A further concern for the therapist working with military veterans is the prevalence of gender-based violence, commonly referred to as Military Sexual Trauma (MST). "According to our interviews with female veterans, there's secrecy and shame about being a victim of MST, along with fear that reporting it will damage opportunities for advancement or add to the risk of combat. Because of warriors' dependency on others in their units, especially those superior in rank, MST can be experienced similarly to childhood sexual abuse by a trusted family member, engendering commensurate feelings of shame and distrust of others (Leitch and Miller-Karas, 2010, page 39, 62). The therapist should be aware of the potential vulnerability or experience of sexual assault to not only female veterans, but also homosexual veterans. This caution may be extended to any soldier who may have been deemed different and/or vulnerable in the male-dominated warrior culture of the military: being female, gay, younger, smaller, Muslim, and so on. The reticence to discuss Military Sexual Trauma reminds the therapist that individuals and couples often present for therapy without naming specific emotional, functional, and relationship problems. They may be holding a shameful secret, but also may not reveal sometimes from not knowing to reveal underlying issues, including and especially traumatic events that cause or significantly impact their relationship. The therapist should be sensitive and vigilant about the propensity of some individuals to exploit the dynamics of power inherent in rank, role, and authority in the military. They may do so through physical, psychological, or sexual abuse. Power dynamics and the corruption of power occur in the military because they occur throughout society in families, communities, and other institutions to vulnerable persons. From one system to another… from the family-of-origin to the couple… from the military, the school, or the church to the couple, traumatic experiences often seriously impact intimacy. Mutual reciprocal intimacy may become convoluted when one of the two partners unconsciously carry emotional numbing from sexual trauma and the intrusive cognitive and sensory memories of molesters/abusers/rapists. Clients may fail to mention such trauma. "Armsworth's (1984) study of incest victims found that it was common for subjects to enter therapy with several therapists before receiving the assistance they believed they needed (reports ranged from one to nine therapists). While some subjects reported no memory of the incest until talking with the third or fourth professional, overall subjects reported disclosing their incest history to only 70% of the therapists from whom they received treatment. While there is no guarantee that initial invitations to discuss sexual issues will result in fruitful or comprehensive interchange pertaining to the couple's concerns in this area, it is still imperative for the therapist to recognize the possibility of and remain open to addressing sexual problems, should they emerge" (Barnes, 1995, page 355-56). A formal comprehensive paper intake process can include one or more specific questions about the client having experienced sexual abuse (molestation, exploitation, or rape). If the therapist feels this may be potentially experienced as insensitive or therapeutically inappropriate, he or she nevertheless should explore for sexual trauma during the therapeutic process. Failure to do so may misdirect clinical work away from core trauma experiences and compensations.
Consuelo was in a very unfulfilling committed relationship (later marriage) with an emotionally disconnected woman who could be very controlling. It had given her concerns when they were dating, but the social, cultural, and political aspects of their relationship were compelling. Morgan promised to be a good partner and provider, if a bit emotionally limited. They had been together for twenty years (married when it became legally permissible) and Consuelo had known for eighteen years that it had been a mistake. Despite this knowledge, Consuelo agreed to get married during the ecstatic euphoria in the homosexual community when same sex marriages became legal in their state. By then, their first child was a pre-teen and she decided to stick it out for him and eventually the second child. The emotional, legal, and practical complexities of producing children that were biological to one or the other compelled their commitment. However, their intimacy deteriorated consistently over the years. They eventually co-existed in the house, coordinated children's scheduling, but hardly talked to each other. Nightly dinners were an ordeal, as Morgan demanded proper etiquette and respect. That meant the children had to eat everything, speak when spoken to, and anticipate her erratic volatile moods. Consuelo felt that she had to protect them from her anger. Her older child had effectively given up on Morgan as an available parent. He couldn't please her no matter how well he did, so now he just did the minimum and tried to stay out of her way. He had stopped asking mommy Consuelo about a couple of years ago to explain his mommy Morgan's behavior. Being passive-aggressive was his strategy to survive long enough to finish high school and get then the hell out of the house. The younger child managed to stay in Morgan's good graces, but played her to get what she wanted. After the kids went to bed and Consuelo settled into her nighttime routines, Morgan got into her nighttime routine of drinking Chivas Regal scotch. Almost every night, she came to bed stinking of alcohol.
To the larger community, Morgan was charming and a good citizen. She played softball and bowled in local recreation leagues and volunteered at the food bank bagging meals. She donated generously to local charities. She participated in a mentoring program to empower inner city girls to go to college. Morgan was a well-respected vice-president of marketing for a large culinary supply company. Consuelo had been content to be more of the traditional maternal role when the children were young, but eventually wanted to use her degree in communications. It had been a major battle to get Morgan to "let" her work. She still took potshots at Consuelo about her job. Morgan blamed her working for anything that didn't go smoothly around the house or if the children had any issues. Consuelo had to work around Morgan's schedule all the time. Consuelo had broached separation a couple times over the years, but talked herself out of it both times. Morgan's got furious both times. One time when she said she'd never let Consuelo go, she claimed that she would do something desperate. Morgan warned Consuelo that she had done some bad things in her younger days… some really bad things. The therapist asked Consuelo if Morgan had threatened her with violence. Consuelo admitted that although she didn't come out and say it, Morgan spent a lot of energy to intimate that Consuelo could never leave the relationship. Later, when Consuelo challenged her about her threats or any of her behavior, Morgan told her she remembered everything incorrectly. When she was younger, Consuelo believed Morgan. She had wanted to believe her or else she'd have to face doing what she was scared to face. Now, she knew what she experienced and felt was real. When asked if she was concerned about Morgan being dangerous, Consuelo's affect switched from interactive warmth to emotional absence. She became evasive. Consuelo admitted some concern for her own safety, but got flooded with terror when thinking about what might happen with the children. The therapist warned her to take great caution to keep Morgan ignorant that she was in a process of decision making (and eventually, her plans to leave- a decision that she came to later).
In the first session as Consuelo revealed Morgan's angry controlling behavior, the therapist became suspicious of how she had accepted and continued to accept Morgan's disconnected and dominating behavior for twenty years. When the therapist asked about her parents and her childhood, Consuelo responded with loving and affectionate recollections about the relationships and experiences. Despite additional inquiry, the therapist could not find any indications of stressful, invalidating, much less abusive experiences. The therapist told Consuelo that when someone sprains his or her ankle or throws out his or her shoulder, the tendons and ligaments become stretched. Despite healing, they retain a vulnerability to be sprained or thrown out again. Something or some experiences must have predisposed her to accepting an abusive, dominating, and controlling partner… again. Since there are no identifying family-of-origin issues such as drug or alcohol abuse or physical or mental illness distorting family dynamics, there had to be something else. Something must have "stretched" Consuelo's psychic sensitivity and vigilance to make her prone to missing cues that Morgan was unhealthy, controlling, and dangerous. Consuelo's emotional, physical, and affective presentation triggered no clinical instincts for the therapist for alternative theories. There were no other indicators. The therapist chose the direct approach and asked, "Were you sexually molested as a child?" Consuelo paused looking directly into the therapist's eyes. Then she said with admiration, "Oh, you're good." Consuelo then told the therapist that she had been molested by a male neighbor when she was 12-years-old. It happened over one summer. He had spoken lovingly to her and gave her presents. He repeatedly re-told the story over the summer to make it a mutual "love" affair. He distorted her reality to the point she no longer knew what had really happened. And then threatened her and threatened that he would kill her parents. She had never told anyone about being molested.
The therapist can proceed in a variety of therapeutic directions when lacking awareness of an underlying trauma. The therapist can readily identify Morgan as a narcissistic personality at the very least, and an alcoholic on top of it. Therapy could have focused on dealing with Morgan's controlling behavior, and/or Consuelo's role as an enabler. It could have addressed the alcoholic family system and the children's scapegoat/rebel and mascot roles. Therapy could examine the emotional, cultural, and social/political pressures of being in an open lesbian partnership or of raising children as a lesbian couple. Therapy could have worked on Consuelo's self-esteem and empowering her to safely get out of the emotionally violent household. This eventually became the appropriate focus of therapy. However, Consuelo needed to process her sexual trauma to understand how it had affected her and specifically, how it contributed to her inability to identify cues that Morgan was dangerous. And, how it influenced her otherwise inexplicable acceptance of Morgan's toxic treatment. She could not assert and protect herself as a child from her molester, and her helplessness activated in the face of Morgan's domination in the marriage. Not just unable to successfully collaborate with her, no matter what she said in conflict with Morgan, Consuelo would be annihilated once again.
"The literature on adults who have been sexually traumatized either in childhood or adulthood indicates that individual concerns associated with the traumatic event will influence not only the victim but also their significant relationships and will often be demonstrated through ongoing interpersonal conflict (Herman, 1992; Sprei & Courtois, 1988) and sexual dysfunction (Feinauer, 1989; Talmadge & Wallace, 1991). While these sexual difficulties may certainly be influenced and maintained by the couple system, the fact that they may be complicated by post-traumatic stress disorder (PTSD); APA, 1994) is significant for understanding the systemic interactions of the couple and for the development of useful therapeutic interventions" (Barnes, 1995, page 351-52). Barnes emphasizes the importance of how sexual trauma and PTSD are related. Problems in the intimate relationship, dissatisfaction with sexual relationships, and sexual problems may be presented by the couple as communications or compatibility issues. They may in fact be the consequence of sexual trauma. Barnes presents research findings from literature that 87% of female victims of father perpetrated incest report history of frigidity, promiscuity, confusion about sexual orientation compared to 20% of nonabused women. Another study found 80% of women with moderate to severe sexual problems including compulsive sexual needs, abstaining, or an inability to relax enough to enjoy sex. Additional consequences include greater sexual anxiety, guilt, dissatisfaction, less motivation, painful feelings, fear of intimacy, avoidance, experience as painful, distressing, or unsatisfying and desire and arousal disorders (page 354). "Foa, Olasov,, and Steketee (1987) reported that sexual assault victims constitute the largest single group of PTSD sufferers, with 60% of all assault victims meeting the criteria for PTSD at some point in their lives (Kilpatrick et al., 1987). In the areas of PTSD and childhood sexual trauma, Deblinger et al. (1989) found that children who had been sexually abused showed a significantly greater incidence of PTSD than did children who been either physically abused or had not experienced any type of abuse. Armsworth (1984) reports that PTSD resulting from childhood sexual abuse is often a chronic disorder that may be maintained into adulthood" (Barnes, 1995, page 352). "Talmadge and Wallace (1991) report that emotional blunting, loss of emotional and physical feeling, psychological physical pain, distrust of others' intentions, poor self-concept, fears and phobias associated with sex, and generalized fear responses including terror and dissociation are common post-trauma responses for the sexual assault victim. They propose that post-sexual assault sexual difficulties are most often the result of 'development of necessary escape mechanisms such as repression, denial, manipulation and dissociation' (p.168). It is critical that therapists' recognize the implications of this ongoing process on future intimate relationships" (page 353=354).
Survivors of sexual trauma often find their relationships to be incomplete and unfulfilling. Relationships are emotionally vacuous, superficial, full of conflict, or largely sexualized, and mistrust, guilt, and shame are common. Women survivors often have negative feelings about men, which leads to frequent conflict. There is a tendency for women to select male partners who have also been abused and subsequently likely to become abusive or neglectful. Relationship problems tend to extend to both their own families and in-laws. They anticipate negative treatment and act more negatively. It is difficult to accept nurturing and support from the older generation. When the therapist is aware of sexual trauma history, "it is easy to understand how the victim's relationships; may be wrought with conflict, anger, fear, and the desire to avoid threatening activities and interactions, and how systemic interactions between the victim and significant others may reinforce and maintain painful interactional patterns (Barnes, 1995, page 355). The therapist needs to consider how sexual trauma affects the motivation of the couple to enter into therapy. Since sexual trauma involves domination and control by another without permission, it becomes important to explore whether a partner who has been previously victimized is instigating, giving into, or possibly being coerced or forced into the therapy. A sexually traumatized partner may experience being coerced or forced into therapy as a revictimization. The therapist should consider nuances and complexity in this dynamic. An individual may agree to therapy out of guilt from being unable to satisfy the other partner sexually or fear of abandonment or rejection. "While the victim's motivation to please the partner and to save the relationship is important to the therapeutic process, it is also, paradoxically, the process that keeps the couple from moving forward to emotional closeness" (page 357). Who initiated couple therapy? The therapist may be surprised not only at who has initiated therapy, but also who has been sexually traumatized.
While there may be greater clinical experience with sexually traumatized women (as children or as adults), the therapist may find men with hidden sexual trauma that had been culturally taboo to admit or discuss with anyone. In addition to being unable to admit having been sexually molested for, some men who were seduced or sexually indoctrinated by older girls or women may not recognize that they had been sexually molested or exploited (author's clinical experience with several male clients). Elliott would inexplicably over time become rude and disrespectful with his girlfriend. He'd emotionally disconnect or feel irrational anger at her. This had been a pattern with other relationships with other girlfriends from as far back as high school. The initial relationship was always sweetness and care with Elliott becoming an emotionally abusive jerk once there was commitment. Elliott did not understand his own behavior, because he cared for his girlfriends- the current one especially. Family-of-origin exploration and direct questions about possible sexual molestation brought no suggestive information. When the therapist asked about when, how, and with whom Elliott began sexual experience, he told about an older female seducing him. He told the story with not a small degree of pride that he "got some" when he was pretty young from an attractive older female. Elliott was 13-years-old and she was 19-years-old. The sex occurred two or three times a week until his older brother found out about it. His brother was furious at Elliott and forbade him to see the young woman again. He confronted and threatened the young woman to stay away from Elliott.
With deeper exploration and prompting by the therapist, Elliott admitted that he was naïve and did not know what was happening in the beginning. He was intellectually, emotionally, and psychologically uncomfortable, but his physiological arousal was automatic when she sexually manipulated him. He said he didn't understand his brother's anger at finding out about the sexual relationship. However, he admitted that he was somewhat relieved that the sex ended with his brother's intervention. His discomfort and confusion at 13 had morphed over the years to a macho story of sexual bravado. The therapist told him that he had been molested. Initially shocked and trying to hold his macho sexual mythology, Elliott came to realize that he had been manipulated and exploited by someone older and more powerful- sexually aware and powerful than he. His shame and anger at being sexually exploited had unconsciously evolved into abusive anger and behavior at his girlfriend. Elliott was punishing her and had been punishing previous girlfriends for the neighbor's sexual abuse he had suffered more than twenty years before. Once his sexual trauma entered overtly into his therapy and his relationship, Elliott was able to process it for himself and manage its effects on his relationship. He could own his anger at the older woman. The anger might remain a part of him, but now he could identify it and work at keeping it from intruding upon his relationship and keeping it in its proper place. Rather than shame for his behavior and for being molested, Elliott found compassion for the young boy he was that had been exploited. He lost his anger at his younger vulnerable self and was able to reintegrate that part of him into his overall self. Simultaneously, he was able to mute his anger at himself for his vindictive urges towards his girlfriend. His treatment of her improved immediately, and eventually it became easier and easier to stay emotionally present with her and manage his intrusive feelings.
In the therapy with Elliott, dealing with his presenting issue of having relationship difficulties required him uncovering and dealing with sexual trauma. He was able to accept the new goals that served the original goals. The therapist needs to be wary of what clients present for the goals of therapy. They may appear logical and inherently productive. However, they may be misguided if there is inaccurate assessment and diagnosis of key issues. Goals for the partner with sexual trauma include experiencing sex as positive, integrating sexuality into one's self, and developing ways to express sexual needs and sexuality to enhance self, life, and the relationship (as opposed to expressions that cause problems). A major goal for the partner is to find and accept compassion for the previously traumatized sexual partner that problematic sexual behavior may be due to sexual trauma history rather than rejection. With greater understanding about the previous and ongoing effects of the trauma, the couple can strive to improve sexual comfort, functionality, and control. The therapist however needs to be aware that this work, including prescriptions for sexual exploration and interaction may trigger PTSD symptoms. Elliott was arguably manifesting PTSD symptoms with his girlfriend. However, dealing with his specific sexual trauma could have triggered emotional numbing, disassociation, or other PTSD symptoms. The client or in the case of a couple, the partners should be forewarned of this possibility.
Couple therapy should include guidance in how to manage such symptoms in nurturing and constructive ways for both partners. Monson et al. (2004) proposes that Cognitive–Behavioral Couple's Treatment (CBCT) has is effective for treating a number of disorders while improving relationships among other benefits. "CBCT specific to PTSD recognizes that couple's behaviors and belief systems interact and reciprocally maintain relationship discord and PTSD symptoms. Thus, the behavioral and cognitive interventions are aimed at the dyad, and at simultaneously improving PTSD symptoms and relationship discord" (page 341). They recommend three treatment phases:
(1) treatment orientation and psychoeducation about PTSD and its related intimate relationship problems;
(2) behavioral communication skills training; and
(3) cognitive interventions.
The therapist may follow these phases in order as recommended by Monson et al. in a fifteen-session program or use individual judgment and clinical style to adapt their principles to the couple. Throughout a formalized program or individualized treatment, the therapist should be promoting compassionate understanding. Communication skills training and cognitive interventions can also build intimacy between partners. Experiential guidance and practice can help deal with emotional numbing and avoidance while teaching communication skills. Through these processes cognitive schemas will be exposed that are connected to the evolution of PTSD symptoms and behaviors.