By: Nicole R. Randall, M.A. & Matthew Golley, M.S.
We are Veterans of the US Marine Corps and clinical psychology doctoral-trainees working with Veterans from the Iraq and Afghanistan conflicts within Veterans Affairs (VA). Within our clinical work, we noticed a myriad of sex and intimacy (S&I) issues that frequently occur in conjunction with posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI; Hirsch, 2009; Turner, Schöttle, Krueger, & Briken, 2015) that are often beneath the surface of clinical attention. This paper will review relevant literature and discuss how we utilized this information to create an interdisciplinary treatment group
A study by Mackenzie, Alfred, Fountain, and Combs (2015) found that for survivors of TBI within the general population, intimacy was their third most important unmet need. Another study found that between 35-75% of Veterans with PTSD report significant intimacy problems (Katz, 2008). Further, Nunnink, Goldwaser, Afari, Nievergelt and Baker (2010) demonstrated that as many as 80% of Veterans with PTSD reported clinically significant sexual problems, which were found to be most closely related to PTSD’s emotional numbing symptom cluster.
These S&I issues lack clinical attention partially because of clients’ reluctance to report them to providers (Lindau, Surawska, Paice, & Baron, 2011) and partially, we suspect, because of providers’ reluctance to ask. We felt some hesitation to discuss these topics, due in part to our preconceived notions of privacy, as well as our concerns about our own lack of clinical knowledge in this area. However, after immersing ourselves in the literature, we realized how important these issues are in the treatment of Veterans. Despite the lack of attention these issues receive in therapy, they remain serious concerns for clients. As Veterans, we were impassioned to shine light on these issues because we are in a unique position to understand the nuances of S&I issues from a military cultural standpoint. We therefore chose to create a novel group-based intervention to function as an avenue for discussing common S&I issues.
We decided to develop a psycho-educational group protocol. We aimed to “break the ice” on the topic of S&I and to open a line of communication between clients and providers. We decided to incorporate discussion, activities, guest speakers, and optional readings for multi-modal delivery of information. To address these complex issues in multiple domains (e.g. intimacy, attitudes about sexual activity, sexual functioning, medical and psychological implications), we utilized Feminist Theory (FT; Friedman, 1963) and Social-Constructionist Theory (SCT; Berger & Luckman, 1966). These theoretical frameworks were essential in elucidating the social and interpersonal contexts from which many of our clients’ S&I issues stem.
An Integrated Theoretical Approach to Treating Sex and Intimacy Issues
We chose to incorporate FT to examine social-gender roles, gender inequality, patriarchy, and stereotyping (Friedman, 1963). Initially, we felt unsure using FT with combat Veterans because we did not want to appear confrontational or politically motivated due to clients’ possible misperceptions of Feminist principles. Luckily, our clients openly used feminist principles of gender equality to not only gain insight into patriarchy and stereotypes, but also liberate themselves from these. For example, one client who stated that he had never questioned certain stereotypes about himself as a male, shared that this protocol facilitated growth in his self-concept. We discussed how Feminist Theory could elucidate the cultural context from which gender oppression continues to be an issue for service-members (Burke, 2004). Compulsory masculinity denies both sexes opportunities to express and utilize the full range of human emotions, requiring through social pressure, preference for typically masculine emotional displays and behaviors. Service-members are commonly discouraged from displaying traits that are culturally defined as feminine for fear of compromising perceptions of strength and unit cohesion, thus promoting hyper-masculinity (Rosen, Knudson, & Fancher, 2003). One client exemplified the relational distress that often results from hyper-masculinity by sharing, “I feel like I can’t ever show weakness, and I know it’s affecting my marriage.”
Broadening the discussion, we incorporated SCT, which helped clients examine how processes like military indoctrination, combat experiences, and their civilian communities influenced their socially constructed assumptions and beliefs about themselves and others. One client described how his identification with his warrior identity, conflicted with his civilian role of husband. He had been treating his family like they were in the military, as he was blending his dual roles. Following the presentation of SCT, he acknowledged how he carried over beliefs and expectations from the Army to his home life. This added insight allowed him to adapt his interaction style and beliefs to civilian society, identifying and modifying his interactional patterns as they carried over into his intimate relationships (Hedges, 2005).
Integrative Approaches to Treating Sex and Intimacy Issues
We recruited eleven male Veterans from an inpatient program for co-occurring TBI and PTSD. When we surveyed participants for input on group content we discovered that S&I issues were a significant area of need. To evaluate our intervention, we assessed prevalence of S&I symptoms, comfort with discussing S&I concerns, and knowledge of content domains including: PTSD/TBI impact on S&I, medication side-effects, and treatment options.
Our curriculum covered: cultural impact on S&I, intimacy types, first steps in rebuilding intimacy, common sexual dysfunctions, medications/side-effects, and treatment options and resources. The first session focused on culturally-derived values and expectations and their influence on the acceptability of sexual practices. We were surprised to see the variety in clients’ reactions to gender stereotypes, the impact of religion, and the range of cognitive flexibility they demonstrated as a group. We initially expected more similarity between responses given the relatively homogenous nature of our sample with regard to sex, age, ethnicity, and SES, we expected more similarity. We were also delighted to see how open-minded everyone was and how enthusiastically they discussed personally intimate details like sexual preferences and disavowed previously held stereotypes, all in the first session.
The second session normalized S&I -related symptoms and disorders, which frequently co-occur as sequelae of PTSD, TBI and military sexual trauma (MST; Hirsch, 2009; Turner, Schöttle, Krueger, & Briken, 2015). We created a handout for Veterans to share with their partners which described common symptoms including erectile dysfunction, decrease in libido, emotional numbing, avoidance of physical touch, and unintentional merging of aggression and violence within the context of physiological and psychological arousal (American Psychiatric Association, 2013). Clients were especially interested in the sexual response cycle (Leiblum, 2006), as many of them struggled with erectile dysfunction. We also introduced treatment options and referrals.
In the third session, clients engaged in a group discovery exercise on types of intimacy including emotional, intellectual, physical, and sexual. After they each gained the vocabulary to describe their personal preferences, it was interesting to see how each Veteran compared himself to other group members, as well as openly discussed his speculations about preferences of their partners. When two clients stated that they would share their handouts with their partners in order to identify ways to meet each other’s needs, we excitedly realized our clients were becoming increasingly empowered.
For the final three sessions, we invited guest speakers (e.g., pharmacists, nurses, and physical therapists) to share their expertise based on requests by clients during the design phase. Our most popular guest speaker was our pharmacist. She presented in-depth information on common medications prescribed for PTSD and TBI and their sexual side-effects. This topic was highly relevant and had an apparent effect on clients’ self-advocacy. After this session, our nursing staff and prescribers saw an immediate increase in the proactive solicitation of information regarding their prescriptions and collaborative discussion of alternative and adjunctive therapies.
Overall, the group was a success. Providers and clients expressed their appreciation of gained information in an underutilized focus of treatment. Several clients requested individual follow-ups with specialty providers and some began direct conversations with partners. All clients reported that the group was worthwhile with 75% requesting group extension. Based on self-report, relevant knowledge increased across domains; including how PTSD affects S&I, TBI’s impact on S&I issues, medications and S&I, and S&I treatment options. In fact, many of our participants reported little or no knowledge in the domains at pretreatment and a majority of our participants reported attaining knowledge in each domain covered.
Conclusions and Future Directions
We were surprised at how comfortable clients reported being with discussing S&I concerns during the first session. It appears that broaching this topic was actually more challenging for us. Since we both have cultural backgrounds where S&I topics are not discussed openly, we found processing our apprehensions and assumptions with each other helped us facilitate the group more effectively. In addition to our shared Marine identity, we also expected our participants to view our role as therapists as a barrier to disclosure. Therefore, vitally important for future providers to address their own hesitations and beliefs around S&I, as this was key to creating a sense of ease and confidence in the group atmosphere.
Further, we understand that our Veteran status may have contributed to clients’ initial comfort level, but we credit their continued openness to our collaborative approach. That is, we matched group content directly to the initial needs assessment. We also collaboratively developed group rules and methods of reinforcement. We suggest future groups do the same to ensure group safety and interpersonal respect.
Regarding lessons learned, it is important that providers address their own hesitations and beliefs around S&I, a key to creating ease and confidence in group atmosphere. As our clients expressed significant benefit from participation, we hope that others will be encouraged to broach the subject with confidence and will find the courage to take on this under-treated area of concern among Veterans. Additionally, the interdisciplinary inclusion of guest speakers offered essential expertise and ease of access for Veterans to follow-up with S&I concerns. It is essential to take an active role in collaborative lesson planning with guest speakers to ensure topics match those requested by group members.
We hope others will be inspired by our rewarding experience and look to fill gaps in their treatment programs. We have found this venture to be extremely rewarding as it received an overwhelmingly positive response from everyone involved, and it allowed us to collaborate with a variety of professionals on a project that will help me define our professional identities. Our hope is that our experience will inspire you to be brave and make your mark!
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Nicole Randall, M.A. is a doctoral candidate in clinical psychology at Argosy University, researching the impact of military culture on military sexual trauma. She is also a Veteran of the United States Marine Corps and a psychology intern for the Veterans Affairs Health Care System where her clinical focus is on sexual and intimacy issues and program development and evaluation. Randall can be reached at firstname.lastname@example.org.
Matthew Golley, M.S. is a doctoral candidate in clinical psychology at Palo Alto University in the Ph.D. program, studying person-centered approaches, mindfulness, rural mental health, and Veteran mental health care issues. His current research focus is on program development/evaluation and understandings of mindfulness.