Men and Trauma: Paths to Recovery

Roger D. Fallot, Ph.D.Roger D. Fallot, Ph.D.

Community ConnectionsCommunity Connections

Conference on Co-Occurring DisordersConference on Co-Occurring Disorders

Long Beach, CaliforniaLong Beach, California

February 8, 2008February 8, 2008

Why is Trauma so Important?

Trauma is pervasiveTrauma is pervasive Trauma’s impact is broad and diverseTrauma’s impact is broad and diverse Trauma’s impact is deep and life-shapingTrauma’s impact is deep and life-shaping Trauma, especially interpersonal violence, Trauma, especially interpersonal violence,

is often self-perpetuatingis often self-perpetuating Trauma is insidious and differentially Trauma is insidious and differentially

affects the more vulnerable, including those affects the more vulnerable, including those seeking helpseeking help

Trauma Prevalence: Community Samples

National Comorbidity Survey: 61% of men (51% National Comorbidity Survey: 61% of men (51% of women) reported at least one traumatic eventof women) reported at least one traumatic event

Detroit Area Survey of Trauma: approximately Detroit Area Survey of Trauma: approximately 90% lifetime exposure; men reported 5.3 90% lifetime exposure; men reported 5.3 traumatic events (4.3 for women)traumatic events (4.3 for women)

Other community studies consistent with these: Other community studies consistent with these: trauma is pervasive, not raretrauma is pervasive, not rare

Types of Exposure to Violence

Emotional AbuseEmotional Abuse Physical AbusePhysical Abuse Sexual Abuse and AssaultSexual Abuse and Assault Community ViolenceCommunity Violence Institutional ViolenceInstitutional Violence Witnessed Violence (may apply to any Witnessed Violence (may apply to any

of the above)of the above)

Why is Trauma so Important?

Trauma is pervasiveTrauma is pervasive Trauma’s impact is broad and diverseTrauma’s impact is broad and diverse Trauma’s impact is deep and life-shapingTrauma’s impact is deep and life-shaping Trauma, especially interpersonal violence, Trauma, especially interpersonal violence,

is often self-perpetuatingis often self-perpetuating Trauma is insidious and differentially Trauma is insidious and differentially

affects the more vulnerable, including those affects the more vulnerable, including those seeking helpseeking help

Adverse Childhood Experiences(www.ACEstudy.org)

Why is Trauma so Important?

Trauma is pervasiveTrauma is pervasive Trauma’s impact is broad and diverseTrauma’s impact is broad and diverse Trauma’s impact is deep and life-shapingTrauma’s impact is deep and life-shaping Trauma, especially interpersonal violence, Trauma, especially interpersonal violence,

is often self-perpetuatingis often self-perpetuating Trauma is insidious and differentially Trauma is insidious and differentially

affects the more vulnerable, including those affects the more vulnerable, including those seeking helpseeking help

Trauma Prevalence: People with Severe Mental Disorders

Virtually universal trauma exposure (well over Virtually universal trauma exposure (well over 90% report at least one traumatic event)90% report at least one traumatic event)

Childhood sexual abuse: 52% of women and 35% Childhood sexual abuse: 52% of women and 35% of menof men

Adult sexual assault: 64% of women and 26% of Adult sexual assault: 64% of women and 26% of menmen

Attacked with weapon in adulthood: 49% of men Attacked with weapon in adulthood: 49% of men and 37% of womenand 37% of women

Witnessed killing or serious injury: 43% of men Witnessed killing or serious injury: 43% of men and 24% of womenand 24% of women

Recent Violence Among Men with Severe Mental Disorders

In past year, 8% experienced sexual In past year, 8% experienced sexual assaultassault

In past year, 34% experienced physical In past year, 34% experienced physical assaultassault

Prevalence of Physical Abuse Among Males

Community samples: >30% Community samples: >30% Clinically-identified samples higherClinically-identified samples higher

Nearly 60% in childhoodNearly 60% in childhood Nearly 80% in adulthoodNearly 80% in adulthood Over 85% lifetimeOver 85% lifetime

Prevalence of Sexual Abuse Among Males

Community samples: 4-24%Community samples: 4-24% Clinically-identified samples:Clinically-identified samples:

Men with severe mental disorders: ~30-Men with severe mental disorders: ~30-35% in childhood and ~25% in adulthood35% in childhood and ~25% in adulthood

Male runaway youths: 38% (?)Male runaway youths: 38% (?) Almost 100% of male/boy prostitutesAlmost 100% of male/boy prostitutes

A Vicious, Repetitive Cycle

HomelessnessIncarceration

Substance Abuse

Mental Health Problems

Violence andTrauma

Why Focus on Trauma Among Men?

Exposure to different types of traumaExposure to different types of trauma Exposure to different characteristics of trauma Exposure to different characteristics of trauma

(even if trauma is same type)(even if trauma is same type) Different appraisals regarding traumaDifferent appraisals regarding trauma Different acute reactions to traumaDifferent acute reactions to trauma Different attributions about traumaDifferent attributions about trauma Different coping stylesDifferent coping styles Different trauma sequelaeDifferent trauma sequelae Different “cultures”Different “cultures”

Gender and Trauma Exposure Community samples (e.g., NCS)Community samples (e.g., NCS)

Women report more sexual assault and child Women report more sexual assault and child abuseabuse

Men report more physical assault, combat, life-Men report more physical assault, combat, life-threatening accidentsthreatening accidents

Individuals with severe mental disorders (e.g., Individuals with severe mental disorders (e.g., Mueser et al., 1998)Mueser et al., 1998) Women report more child sexual abuse and Women report more child sexual abuse and

sexual assault in adulthoodsexual assault in adulthood Men report more attacks with a weapon and Men report more attacks with a weapon and

witnessing a killing or serious injurywitnessing a killing or serious injury

Gender and Child Sexual Abuse Trauma Characteristics Women report more negative coercion Women report more negative coercion

(force and threats)(force and threats) Men report more positive coercion (rewards Men report more positive coercion (rewards

or promised rewards)or promised rewards) Women more likely to report multiple Women more likely to report multiple

victimizationsvictimizations Women more likely to report abuse by close Women more likely to report abuse by close

family memberfamily member

Gender and Trauma Appraisal

““Subjective” interpretations of trauma Subjective” interpretations of trauma rather than “objective” exposure variablesrather than “objective” exposure variables

Women report stronger sense of threat and Women report stronger sense of threat and greater loss of controlgreater loss of control

Men report higher levels of perceived Men report higher levels of perceived controlcontrol

Lower perceived control related to PTSD Lower perceived control related to PTSD riskrisk

Gender and Acute Reactions to Trauma

Women report stronger emotional responses Women report stronger emotional responses to trauma exposure: fear, anxiety, to trauma exposure: fear, anxiety, helplessness, horrorhelplessness, horror

Men report less fearMen report less fear Men report less peritraumatic dissociationMen report less peritraumatic dissociation Dissociation and hyperarousal as gender-Dissociation and hyperarousal as gender-

specific pathways to PTSD?specific pathways to PTSD?

Gender and Trauma Attributions

Women more likely to blame themselves(?)Women more likely to blame themselves(?) Women more likely to hold negative views Women more likely to hold negative views

of themselves(?)of themselves(?) Women more likely to perceive the world Women more likely to perceive the world

as dangerousas dangerous Women more likely to experience betrayal Women more likely to experience betrayal

traumatrauma

Gender and Coping Styles

Women use more emotion-focused Women use more emotion-focused strategiesstrategies

Men more action-oriented and Men more action-oriented and instrumental, including interpersonal instrumental, including interpersonal withdrawalwithdrawal

Women: “tend and befriend”Women: “tend and befriend” Men: “fight or flight”Men: “fight or flight”

Gender and Trauma Sequelae Boys more “externalizing” and girls more Boys more “externalizing” and girls more

“internalizing”“internalizing” Boys: more aggression, truancy, substance useBoys: more aggression, truancy, substance use Girls: more depression, anxietyGirls: more depression, anxiety

Women: PTSD linked to major depression (both Women: PTSD linked to major depression (both 2x as frequent among women); “borderline” 2x as frequent among women); “borderline” personality stylespersonality styles

Men: PTSD linked to “antisocial” personalityMen: PTSD linked to “antisocial” personality Gender-specific pathways to substance abuse?Gender-specific pathways to substance abuse?

Gender and “Culture”

Gender role expectations shape the ways in which Gender role expectations shape the ways in which trauma is experienced and interpretedtrauma is experienced and interpreted

These expectations may shape the ways in which These expectations may shape the ways in which trauma recovery proceeds: male gender role stresstrauma recovery proceeds: male gender role stress Relationship between PTSD severity and Relationship between PTSD severity and

difficulty differentiating/expressing emotional difficulty differentiating/expressing emotional states (“normative” male alexithymia?) states (“normative” male alexithymia?)

Relationship between PTSD recovery and Relationship between PTSD recovery and social supportsocial support

Male gender role stress associated with both Male gender role stress associated with both alexithymia and perceived lack of social alexithymia and perceived lack of social supportsupport

Stages in Trauma Recovery

Early recognitionEarly recognition: obstacles for survivors and for : obstacles for survivors and for clinicians in addressing traumaclinicians in addressing trauma

RecognitionRecognition: engagement becomes highest : engagement becomes highest prioritypriority

Active trauma recoveryActive trauma recovery: group or individual : group or individual work focused on trauma and recoverywork focused on trauma and recovery

Future orientationFuture orientation: continuing the healing : continuing the healing process and consolidating recovery skillsprocess and consolidating recovery skills

I. Early Recognition: Problems in Recognizing Male Trauma

Under-reportingUnder-reporting Gender role barriersGender role barriers Cognitive barriersCognitive barriers

Under-recognitionUnder-recognition Unasked or unclear questionsUnasked or unclear questions Stereotypes minimizing prevalenceStereotypes minimizing prevalence Stereotypes minimizing impactStereotypes minimizing impact Lack of service resourcesLack of service resources

Inadequate follow-throughInadequate follow-through

II. Recognition: Engaging Male Trauma Survivors in

Services

Addressing obstacles to men’s involvement Addressing obstacles to men’s involvement in trauma-specific servicesin trauma-specific services

Addressing strengths men bring to trauma-Addressing strengths men bring to trauma-specific servicesspecific services

Obstacles to Engagement

The “Disconnection Dilemma”The “Disconnection Dilemma” Lack of familiarity and/or comfort with Lack of familiarity and/or comfort with

emotional languageemotional language Lack of comfort with relationship-centered Lack of comfort with relationship-centered

discussionsdiscussions Extreme responses to potential stressors: Extreme responses to potential stressors:

all-or-nothing intensityall-or-nothing intensity

Strengths for Engagement

Pride and self-esteem related to survival Pride and self-esteem related to survival and coping: “Look what I’ve been and coping: “Look what I’ve been through.”through.”

Analytical tendencies: “I can figure this Analytical tendencies: “I can figure this out.”out.”

Bias in favor of problem-solving: “It’s Bias in favor of problem-solving: “It’s what men do.”what men do.”

III. Active Trauma Recovery

Understanding relationships between Understanding relationships between gender role expectations and traumagender role expectations and trauma

Understanding emotions and relationshipsUnderstanding emotions and relationships Understanding trauma and its often broad-Understanding trauma and its often broad-

based impactbased impact Understanding recovery skills and their useUnderstanding recovery skills and their use

Gender Role Expectations and Trauma

The “Male Messages”The “Male Messages” Being a man is not the problemBeing a man is not the problem Rigid male stereotypes are a problemRigid male stereotypes are a problem Emotional constriction is a problemEmotional constriction is a problem Drawing on strengths is part of the solutionDrawing on strengths is part of the solution

Trauma and Men’s Experience: An Example

Male MessagesMale Messages List of ten male gender role messagesList of ten male gender role messages Identification of the most significant Identification of the most significant Sources of these messages?Sources of these messages? Hardest/easiest to live up to?Hardest/easiest to live up to? Advantages and disadvantages?Advantages and disadvantages? Which one would you like to eliminate?Which one would you like to eliminate?

Subsequent references to this sessionSubsequent references to this session

Emotions and Relationships

What do men need in order to address What do men need in order to address trauma more directly?trauma more directly?

Key emotional realities: anger, fear, Key emotional realities: anger, fear, sadness, shame, hopesadness, shame, hope

Key relational realities: trust, hurt and loss, Key relational realities: trust, hurt and loss, sexuality and intimacysexuality and intimacy

Trauma and Its Impact

Understanding trauma in generalUnderstanding trauma in general Understanding specifics of emotional, Understanding specifics of emotional,

physical, and sexual abusephysical, and sexual abuse Understanding the impact of trauma on Understanding the impact of trauma on

psychological “symptoms,” on addictive or psychological “symptoms,” on addictive or compulsive behavior, and on relationshipscompulsive behavior, and on relationships

Men’s Trauma Recovery and Empowerment Model (M-TREM)

History and context: why separate groups History and context: why separate groups for women and men?for women and men?

Rationale for gender-specific groups in both Rationale for gender-specific groups in both clinical experience and research literatureclinical experience and research literature

Kimerling, R., Ouimette, P., & Wolfe, J. (Eds.) (2002).  Kimerling, R., Ouimette, P., & Wolfe, J. (Eds.) (2002).  Gender and PTSDGender and PTSD.  New .  New York: The Guilford Press.York: The Guilford Press.

Tolin, D. & Foa, E. (2006). Sex differences in trauma and PTSD: A quantitative Tolin, D. & Foa, E. (2006). Sex differences in trauma and PTSD: A quantitative review of 25 years of research. review of 25 years of research. Psychological Bulletin, 132Psychological Bulletin, 132(6), 959-992.(6), 959-992.

Olff, M., Langeland, W., Draijeer, N. & Gersons, B. (2007). Gender differences in Olff, M., Langeland, W., Draijeer, N. & Gersons, B. (2007). Gender differences in posttraumatic stress disorder. posttraumatic stress disorder. Psychological Bulletin, 133Psychological Bulletin, 133(2), 183-204.(2), 183-204.

M-TREM Core Assumptions

Gender roles matterGender roles matter ““Disconnection Disconnection

Dilemma”Dilemma” Extreme responses in Extreme responses in

emotions and emotions and relationshipsrelationships

Severed connections Severed connections and gender role and gender role expectationsexpectations

Disrupted skill Disrupted skill developmentdevelopment

Recognition of Recognition of strengths as survivorstrengths as survivor

Problematic behaviors Problematic behaviors and origins in copingand origins in coping

All coping attempts All coping attempts have pros and conshave pros and cons

M-TREM Group Content Twenty-four sessions—each with specific Twenty-four sessions—each with specific

topic, goals, and guiding questionstopic, goals, and guiding questions Three main parts of the interventionThree main parts of the intervention

Part One: Male Messages, Emotions, and Part One: Male Messages, Emotions, and Relationships (11 sessions)Relationships (11 sessions)

Part Two: Trauma Recovery (7 sessions)Part Two: Trauma Recovery (7 sessions) Part Three: Advanced Recovery Skills (6 Part Three: Advanced Recovery Skills (6

sessions)sessions)

M-TREM Part One Goals

To facilitate a sense of safety and trust in To facilitate a sense of safety and trust in the groupthe group

To discuss the importance of gender rolesTo discuss the importance of gender roles To develop a shared emotional vocabularyTo develop a shared emotional vocabulary To introduce key relationship themesTo introduce key relationship themes To begin preliminary discussion of the role To begin preliminary discussion of the role

of violence and abuse in members’ livesof violence and abuse in members’ lives

M-TREM Part Two Goals

To help members deepen an understanding of To help members deepen an understanding of trauma and its broad-ranging impacttrauma and its broad-ranging impact

To identify characteristic ways of coping with To identify characteristic ways of coping with traumatic eventstraumatic events

To help members understand the connections To help members understand the connections among trauma and other life difficultiesamong trauma and other life difficulties

To reframe certain problem behaviors or To reframe certain problem behaviors or symptoms as coping attemptssymptoms as coping attempts

To build on personal strengths in developing To build on personal strengths in developing alternative coping methodsalternative coping methods

M-TREM Part Three Goals

To apply an understanding of trauma’s To apply an understanding of trauma’s impact to a variety of life domainsimpact to a variety of life domains

To develop, practice, and consolidate To develop, practice, and consolidate recovery skillsrecovery skills

To deepen the mutual help functions of the To deepen the mutual help functions of the groupgroup

M-TREM Group Structure Eight to ten group members with histories of Eight to ten group members with histories of

interpersonal violenceinterpersonal violence Two co-leaders; usually both menTwo co-leaders; usually both men Weekly 75 minute sessionsWeekly 75 minute sessions Maximally inclusive: men diagnosed with severe Maximally inclusive: men diagnosed with severe

mental disorders, substance use disorders, co-mental disorders, substance use disorders, co-occurring disordersoccurring disorders

Wide range of settings (MH, SA, CJ, DV, Wide range of settings (MH, SA, CJ, DV, homeless shelters, other social services)homeless shelters, other social services)

Typically offered as part of a comprehensive Typically offered as part of a comprehensive system of care but can stand alonesystem of care but can stand alone

Trauma Sequelae: Risks Addressed by M-TREM

PTSD and generalized anxietyPTSD and generalized anxiety Difficulties with modulating emotional expression, Difficulties with modulating emotional expression,

especially angerespecially anger Emotional numbness and dissociationEmotional numbness and dissociation Difficulties maintaining safe, stable, and satisfying Difficulties maintaining safe, stable, and satisfying

interpersonal relationshipsinterpersonal relationships DepressionDepression Difficulties in accurate appraisal of self and the worldDifficulties in accurate appraisal of self and the world Substance abuseSubstance abuse

M-TREM Trauma Recovery Skills

Self-awarenessSelf-awareness Self-protectionSelf-protection Self-soothingSelf-soothing Emotional modulationEmotional modulation Relational mutualityRelational mutuality Accurate labeling of Accurate labeling of

self and othersself and others

Sense of agency and Sense of agency and initiative-takinginitiative-taking

Consistent problem-Consistent problem-solvingsolving

Reliable parentingReliable parenting Possessing a sense of Possessing a sense of

purpose and meaningpurpose and meaning Judgment and Judgment and

decision-makingdecision-making

M-TREM and Anger: An Example

Anger and BehaviorAnger and Behavior QuestionsQuestions

Name the situations that make you feel Name the situations that make you feel angry.angry.

Construct an “anger continuum” from “a Construct an “anger continuum” from “a little” to “very” angry.little” to “very” angry.

What negative consequences have you What negative consequences have you experienced as a result of…expressing your experienced as a result of…expressing your anger? Of not expressing your anger?anger? Of not expressing your anger?

What benefits?What benefits? Exercise: 1) List of effective ways to handle Exercise: 1) List of effective ways to handle

anger; 2) Relaxation exercise/practiceanger; 2) Relaxation exercise/practice

IV. Future Orientation

Consolidating skills in new activities and Consolidating skills in new activities and relationshipsrelationships

Setting realistic goalsSetting realistic goals Planning steps to meet vocational, Planning steps to meet vocational,

educational, and residential needseducational, and residential needs Realistic appraisal of future relationshipsRealistic appraisal of future relationships Assessment of future services and sources Assessment of future services and sources

of helpof help

Developing a Toolkit

RecognizeRecognize: What is going on with me right now?: What is going on with me right now? UnderstandUnderstand: What is the connection to trauma?: What is the connection to trauma? ChooseChoose: What response or skill is most likely to be : What response or skill is most likely to be

helpful and positive in my recovery as a whole?helpful and positive in my recovery as a whole? PracticePractice: How and when can I try out this new : How and when can I try out this new

skill?skill? EvaluateEvaluate: How did this new response work out?: How did this new response work out?

Summary

Male trauma exposure is widespread Male trauma exposure is widespread Men bring unique strengths and Men bring unique strengths and

vulnerabilities to each stage of trauma vulnerabilities to each stage of trauma recoveryrecovery

Clinicians need to be flexibly attuned to Clinicians need to be flexibly attuned to gender roles in relation to trauma and gender roles in relation to trauma and recoveryrecovery