MST Military Sexual Trauma

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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. esfuture@sonic.net & 503 327-1772

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     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.