) processes or body unrealistic attribution of total power to perpetrator Alterations in self-perception, which may include a sense of • Caution: Victims assessment of helplessness, shame, guilt, stigma, power realities may be more and a sense of being completely realistic than clinician’s different than other human beings Prevailing Symptoms In MST Survivors • Alterations in relations • Repeated failures of self- with others, including: protection isolation and withdrawal, disruption in intimate • Alterations in systems of relationships, repeated meaning: search for rescuer (can • Loss of faith alternate with isolation and withdrawal) • Sense of hopelessness & despair • Persistent distrust DoD SAPRO Program Department of Defense Sexual Assault Prevention & Response Office • Founded in 2005 by Congressional Mandate • Reporting options and advocates were issued to bases stateside and in CAI along with guidelines and procedures for sexual assault (SA) and sexual harassment (SH) • The Department of Defense tracks the numbers of sexual assaults reported and prosecuted each year and issues them in FY SAPR reports • The individual services vary on their SAPRO implementation • SAPRO has two main websites with two distinctly different missions: www.sapr.mil and www.myduty.mil Breakdown of Victims and Subjects In Unrestricted Reports 07-09 Among treatment recommendations: Ensure service members who report they were sexually assaulted are afforded the assistance of a nationally certified victim advocate. Ensure victims understand their rights, including the opportunity to consult with legal counsel to minimize victim confusion during the investigative process. Improve medical care for victims of sexual assault, particularly those in deployed areas. Ensure gender-appropriate care for male victims. Inform victims and service members of disciplinary actions related to sexual assault. Resources: • Organization for Military Accountability: www.militaryaccountability.com • Use the SAPRO pages for DoD reporting options and guidelines as well as to reference published reports • SWAN has a helpline! http://www.servicewomen.org/peer.asp?Field=peer1 • For up to date policy papers on MST, consult Swords to Plowshares and Iraq and Afghanistan Veterans of America (IAVA). • Veterans For Common Sense-Advocacy & Policy: http://www.veteransforcommonsense.org More Resources • For a complete list of rape crisis centers near military bases, check out Veterans For America’s link: http://www.veteransforamerica.org/woundedwarrior/mil itary-women/rape-crisis-centers . • Several community organizations have free retreats for Service Members and Veterans: check out :Vets4Vets, The Coming Home Project, and Outward Bound Care of the Advocate or Clinician Recognizing Secondary Trauma • Secondary Trauma is a reality. A good therapist cannot hear MST survivor stories without empathically feeling a great deal. • You are working with very difficult and hard to process issues. Be sure that as you take on more of this work, you also balance it with your own self-care. • Seek council when needed • Exercise, eat well, stay rested and please use what restorative measures you need to keep yourself replenished. Reconciliation • Those of you who are working with survivors of military sexual trauma are helping to strengthen and bring compassion to the country's system of psychosocial counseling, promoting much needed individual and, perhaps, national healing from this shared trauma that impacts us all. • And we thank you for your efforts.
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