Group Psychotherapy Pilot Programme
Survivors Manchester
Acknowledgments
Contents
Acknowledgments
02 Acknowledgements
11 The Research
03 Introduction
12 The Participants
04 The Rational
14 The Outcomes
05 The Group Program
22 F eedback, Conclusions
10 G roup Contract/ Ground Rules
& Future Direction
23 References
I would like to thank Judith Margolin for writing the book that would provide the flexible and robust framework necessary for our own psychotherapy group program to be safely held within it. Thank you for allowing us to use your work, and also for your invaluable words of support and advice. Thank you Duncan Craig –CEO of Survivors Manchester for trusting me with this project, and having the vision to allow me to do it. Also thank you to all members of the Survivors Manchester team for contributing with data inputting as well as being a constant and invaluable source of support. And last but by no means least; I would like to thank all eight of the male participants who took part in the program, because without you there wouldn’t have been a pilot. You are all an inspiration, and I truly appreciate your allowing me to share this incredible experience with you.
Tom Taylor MBACP Accred. Clinical Lead & Trauma Focused Psychotherapist
@SurvivorsMcr #BreakTheSilence
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Group Psychotherapy Report
Introduction
Working with men on a daily basis I am frequently in the presence of what I consider to be magnificent displays of great strength, courage and resilience. So much so that it can often be extremely frustrating to hear so many male clients repeating the well versed gender myths, and socio-normative perceptions of masculinity such as men don’t cry, and that men showing any signs of vulnerability is tantamount to showing weakness.
Not only the profoundly debilitating impacts of being raped, beaten and/or physically and psychologically humiliated. Not even only the potential impacts of growing into adulthood with a painful and miserable childhood history permeated by neglect, physical and/ or sexual abuse and deprivation. No, what often takes form are individual life stories incorporating aspects of all of these types of developmental, and life traumas and more, that are simultaneously ‘locked down’ tighter still by the belief that as men they are not supposed to be feeling what they’re feeling. Vulnerability, fear and confusion are emotions that are undeniable elements of traumatic experience, and therefore unavoidable factors of the healing process to be expressed and explored as a part of recovery. However, for men who have firmly entrenched core beliefs about themselves, the world and the people in it that are informed by gender stereotypes, these can represent formidable barriers to accessing or even acknowledging such emotional states.
Introduction I consider myself to extremely lucky in terms of my professional career. It may have took me a lot longer than many people to create some direction in life, and begin to make the kinds of decisions regarding my future that would ultimately lead to my becoming a psychotherapist, but I can honestly say that when I did, it was due to my knowing for the first time in my life what I wanted to do. As such, I consider myself to be quite extremely fortunate, in the sense that I have a job that I both enjoy and feel extremely passionate about that I’m actually paid for doing. It’s a profound privilege to be invited by the incredible men I work with, to accompany them on their journeys for a short time, as they undertake what can often be an incredibly painful and emotionally exhausting experience, working towards their individual recovery from sexual abuse. Unfortunately, the male social stereotype of masculinity still represents such a significant and formidable barrier for men to overcome regarding their experience and expression of vulnerability. So much so that the very notion of being a ‘victim’ of sexual abuse, even during childhood (when we are by definition at our most vulnerable) can seem both incomprehensible and unacceptable for many men. Therefore, for the currently recognised ‘one in six’ of men who have experienced sexual trauma, this can both create and maintain a negative view of self that often culminates in a literal ‘crisis of masculinity’. Sadly it is all too common for men who have been sexually abused to struggle with their own sense of ‘maleness’ and ‘being a man’ as a result of their experiences. Words such as ‘man’, ‘male’ and ‘masculinity’ are extremely potent and loaded regarding their meaning and subsequent power within society. The historical, cultural, political and social influences that are undeniably present when using them represent a formidable force that contribute greatly to men’s subjective understanding and meaning of what it means to be a man within the modern world. This is where the metaphorical ‘straight jacket of masculinity’ (Height 1985) can be at its most oppressive and suffocating, particularly for male survivors of sexual abuse.
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“Unfortunately the male sterotype of masculinity still represents such a significant and formidable barrier for men to overcome” The harmful effects of such negative, reductive and ultimately myopic views and beliefs regarding masculinity must not be underestimated, because these are the very views and beliefs that inform the internalised ‘rules for living’ by many men in society. Irrespective of age, gender, socio-economic status or sexual orientation men continue to be subjected to the bombardment of information regarding what is and what isn’t expected behaviour for men within society. This information is drip fed and subsequently ‘sucked up’ from a myriad of external sources, including film, television, music and culture, all of which yield profound influence both for society as a whole and for the individuals within it. In working with men I frequently experience the long-term damage that the continued perpetuation of the male stereotype has the power to cause. As a result of the distorted messages that boys and men have been subjected to throughout their lives they often present at Survivors Manchester with an internal conflict raging within them so powerful that it often makes the energy within the therapy room quite literally crackle with intensity. When collaboratively explored in greater depth, what regularly begins to take form is not only the devastation, pain and legacy of being sexually abused.
Thankfully however, there is hope, and this comes in the form of other men who are open to both learning from each other and leading by example. There is no better way, or indeed no better place, to learn about being a man whilst simultaneously ‘unlearning’ any distorted and unhelpful views and values on the issue than in a room with other men. This has never been clearer to me than it is now, and this is because of each man who took part in the Survivors Manchester group psychotherapy pilot program, and the fact that they allowed me to share in their group experience, granting me an opportunity and privilege for which I shall be eternally grateful. The compassion and acceptance that they demonstrated towards each other throughout the process was quite literally, both beautiful and humbling to witness, whilst the courage, resilience and integrity that was consistently present within the room will be something I shall never, ever forget. Thank you each of you for choosing to take part, because by doing so you contributed to an experience that although clearly greater than the sum of its parts, and therefore bigger than all of us, would not have been anywhere near as precious had any of you not chosen to be there and contribute.
Survivors Manchester
The Rational
The Rational The idea of a psychotherapy group for male survivors has been an idea that has been in development for a long time. The initial concept was explored further as the topic of discussions between me and Duncan Craig (CEO) of Survivors Manchester in 2013. At this point the idea was shelved due to more pressing priorities regarding organisational development and service delivery at that time. However, it was certainly highlighted as a topic for future discussion, with an aim to revisit at a time when we could be more resilient as an organisation, to assist with the delivery of a more robust pilot program. This was a decision reached in the interests of maximising effectiveness, and promoting a treatment intervention that whilst being sustainable, also had the capacity and flexibility to evolve and develop over time.
As an organisation Survivors Manchester has experienced a significant raising of its profile within the public domain over the last 3 years, enabling our message strap-line of ‘breaking the silence’ to reach further afield and be heard by more male survivors as a result. This isn’t just a simple catch phrase; it’s something so much more than that. It’s about breaking the legacy of sexual abuse for thousands of boys and men who have suffered horrific experiences of rape, sexual abuse, sexual violence and trauma. It’s about screaming from the rooftops that these boys and men have suffered, and continue to endure the most unimaginable torment and pain as a result of their abuse
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that manifests itself in a multitude of destructive psychological, emotional, physical and behavioural symptoms throughout the lifespan. The long-term effects of childhood sexual abuse (CSA) are well documented, with adults who were sexually abused as children often having significantly poorer health than their non-abused counterparts, and that without effective intervention they are significantly more likely to develop a number of serious and/or life threatening conditions and illnesses (Kendal-Tackett cited in Goodyear-Brown 2012). The Saville enquiry and subsequent media maelstrom that ensued as a result initiated a momentous shift regarding the public’s knowledge, awareness of and attitudes towards CSA. Thankfully this zeitgeist moment shows no signs of abating, as well known household names and media celebrities from the 1970’s and 1980’s continue to be ‘named and shamed’ and prosecuted for their previously unanswered crimes regarding the sexual abuse and exploitation of children and young people during their heyday. Politicians and institutions also feature front and centre regarding their involvement either directly or indirectly with the sexual abuse of children, throughout what are in many cases decades of sexual crimes. The public’s response has been understandably intense, moving swiftly from initial shock, to eventual anger and outrage, as they struggle to comprehend just how far down the rabbit hole this may lead. It is of course no surprise that due to the sustained media attention involving continued news coverage via newspaper, radio and television, that adult survivors of childhood sexual trauma have been directly affected as a result.
a popular male characters rape at the hands of another male and Survivors Manchester’s active involvement within a consultancy capacity regarding the scriptwriting,also played a significant role in raising the public’s awareness to the fact that men and boys are raped and sexually abused too. Once again our service witnessed an increase in self-referrals from men, and also from men accessing our helpline as they began to choose to take a risk and break their own silence regarding their own sexually traumatic experiences. What we were frequently hearing was that this was often in response to what they were hearing on the radio, watching on television and reading in the newspaper, and that this had in some way acted as a ‘trigger’ for them regarding their own traumatic experiences, and that they were overwhelmed by the intense thoughts, memories, emotional content and physical sensations that had been reawakened as a result. Therefore, the decision to deliver a trauma focused psychotherapy group program, specifically for male survivors of sexual abuse in 2015 was in part influenced by the growing number of men accessing our services as a result of the rising political and cultural emphasis on sexual violence, but also in response to the fact that the message that ‘boys and men are raped, sexually assaulted and sexually exploited too’ was being heard. It was being heard by the general public, but it was also more importantly, being heard by men who had themselves been sexually traumatised. Survivors Manchester pride ourselves on striving to provide flexible, evidence based treatments that are very much informed by the needs of the men we work with. In other words we responded to the needs of our clients primarily, whilst remaining responsive to the political, cultural and social transformations of the time.
“the message that ‘boys and men are raped, sexually assaulted and sexually exploited too’ was being heard.” Survivors Manchester began to see a steady increase in the number of monthly self-referrals received about four to six weeks after the Saville enquiry was announced, that has continued ever since. The airing of the Hollyoaks storyline involving
The rest as they say, is history, and is ultimately what initiated the creation and eventual delivery of the treatment pilot that is the focus of this written report.
Group Psychotherapy Report
The Group Program
The purpose of the group psychotherapy program outlined within the book is, in the author’s own words:
Due to Survivors Manchester’s target demographic being adult male survivors as averse to female, there were of course changes made to some of the session themes and topics covered, in addition to some slight structural amendments where necessary.
The Group Program In 2013 whilst researching group psychotherapy as a potential treatment intervention to be offered here at Survivors Manchester I read a book called Breaking the Silence Group Therapy for Childhood Sexual Abuse: A practitioners Manual, by an American psychologist called Judith A. Margolin (1999). The book presented a clear, group treatment guide that outlines a framework specifically developed for adult male survivors of childhood sexual abuse. It was this flexible framework within which our own group psychotherapy pilot program was safely held, in terms of it providing a structure, whilst simultaneously allowing for our own group process to organically develop and take its own form within it. The group program offers an integrative based framework incorporating both structured and non-structured elements that include psychoeducation and group activity based exercises, all in the aim of discussing, exploring and ultimately reducing the symptoms of childhood trauma.
“To provide adult survivors of childhood sexual abuse with a forum to therapeutically explore the impact of the past trauma” (margolin, 1999)
Despite the groups’ initial conception that is outlined in the book being specifically created for a group program specifically for adult female survivors of childhood sexual abuse, the author does write about the flexibility of the group program, and its adaptability for the use of variant client groups.
Since the book’s initial publication in 1999 there have been significant research and clinical advances within the field of trauma and treatment. Innovations incorporate a broad range of perspectives including neurology, developmental trauma, attachment and somatic experiencing, all representing exciting advancements within the arena. Therefore adjustments were made to the group structure and framework accordingly, as a means of striving to remain as evidence based and as up to date as possible regarding psycho-education and treatments, whilst still remaining accessible and useful for the male participants. The group program was designed to be co-facilitated by two suitably qualified and experienced psychotherapists. The additional value of having two facilitators is apparent throughout the process, allowing for a more balanced facilitation of the group space and subsequent dynamics whilst enabling the potential for facilitator’s sickness and/or unforeseen events to be managed effectively without the group treatment being halted as a result. As a short-term program, the example in the book consisted of fifteen sessions, with two sessions to specifically prepare for endings. However, we made the decision to extend our own group treatment program to twenty sessions, to allow longer for the male participants to work towards a positive ending as a group, and including the additional five sessions to assist in doing so.
When asked...
What did you find most helpful about the session?
“
I’m free to say what I want, knowing I am going somewhere, learning to trust people within the group and feeling more at ease with myself and others.
“
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Survivors Manchester
The Group Program
The group program that was finally delivered consisted of the following structure, and incorporated the following session themes:
Session 1: Starting out – Introduction
Session 2: Trust & Safety
Session 3: Exploration of Emotions and Beliefs
Session 4: Breaking the Silence – Disclosure
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Establish guidelines for group formation and to begin to develop a safe, supportive setting conducive to open discussion, acceptance and approval. All these conditions are critical if the therapeutic objectives are to be achieved.
Due to the extremely significant issue of trust regarding male survivors of childhood sexual abuse and/or rape, trust amongst group members can facilitate an environment conducive to positive change. Explicit discussion around the issue of trust allows for recognition of the impacts of early breaches of trust, provides understanding of current and historical difficulties in relationships as well as highlighting the group members’ commonalities and shared experiences within this context.
Adult male survivors of childhood sexual abuse often face significant internal conflicts regarding their recognition and understanding of what can often be intense emotional discomfort. Often experiencing problems with intimacy, and feelings of isolation and anger, there has been little attention paid to how male survivors may learn to negotiate intimacy, and learn how to disclose emotions within a relationship context (Keating, Sorsoli & Grossman 2009). The group process can provide invaluable opportunities for male survivors to learn to develop intimate relationships, to build trust and explore their own emotions and belief systems whilst engaging in shared experiencing and participating in collaborative acceptance.
The opportunity to tell ones story and ultimately breaking the secrecy associated with childhood sexual abuse within a safe, supportive and facilitative environment represents a key factor in the process of self-healing and psychological growth. It offers the survivor opportunity to examine the flawed constructions of the sexual abuse experience and to reframe them from an adult perspective. Shame and secrecy are by definition challenged and reduced by an accepting relationship and shared experiences generated and developed within the group process. Sharing and re-experiencing their childhood trauma with others have had similar experiences can lead to the beginnings of new conceptualisations of self and others and alternative actions for recovery, change and growth.
Group Psychotherapy Report
Session 5: The Aftermath of the Abuse
Session 6: Family Dynamics & Attachment Theory
Session 7: Sexuality and Intimacy
Session 8: Anger – The Emotional Default Setting for Male Survivors
The Group Program
The complex short and long-term effects of CSA can result in a myriad of symptoms and/or disorders that may impact negatively in many domains of human functioning. Male survivors may often deny or minimise the effects of the abuse due to the shame and stigma that are associated with it. The consequences of CSA, the effects of the trauma and the connection with resulting mental health conditions and disorders need to be explicated, acknowledged and understood therapeutically.
Many adult male survivors of childhood sexual abuse disclose problems with intimacy and indeed in maintaining any long lasting attachment relationships. Therefore, it can be of benefit that members of the group gain a developmental and therapeutic understanding of the nature of attachment theory and its importance in understanding our patters of relating to others. It’s relevance for pre-disposing factors of developing PTSD can also be explored, and its implications for life-long development regarding learned internalised working models of attachment, and the powerful role such processes play in the development and maintenance of healthy relationships throughout the lifespan.
Male survivors often experience internal conflicts and challenges resolving their own sexual abuse experiences with the more ‘stereotypical’ and socio-normative ideals of masculinity. The strong links between CSA and adult sexual functioning are strongly established within the research literature, with high incidences of CSA and its negative consequences for adult sexuality and/or sexual attitudes and behaviours well documented. Traumatic sexualisation refers to the process in which a child’s sexuality (including both sexual feelings and sexual attitudes) is shaped in a developmentally inappropriate and interpersonally dysfunctional fashion as a result of the sexual abuse (Finkelhor 1986). Having a safe, supportive environment in which to discuss and explore personal experiences and subjective meaning of such issues without fear of judgement is conducive to individual recovery and self-acceptance.
As an emotion, anger receives a lot of bad press, and is for the most part perceived within society as a negative and destructive emotion and for many seen as synonymous with aggression and violence. However, there is a raft of potential benefits associated with male survivors developing a more harmonious and ultimately productive relationship with this emotion, whilst becoming more accepting and less fearful of it. The group process can provide a safe space to explore feelings of anger and resentment towards self, perpetrators and family members, whilst allowing men to verbalise their own relationships with the emotion within the context of their own history and recovery.
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Survivors Manchester
Session 9: Trauma and the Brain
The Group Program
Taken together the reptilian brain and limbic system make up what Van Der Kolk (2014) calls the ‘emotional brain’, which is at the very centre of our central nervous system and is tasked primarily with keeping us safe by initiating preprogramed escape plans such as the ‘fight-or-flight responses’. Psycho-education regarding the neurological and neuro-physiological factors at play in our response to traumatic events, as well as the complex psychological processes involved can empower adult male survivors to understand their symptoms and behaviours more fully, whilst ultimately promoting mastery over them.
Session 10-15: Exploring the Meaning – Unstructured Sessions
Session 15-20: Towards Endings – Making Sense of it All
These sessions provide opportunity for group members to raise issues that they consider important, current and in need of further detailed discussion. These sessions also provide valuable opportunity for themes and topics previously identified within earlier sessions to be explored in greater depth should the group see fit. This empowered the group to take charge of their space, address their needs, take responsibility for their actions and perhaps where relevant explore and assume new roles within the group. Group processes, dynamics and interactional patterns can also be addressed in greater detail during this time.
As the group process enters this final phase it is important to begin discussing reactions to the imminent ending. It is useful to begin this stage of the treatment by encouraging male survivors to reflect on their feelings regarding the ending as a means of introducing it with the next 5 sessions representing a forum to explore personal meanings and interpretations in greater depth. Male survivors may experience feelings of loss, rejection, abandonment, anxiety, sadness or even relief. Whatever their individual experience it is of great benefit for the unique healing process of each group member to individually discuss and explore these within the group process. Pre-learned patterns of behaviour and/or perceptions of endings may be productively reframed as a result, to assist with positive change. Theoretical Approaches, Skills and Interventions Used within the Group Program The integrative framework both allowed for and complimented the use of a diverse range of theoretical approaches and philosophies, whilst enabling an eclectic method of psychoeducational resources and skills to be offered to assist with a more flexible and ‘best fit’ method of delivery. Common and/or reoccurring theoretical approaches and skills utilised within the program to assist with positive change and to inform the process included: -
Dialectical behavioural therapy (DBT)
-
Cognitive behavioural therapy (CBT)
-
Eye movement desensitization reprocessing (EMDR)
-
Mindfulness approaches
-
Attachment focused work
-
Transactional Analysis (TA)
-
Inner child work
-
Existential psychotherapy
-
Art/creative approaches
-
Psycho-sexual theories
Exercises and strategies were offered and built in to the structure of the program throughout its duration, in the interests of striving to ensure that each participant was sufficiently stabilised throughout the group process, and had effective coping strategies in place should destabilisation occur in between sessions.
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Group Psychotherapy Report
The Group Contract/Ground Rules
Substance/Alcohol Misuse
Commitment
Group participants agree that there will be no attending the group whilst under the influence of illicit substances and/or alcohol.
Group participants agree to commit to the best of their ability to the twenty week program, and strive to attend weekly. There is strong group agreement that external factors, and/or priorities may result in being unable certain weekly sessions. However, each group member agrees to contact either the Survivors Manchester Office or Tom directly when unable to attend, to ensure that the groupis informed and aware.
The Group Contract / Ground Rules The group ground-rules were collaboratively discussed and agreed during the first session with a unanimous agreement that each group participant would both respect and adhere to them to the best of their ability.
Confidentiality Group participants agree to respect and maintain the confidentiality of the group, and all individual group members. Group participants agree that ‘what happens in the group, stays in the group’ regarding all personal and sensitive information. Survivors Manchester staff/co-facilitators has informed group participants of the potential limitations to confidentiality regarding risk to self, and/or others, and the staff and organisations duty of care to the public interest.
Turn off Mobile Phones Group participants agree to turn off mobiles phones, or place them on silent for the duration of weekly group sessions. In circumstances when participants may be awaiting an important telephone call/text message, they agree to inform the group facilitators and participants prior to the beginning of the group, and to leave the room to reply and/or respond as discretely as possible to minimize disruption.
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Survivors Manchester staff/co-facilitators informed the group that any participants who attend whilst under the influence will be asked to leave in the interests of safeguarding, and the reduction of risk.
Safety – Trust Group participants acknowledge the importance and value of safety and trust, as well as its profound relevance for the group process. All participants agree to assist with creating a safe, non-judgemental environment, that’s conducive to learning, personal development and positive change. Therefore, each individual group participant agrees to contribute to developing such a space, for the collective benefits of the group.
Lateness Group participants agree to try to the best of their ability to attend each week in good time for the 7.00pm start time. There is a strong group agreement that lateness may potentially cause disruption to the group process, and/or disturb potentially sensitive group interactions. Each group member agrees to contact either Survivors Manchester office or Tom direct via mobile, to inform them prior to the group sessions of potential lateness whenever possible.
Opt-out/Pass Option Group participants agree that each has the right to ‘opt out’ of any activities and/or group exercises in the interests of keeping himself safe, and ultimately ensuring and maintaining a safe environment.
Respect Group participants agree to treat each other respectfully for the duration of the group program. Different views, values and beliefs are collectively recognised as a valuable element of any group process, and therefore will be respected accordingly.
Survivors Manchester
The Research
The Research In a comprehensive review of the research literature specific to the rape and sexual assault of men (Burrows & Horvath 2013), it was identified that the current evidence base for therapeutic work with male survivors is small within the UK, and subsequently lacking the robustness necessary to provide empirical support for the effectiveness of therapeutic treatments with this population. It is indeed disappointing that this dearth of research literature pales so significantly in comparison to the wealth of academic and clinical research data available regarding female rape and sexual assault, which is indicative of this previously marginalised and understudied population within research domains. However, it also generates opportunities rich with potential regarding contributing to and creating the research data that is paramount to ensuring that men receive the most effective evidence based treatments available. Whilst the short and long-term effects of childhood sexual abuse for adult male survivors of childhood sexual abuse are gradually becoming more documented (see Easton 2013, Ray 2009, Easton et al 2013), the aforementioned gaps in research regarding what therapeutic treatments actually work, means that for now at least, the few organisations and professionals that are actually working with this population are doing so relying on experience and intuition. The world health organisation (WHO) and the national institute of clinical excellence (NICE) guidelines clear recommendations for the treatment of trauma and post-traumatic stress disorder (PTSD) incorporate eye movement desensitisation reprocessing (EMDR) and trauma focused cognitive behavioural therapy (TFCBT). Both of these trauma - focused treatments have a strong empirical evidence base regarding their effectiveness, and both are currently offered here at Survivors Manchester. However, despite these representing effective therapeutic approaches for 1:1 treatment, the evidence base for psychotherapy groups with this population is less persuasive.
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There is however evidence that suggests that despite a significantly increased risk of longterm mental and physical health problems, that many male survivors of CSA experience positive changes in many areas of life. Men reported improvements in personal strength and interpersonal relationships following their having more of an understanding of their sexual abuse experiences leading to significant post-traumatic growth (Easton et al 2013). There is no better place for men to learn about being a man than in a group with other men. This is my own experience of being in a group with other men, both as a facilitator and member, and this psychotherapy group treatment pilot for male survivors of childhood sexual abuse confirmed that even more.
Men who are in recovery generally do so faster and more effectively in the company of other men who are also in recovery. This has been my experience as a group facilitator working within drug and alcohol services for many years as well as my experience here at Survivors Manchester.
“There is no better place for men to learn about being a man than in a group with other men.�
Group Psychotherapy Report
The Participants
The maximum number of male participants for the psychotherapy group was originally set at twelve. This was a decision based on Tom Taylor’s previous experience of delivering and facilitating group interventions within a range of different sectors and contexts, as well as the use of service user feedback within our alternative peer support group space – The Safe Room.
The group program began with a final, total number of eight male participants. Each had been subject to a full comprehensive assessment as per Survivors Manchester treatment service pathway, and as such all had been assessed as group psychotherapy representing the most appropriate treatment intervention.
The Participants The group psychotherapy program was advertised online via our own website and posters were designed and then disseminated to NHS services, third sector organisations, partner agencies and service providers as widely as possible. The accompanying information in the email was inviting professionals to display the posters in GP surgeries and other services as means of generating widespread interest in the hope that this would assist with as many male survivors as possible seeing them, and/or professionals from other services discussing the program with male survivors that they may be currently working with to assist with the number of applicants and/or referrals.
Despite the Safe Rooms peer supportive, step 2 - focus representing a radically different space in key aspects, the co-facilitators of this space had invaluable knowledge and experience regarding the therapeutic factors and group dynamics involved in group work with male survivors of sexual trauma.
The group demographics were as follows: • The ages of male participants ranged from 30 years to 61 years with a mean age of 42 years (see Fig 1.)
Age of Participants
3
2
1
30-39
1
40-49
50-59
Fig 1: Age of group participants
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60-69
Survivors Manchester
The Participants
Ethnicity
Sexual Identity
12.50% 25% 75% 87.50%
White British
British Asian
Fig 2: Ethnicity of group participants
• Regarding ethnicity - participants predominantly identified as white British (87.5%), with one (12.5%) Asian British (see Fig 2.)
Heterosexual
Gay
Fig 3: Sexual Identity of group participants
• Regarding sexual identity – 75% of participants identified as heterosexual, with 25% identifying as ‘gay’ (see Fig 3.)
17% 33% 17%
ES - F/T Employed
ES - Sick
ES - P/T Employed
ES - Unemployed
ES - Retired
17%
16%
Fig 4: Employment status of group participants
• Regarding employment – 75% of participants were in full time employment with 12.5% retired and 12.5% currently claiming sickness related benefits (See Fig 4.)
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Group Psychotherapy Report
For male survivors who are by definition familiar with the process of feeling disempowered, their assertive action in selfreferring themselves into our organisation can have profound significance within the context of regaining control of their lives. St Marys sexual assault referral centre (SARC), who we have a close working partnership with represent another referral pathway for this group cohort, with mental health services also represented (See fig 5.)
When asked...
What did you find most helpful about the session?
“
The chance to talk with other men about their childhood experiences including anger etc
Referral Pathways
14% 14% 72%
Mental Health (Adult Primary Care)
SARC
Self Referral
Fig 5: Referral pathways for group participants of the pilot program
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“
The referral pathways for participants taking part in the pilot consisted of predominantly self-referrals which clearly reflects the trend for Survivors Manchester clients accessing our services. Whilst we do of course accept referrals from a wide range of sources including statutory and third sector organisations, our preferred referral pathway as an organisation is always self-referral. This is based on our experience being that men who self-refer generally being more ready to access support and treatment, as well as the self-referral process representing an empowering process in itself.
The Participants
Survivors Manchester
The Outcomes
The Outcomes The clinical outcomes measurement tools used for the psychotherapy group treatment pilot consisted of the following:
The Impact of Events Scale- Revised (IES-R): One of the most widely used PTSD related scales that has been applied over a broad range of various trauma samples, the tool assesses the extent of the avoidance/numbing and intrusive symptoms of PTSD as averse to the full range of symptoms associated with the disorder. The scale is comprised of 15 items that respondents are required to subjectively score reflecting on their experiences over the last seven days.
The maximum mean score on each of the three subscales is ‘4’, meaning that the maximum total mean IES-R score is 12. A total IES-R score of 33 or above from a theoretical maximum total of 88 is indicative of a likely presence of PTSD. The IES-R was administered every third session to allow for sufficient gaps between scores to enhance the quality and validity of the data. The following graph (see Fig.6), displays the first and last sessions IES-R scores for each of the seven group participants.
IES-R Outcome Scores 80
IES-R Scores
70 60 50 40 30 20 10 0 1
2
3
4
5
6
Group Participants
IES-R Session 1
7
IES-R Session 20
Fig. 6: Individual IES-R scores for group participant’s sessions 1 and 20
As the graph clearly demonstrates there were significant reductions in IES-R outcome scores for the majority of group participants having completed the twenty week program, with one exception. Participants increased scores may of course be due to a range of associated factors, one being that despite the IES-R screening tool being widely used, and easy to administer, it does have significant limitations due to its sole emphasis on the intrusive and avoidant aspects of PTSD.
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There are unfortunately always issues with the use of PTSD screening tools regarding specificity, sensitivity and overall accuracy. This was complicated further still by the fact that all members of the group were adult survivors of historical trauma. The IES-R is primarily concerned with symptomatic status within the preceding week in reference to the traumatic incident, meaning that due to the event not being fixed this will vary greatly from person to person (Wilson & Keane 2004).
The imminent ending of the group program was also a significant stressor for participants that was explicitly discussed and explored as a group. Therefore this too, represents a key variable in the fluctuating self-scores of group participants, in addition to the unique, personal experiences of men over the last seven days that may contribute to symptoms of stress.
Group Psychotherapy Report
The Outcomes
Clinical Outcomes Routine Evaluation 10 (CORE 10):
When asked...
What did you find most helpful about the session?
A widely used and accessible outcome measurement tool used to measure and monitor individual differences upon entry in to therapy and positive change. The tool includes 10 items covering problems/symptoms, wellbeing, life functioning, as well as risk to self and others. Participants were requested to complete this outcome tool weekly. The graph displayed in Fig.7 outlines a comparison of the CORE 10 scores of participants gathered from the first and last sessions of the twenty week program.
“
Listening to others is very helpful to me. Knowing that every time I go to my session it puts me one more rung up the ladder of hope.
“
CORE 10 Clinical Outcome Scores 35
IES-R Scores
30 25 20 15 10 5 0 1
2 Session 1
3
4
5
6
Group Participants
7
Session 20
Fig. 7: Individual CORE 10 scores for group participant’s sessions 1 and 20
Interestingly the CORE 10 outcome scores for the final session did indicate increases for three of the participants. However, this was something that was actively discussed as a group during sessions fifteen to twenty which represented the ‘ending phase’, and therefore generated strong emotions for the men involved as the inevitable ending approached. Every care was taken to ensure that endings as an overall experience were
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discussed and explored within the context of each individual’s lived experience, with an emphasis on encouraging the men to collaboratively work together in creating a positive ending for the group. However, this was an understandably difficult ending for all of the men involved due to the profoundly intimate, bonding that had taken place during the preceding twenty weeks, some of which I believe is captured in the last sessions outcome measurement scores.
Survivors Manchester
The Outcomes
Survivors Manchester Group Psychotherapy Weekly Feedback Form: A form designed by the facilitator of the group to specifically capture participants weekly feedback of the program sessions. This feedback would then be used to inform the future development of the program, whilst representing a valuable snapshot of its overall effectiveness as an intervention. Utilising a multi-method approach the form incorporated five items in total – three items using a Likert Scale, one item using ‘yes/ no’, and one item having a blank box for participants to write their responses in. There was also another space inviting participants for any additional feedback and/or information. Items 1, 3, 4 and 5 are presented in the pages following, with participants weekly recorded responses to each item presented in graph format.
When asked...
What did you find most helpful about the session?
“
“
Hearing how different people’s family and support network differs entirely from mine.
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Group Psychotherapy Report
The Outcomes
1.
>>>>
How helpful was today’s group session for you?
Item 1 Weekly Responses 6 5 4 3 2 1 0 Wk 1
Wk 2
Wk 3
Wk 4
Strongly Agree
Wk 5
Wk 6
Wk 7
Agree
Wk 8
Wk 9
Wk 10
Wk 11
Wk 12
Undecided
Fig. 8: Weekly responses to item 1
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Wk 13
Wk 14
Disagree
Wk 15
Wk 16
Wk 17
Wk 18
Wk 19
Wk 20
Strongly Disagree
Survivors Manchester
The Outcomes
2.
>>>>
What did you find most helpful about the session?
“
Opening up to our group and
in fellow members.
“
“
Learning
“
“
my actions can be said to be similar.
Hearing the experiences of others and identifying with them. It allowed me to admit to myself about feelings
“
“
when growing up, and how they have shaped my adult life.
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and laughter.
Passive aggressive Father –
about anger and CBT.
Exploring sex
“
“
insecure due to having trust
“
not feeling vulnerable or
Group Psychotherapy Report
The Outcomes
3.
>>>>
To what extent did this group session help you to feel less isolated?
Item 3 Weekly Responses 6 5 4 3 2 1 0 Wk 1
Wk 2
Wk 3
Wk 4
Strongly Agree
Wk 5
Wk 6
Wk 7
Agree
Wk 8
Wk 9
Wk 10
Wk 11
Wk 12
Undecided
Fig. 9: Weekly responses to item 3
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Wk 13
Wk 14
Disagree
Wk 15
Wk 16
Wk 17
Wk 18
Wk 19
Wk 20
Strongly Disagree
Survivors Manchester
The Outcomes
4.
>>>>
Do you feel as if you have more of an understanding of how your childhood experience of sexual abuse has affected you?
Item 4 Weekly Responses 6 5 4 3 2 1 0 Wk 1
Wk 2
Wk 3
Wk 4
Wk 5
Wk 6
Wk 7
Wk 8
Wk 9
Wk 10
Yes
Wk 11
Wk 12
No
Fig. 10: Weekly responses to item 4
20
Wk 13
Wk 14
Wk 15
Wk 16
Wk 17
Wk 18
Wk 19
Wk 20
Group Psychotherapy Report
Introduction
5.
>>>>
To what extent did the group session help you understand the various ways you have previously developed and used to help you cope with this experience?
Item 5 Weekly Responses 6 5 4 3 2 1 0 Wk 1
Wk 2
Wk 3
Wk 4
Strongly Agree
Wk 5
Wk 6
Wk 7
Agree
Wk 8
Wk 9
Wk 10
Wk 11
Wk 12
Undecided
Wk 13
Wk 14
Wk 15
Disagree
Wk 16
Wk 17
Wk 18
Wk 19
Wk 20
Strongly Disagree
Fig. 11: Weekly responses to item 5
As the results of the weekly feedback form clearly demonstrate, the overall effectiveness of the group program was extremely significant for the men involved. The responses indicate that feelings of isolation were dramatically reduced as a result of engaging with other male survivors within a structured group process. Psycho-education regarding the effects of trauma on the mind, brain and body, as well as other associated psychological theories and perspectives such as attachment, sex/masculinity/sexual identity, the CBT model of behaviour
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and anger interventions were also useful. It is also clear that the opportunity to discuss, explore and fully understand previously maladaptive and/or destructive methods of coping was also positively received. The opportunity for male survivors of childhood sexual abuse to understand their traumatic experiences as adults, particularly within the context of the legacy issues that their experiences left them with, and to view their behaviours as natural survival responses can have profound effects.
Feelings of intense shame, guilt and self-blame can be dramatically reduced if men are equipped with the necessary knowledge and tools to reframe their lived experiences within the context of natural survival responses in regard to trauma. The ability to do so can dramatically assist men in reclaiming their lives, to become more integrated and fully functioning individuals resulting in significantly more positive futures.
Survivors Manchester
Feedback, Conclusions & Future Direction
Feedback, Conclusions & Future Direction The feedback from the male participants who took part in the pilot program was wholly positive, with each member speaking about how they had found the process beneficial in a variety of ways. There was a general consensus that the group’s effectiveness would have been increased had it been longer than its twenty session structure allowed, which represents a valuable point of consideration for future projects. Men’s feedback regarding the most valuable aspects of the program for them in terms of what they found most useful and consequently would have liked to have more time to focus on in more depth included: • The ability to feel heard and supported by peers without fear of judgement • To have opportunity to share their vulnerabilities with other men without fear of this being exploited • To have experienced feeling fully understood by other men who “really know” where they’re coming from
The group program began with eight male participants in total, with one failing to return after the initial session, but the remaining seven continuing for the duration of the program. This level of commitment in itself represents accolade indeed, regarding the usefulness and meaning of the group process for each of the men involved, and is indicative of the pilot programs overwhelming success as a treatment intervention for those men that participated. The outcomes of the pilot program and the participant feedback clearly demonstrate that there is significant recovery value in placing adult male survivors of child sexual abuse together within a structured clinical setting, where they feel safe enough to work through their own understandings of their traumatic experiences, whilst learning from each other. Psycho-education regarding the effects of trauma and PTSD, as well as the associated psychological theories and research within the field are also of significant value, whilst having the opportunity to learn about how our developmental experiences play a pivotal role in our ability to self sooth and self-regulate.
Further benefits regarding men’s understanding of attachment theory, and this representing a framework within which to conceptualise and explore their own relationships with self and others, whilst developing healthy, secure attachment experiences with other participants within the group, and thus re-scripting internal working models represent powerful examples of the group’s treatment effectiveness. Regarding future direction, Survivors Manchester is due to deliver our next cohort of the program towards the end of 2015. Feedback and recommendations regarding themes and content will be taken on board with amendments made accordingly where appropriate. Regarding the length of the treatment program it will be kept at twenty sessions for the next delivery process. This will be in the interests of having two twenty week programs having been delivered thus far, to represent a stable and robust foundation which may effectively inform future developments and ideas regarding the groups future development.
• To be informed and educated regarding male sexual abuse issues • Attachment theory, particularly within the context of childhood trauma
“The outcomes of the pilot program and the participant feedback clearly demonstrate
• Anger
that there is significant recovery value in
• The CBT model as a means of understanding cognitions and their influences on our emotional reactions and behaviours
placing adult male survivors of child sexual
• Psycho-sexual issues and/or impacts of childhood sexual trauma on sexual functioning, sexual relationships and sexual identity
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abuse together within a structured clinical setting”
Group Psychotherapy Report
Introduction
References Burrows, N. & Horvath, T. (2013) The Rape and Sexual Assault of Men – A Review of the Literature.
Easton, S.D. (2013), Disclosures of Child Sexual Abuse Among Adult Male Survivors. Clinical Social Work Journal, Volume 41, Issue 4, pp 344-355.
Easton, S.D. Coohey, C. Rhodes, A.M. & Morthy, M.V. (2013), Posttraumatic Growth Among Men With Histories of Child Sexual Abuse. Child Maltreatment, Vol 18, No 4, pp 211-220.
Finkelhor, D. (1986), a Sourcebook on Childhood Sexual Abuse. Sage Books. London
Goodyear-Brown, P.(Ed) (2012) Handbook of Child Sexual abuse Identification, Assessment and Treatment. John Wiley & Sons, Inc. London
Hite, S. (1985), The Hite Report on Male Sexuality: How Men Feel About Love and Sex, Ballentine Books Inc, London.
Margolin, J.A. (1999), Breaking the Silence Group Therapy for Childhood Survivors of Sexual Abuse: A Practitioners Manual. The Haworth Press. USA.
When asked...
What did you find most helpful about the session?
“
“
Listening to others experiences gave me the strength to share mine.
Ray, S. L. (2009), Male Survivors Perspectives of Incest/Sexual Abuse. Perspectives in Psychiatric Care, Volume 37, Issue 2, pp 49-59.
Van Der Kolk, B. (2014), The Body Keeps The Score: Mind, Brain and Body in the Transformation of Trauma. Penguin Group, London.
Wilson, J.P. & Keane, T.M. (Ed), (2004), Assessing Psychological Trauma and PTSD (2nd Ed), Guilford Press, London.
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“Breaking the silence - this isn’t just a simple catch phrase, it’s about breaking the legacy of sexual abuse for thousands of boys and men.”
@SurvivorsMcr #BreakTheSilence