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Assisting males to manage distress and live with trauma

A guide for practitioners

Don't believe everything you think

This being human is a guest house.
Every morning a new arrival.
A joy, a depression, a meanness,
Some momentary awareness comes
As an unexpected visitor.
Welcome and entertain them all!
Even if they’re a crowd of sorrows,
Who violently sweep your house
Empty of its furniture,
Still, greet each guest honourably.
He may be clearing you out for some new delight.
The dark thought, the shame, the malice,
Meet them at the door laughing,
And invite them in.
Be grateful for whoever comes,
Because each has been sent as a guide from beyond.

‐ Julaliuddin Rumi, Sufi poet

“If it is true that the core of our traumatised and neglected patients’ disorganisation is the problem that they cannot analyse what is going on when they experience the physical sensations of past trauma, but that these sensations just produce intense emotions without being able to modulate them, then our therapy needs to consist of helping people stay in their bodies and to understand these bodily sensations. And that is certainly not something that any of the traditional psychotherapies, which we have all been taught, help people to do very well.”
‐ Bessel Van der Kolk (1998)

Introduction

When people experience traumatic events – and by “traumatic” we don’t mean unpleasant or painful, but an event or events that threaten a person’s safety or that of loved ones – then life changes and, in some ways, is never the same again. The event becomes, in the words of Martin Buber, “a wound in the order of being”, life shifts, the world looks different and it will probably never look the way it did before. The person’s world view and the meanings they make of themselves, their life, their place in the world and their relationship with other humans is irrevocably changed. This does not necessarily mean, however, that the person who experiences trauma is permanently damaged – there are numerous examples of public figures who endured unspeakable pain – just think of Holocaust survivors – and continued to lead fulfilling and full lives, even while still holding some of the pain of the trauma. In recent years, a welcome addition to the field of trauma has come with the concept of “post-traumatic growth” (Shakespeare Finch; Tedeschi & Calhoun, 2004), which posits that although it is unlikely that a person will ever believe that they are glad the trauma occurred they may well be able to recognise ways in which they have grown and developed in their relationships with themselves and others, often in quite unexpected ways.

Until fairly recently, most of the literature around trauma focussed on the diagnostic category of Post-Traumatic Stress Disorder (PTSD). Increasingly, this is being seen as only part of the picture. PTSD, which will be discussed further below, is more likely to be a result of single-event or time-specific event/s (Briere, 2012). For people who have experienced multiple-event trauma, or long-term, developmental trauma, the concept of “Complex Trauma” may be more useful. Complex Trauma is most likely when the trauma was interpersonal (that is, inflicted by another human being), long-term with multiple events and developmental (that is, the traumatic events occurred at least partly during pre-adult developmental stages). The effects of Complex Trauma are more diffuse and less distinct than for PTSD; they can include difficulties in emotional and interpersonal regulation, particularly in intimate and family relationships, major changes in meaning (for example, people who experience a single event trauma may be more likely to still be able to see that there is still safety in their world whereas those who experience long-term trauma in an interpersonal context may not be able to experience any relationship as safe), and difficulties in attachment, particularly if the traumatic experiences occurred during early attachment stages.

Males who have experienced sexual assault may have experienced either a single event or multiple events (or both, often) over long periods of their lives, so may experience either or both PTSD and Complex Trauma. Males also bring to their experience of sexual assault a template that is offered to them around ways that men identify, tolerate, avoid or process pain and this is mediated by socially conditioned gender training (Connell, 1995). One of the clearest ways of seeing this is that many men express the hyperarousal associated with trauma (that is, a strong emotion “spiking” seemingly out of the blue) as anger, whereas the experience of many women who have experienced trauma is sudden arousal of sadness. This may well be because males in Western cultures are conditioned to be more comfortable with both the experience and expression of anger rather than sadness.

Here we will be looking at the application of mindfulness to work with males who have experienced sexual assault. Mindfulness has become the new therapeutic “flavour of the month”, popularised in Australia particularly through Acceptance and Commitment Therapy (ACT) (Hayes, 2001; Harris, 2010). We need to guard against any moves to impose professional ownership on Mindfulness, as it has a long history, particularly in Theravada Buddhism, but also in Christian (centring prayer), Islamic (mystical Sufism) and Hindu (yoga, Transcendental Meditation) traditions.

In this section we will looks at some of the definitions of mindfulness and its practical application to:

  • Distress identification.
  • Distress tolerance.
  • Distress reduction.

This will include looking at ways of dealing with sleep disturbances, including night terrors and trauma nightmares, intrusive thoughts and memories of traumatic events, avoidance of people, places and things, and ways of separating the past from the present.

Summary and explanation of terms

Trauma & its effects

“Trauma occurs when a person is confronted with a threat to the physical integrity of self or another, a threat that overwhelms coping resources and evokes subjective responses of intense terror helplessness and horror. Trauma nearly always involves a sense of loss. It is a moment when we can see the world shift and turn, understanding that neither we nor the world will ever be the same. Once we have been so wounded, we are faced with our own vulnerability in an irrevocable and palpable way.” (Susan Johnson. 2002)

Many people who experience potentially traumatic events do not develop long-term effects; it is not clear as to why this is so but it would appear that the degree of support available immediately after the trauma, and some pre-existing resiliency elements of the individual are key elements. (Briere, 2012) What is clear is that people who go on to experience the longer-term effects of trauma, usually have a combination of the following:

  • Re-experiencing of the causal events (often, but not always, in the form of intrusive imagines – both partial and fully integrated – either awake or during sleep.
  • Active behavioural avoidance of reminders of the event, ether actual people, places and things, or more abstract avoidance such as avoidance of thoughts, feelings and bodily states.
  • Persistent states of hyper-arousal, usually expressed through emotional lability and volatility, often with little obvious triggers, as well as sleep disturbances (exacerbated by trauma nightmares and night terrors), concentration difficulties and hyper-vigilance.

Where trauma is complex, long-term and multi-event, then these effects can be more diffuse, but may also include the following:

  • Chronic difficulties in identity, including feelings of emptiness and a poor sense of self.
  • Difficulties in maintaining interpersonal/family boundaries.
  • Difficulties in maintaining longer term intimate relationships – relationships can be chaotic and harmful.
  • Difficulties in affect regulation and impulse control, with greater utilisation of external tension reduction strategies such as self-harming, and compulsive or addictive behaviours.

(Briere, 2012; Courtois; Linehan)

Mindfulness strategies have been demonstrated to effectively respond to many of these effects.

Mindfulness and meditation

What is mindfulness?

There are numerous definitions of mindfulness, for example;

“The non-judgmental observation of the ongoing stream of internal and external stimuli as they arise.” (Baer 2003)

“Keeping one’s complete attention to the experience on a moment to moment basis.” (Martlett & Kristeller, 1999)

“The intentional process of observing, describing, and participating in reality, nonjudgmentally, in the moment, and with effectiveness.” (Dimidjian & Linehan, 2003)

The definition that is most commonly used is that offered by Jon Kabat-Zinn (2003):

“The awareness that emerges through paying attention on purpose, in the present moment, and nonjudgmentally to the unfolding of experience, moment to moment.” (emphasis added).

These are the four key elements in almost all definitions of mindfulness:

  1. Purposeful attention.
  2. Awareness of the present moment.
  3. A nonjudgmental stance.
  4. A sense of awareness unfolding in each moment.

An easy way of grasping what mindfulness IS, is to think of examples of mindLESSness:

  • Breaking things, spilling things, clumsiness, accidents because of carelessness, inattention or thinking about something else.
  • Failing to notice subtle or not-so-subtle sensations of physical discomfort, pain or tension.
  • Forgetting somebody’s name as soon as you hear it.
  • Being preoccupied with the future or the past.
  • Snacking without being aware of eating.
  • Having periods of time where it is difficult to remember details of what happened (not to be confused with a dissociative state, where there is no recall of events whatsoever).

(see Appendix A – Mindlessness Inventory).

There would appear to be five factors either explicit or implied in all of the working definitions of Mindfulness; 1) the observation of thoughts, emotions, bodily sensations and external stimuli; 2) non-reactivity to thoughts and feelings; 3) the restraining of judgment of experience; 4) acting with awareness, and; 5) describing/labelling experience in words.

“We shall not cease from exploration
And the end of all our exploring
Will be to arrive where we started
And know the place for the first time.”

‐ T.S. Eliot, Little Gidding

There are numerous “schools” of mindfulness, all of which incorporate, to some extent, these elements. Some of these frameworks are mindfulness-based (MBSR, MBCT), while others are mindfulness-informed (DBT). Some of the better known models are:

  • Mindfulness Based Stress Reduction (MBSR) – developed by John Kabat-Zinn (2001), initially for chronic pain but extended to work with depression and anxiety.
  • Mindfulness Based Cognitive Therapy (Segal, Wiliams & Teasdale, 2001).
  • Acceptance & Commitment Therapy (Hayes).
  • Dialectical Behaviour Therapy (Linehan).
  • There are numerous recent offshoots of these models; for example, Mindfulness Based Eating Awareness Training (MBEAT) (Kristeller); Mindfulness-Based Sobriety (Turner et al).

Mindfulness-BASED frameworks different from traditional Cognitive Behavioural Therapy in a couple of significant ways. CBT talks about positive and negative thoughts and emotional states, and assists people to move from “negative” cognitions and feelings (e.g. “I am a loser”, feelings of anger, sadness, hurt, loneliness, etc), to “positive” cognitions/feelings (“I can do this”, “I will survive because I am strong”, feelings of hope, contentment, joy, etc). Mindfulness strategies encourage a different and non-adversarial and even curious relationship with thoughts, feelings and bodily states, and while not explicitly suggesting shifts suggest that this new and somewhat interested but non-judgmental relationship to internal and external stimuli and responses will almost inevitably create a shift through this new relationship with experience.

“Don’t turn your head
Keep looking at the bandaged place
That’s where the Light enters you.”

‐ Jelaliuddin Rumi, Sufi poet

How is mindfulness different from meditation?

Meditation is commonly divided into two areas:

  • Calm-abiding meditation : similar to how some mindfulness practices begin, in that it usually requires one-pointed concentration, e.g. a mantra, candle, image or breath, but its aim is to sit in mental and physical stillness, often within a spiritual context. A bit like aiming to attain a connection with the ‘Higher Self’, giving the thinking mind a rest.
  • Insight meditation (Vipassana): a more advanced practice where the thoughts and feelings are allowed to flow freely and over long periods of time with the ‘observer’ self simply observing (or attempting to), again with a focus on identifying the ‘true’ or ‘higher self’ through the process.

Mindfulness practice (sometimes referred to as mindfulness meditation in the texts) is active and intentional.

While the mindfulness practices used in western therapeutic modalities have their history in the Buddhist meditation traditions, these practices have been the subject of much research in neuroscience and medicine, particularly in the areas of neuroplasticity.

Mediation can be seen as more like ‘zoning in’, a way of living day to day consciously and mindfully, resulting in better concentration rather than having our mind wandering around on autopilot. Its ultimate goal is to help us consciously make healthy, long-term, loving, peaceful, compassionate choices and have all our actions and reactions reflect these choices. (Ira Israel: HuffPost Healthy Living 30.5.13).

 

Relaxation therapy

Mindfulness is sometimes mistakenly regarded as a pathway to relaxation. This may be an effect of mindfulness, but it is not its intent. How do mindfulness and relaxation therapy differ?

Relaxation, distraction/diversion techniques all have a specific goal – reduction in current distress levels, through slowing of breathing, slowing of heart rate and reduction in muscle tension.

Relaxation strategies involve:

  • Use of the imagination to go out of the present experience (e.g. guided visualisations).
  • Introducing something new through imagination into the present (e.g. breathing in peace/calmness).
  • Manipulating muscle tension and/or breathing to create a more relaxed state.
  • Removing yourself physically from a distressing situation and doing something that induces bodily relaxation.

In the field of mindfulness, it is the non-judgmental awareness of internal bodily tension and distress that is the goal, rather than a reduction, although frequently this is an effect (but not always – as will be outlined below, sometimes it is sufficient for a person to have the experience of being able to tolerate thoughts/feelings/sensations that were previously avoided because of a fear of them becoming overwhelming).

The body is the harp of your soul,
And it is yours to bring forth sweet music from it or confused sounds

‐ Kahil Gibran

Continue reading Part 2: Dealing with distress

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