INTERVIEWS WITH MALE SURVIVORS OF TRAUMATIC EVENTS AND ITS IMPLICATIONS FOR TREATMENT

by George Mike Marketing manager

By Jason Arnold, Ph.D. from Waltham, Massachusetts

DEDICATION

For my patients, who every day, rise to the awesome challenge that is living life after such adverse circumstances. Their courage is inspiring and makes every day working with them such an honor and privilege.

Introduction

The focus of this study was to examine the specific means by which males actively cope with traumatic or negative life events. There is a wealth of knowledge of information on the association between traumatic experiences, coping style, and the development of trauma-related psychopathology. However, there is very little available research in the available clinical literature regarding the coping responses of men who have experienced traumatic or negative life events such as automobile accidents, the loss of a loved one, and those events that would be considered extreme outliers in the human experience such as natural disasters and terrorism.

Since the terrorist attacks on September 11, 2001, and the decimation of the gulf coast by Hurricane Katrina, how individuals respond to these experiences has become of great interest to mental health community. With the wars in Iraq and Afghanistan currently in the forefront of the American psyche, it is integral that the mental health community be able to explore ways of assisting those who have experienced events which would be considered traumatic (i.e., events in which the individual experiences feelings of helplessness and horror and that there is the expectation of personal injury or death).

Many people in the United States population have experienced some type of trauma including but not limited to motor vehicle accidents, vicarious traumatization (e.g., witnessing an automobile accident), sexual assault, incest, and domestic violence. According to the National Center for Post-Traumatic Stress Disorder (2008) 25% of men and 13% of women have experienced motor vehicle accidents, 10% of men and 17% of women have experienced sexual assault or rape, and 10% of men and 25% of women have experienced child sexual abuse or incest.

Research (Bryant & Harvey, 2003; Hasin, Keyes, Hatzenbuehler, Aharonovich, & Alderson, 2007; Sciancalpore & Motta, 2004) has suggested that active coping, which refers to a a proactive approach to dealing with a particularly traumatizing event is associated with fewer symptoms of trauma-related psychopathology such as Post-Traumatic Stress Disorder, Acute Stress Disorder, and Major Depressive Disorder. Research has also suggested that there are gender differences in how men and women experience traumatizing events (Freedman, Gluck, Tuval-Mashiach, Brandes, Peri, & Shaley, 2002) Additionally, there is a gap in the literature regarding the trauma responses of men. A majority of research exploring this topic focuses on military combat (Prigerson, Maciejewski, & Rosenheck, 2002) and not of those experiences that would not be considered extreme.

This study attempts to fill that gap by examining the specific coping responses of men. The study examined the coping responses of men by means of interviewing college undergraduate males regarding their trauma experiences. Discussion of preliminary results as well as its implications is also included.

Research on Trauma

Research on Trauma and Active Coping

In 2007, Hasin, Keyes, Hatzenbeuhler, Ahronovich, and Alderson examined the effects of exposure to or the interpersonal loss due to the September 11, 2001 World Trade Center terrorist attack on posttraumatic stress and alcohol consumption. Research lead them to theorize that on a national level, individuals in proximity to the World Trade Center during the terrorist attack on 9-11 would exhibit post-traumatic stress symptoms and Post-Traumatic Stress Disorder (PTSD) than those who were not in close proximity during the disaster.

Hasin and colleagues examined the effects of the World Trade Center terrorist incident on the participants’ level of PTSD and alcohol consumption. Participants from the study were taken from the Community Health Survey and were sampled from a New Jersey county approximately 21 miles from lower Manhattan via random digit phone dialing. The sample of 579 participants ranged from the ages of 18-61. Approximately 465 were female and 84 % were identified as white or Caucasian. Of the sample, 64% reported that they had lost a friend, family member, or loved one in the World Trade Center attack. For the study, the participants were given the Alcohol Use Disorder and Associated Disabilities Interview Schedule (AUDADIS), with particular focus given to the post-traumatic stress scale on the instrument to assess trauma related to the terrorist attack. The researchers used two-tailed F and t-tests for significance with an alpha level set at less than .05. The main findings supported the theories put forth by Hasin and colleagues regarding alcohol consumption and post-traumatic stress symptoms after a terrorist attack. The data indicated that alcohol consumption increased, as did post-traumatic stress symptoms. The researchers indicated that the increased alcohol consumption increased due to the use of the substance as a method to cope with the terror attacks. Additionally, Hasin and colleagues’ data suggests that previous histories of psychiatric illness or symptoms, such as depression, have an effect on the development of post-traumatic stress symptoms due to its tendency to co-occur with other psychiatric disorders. Hasin and others also suggest that physical proximity does not play a part in the development of post-traumatic stress symptoms or an increase in alcohol consumption.

The study by Hasin and others suggests the negative impact that traumatic or negative life stressors such as the terrorist attacks of 9-11 can have on individuals including the development of psychiatric symptoms such as those associated with Post-Traumatic Stress Disorder as well as an increase in substance abuse as an end result of maladaptive coping. This study indicates that effective, active coping strategies such as stress management, social support, and direct clinical services, must be utilized in the event of a traumatic event such as a terrorist attack.

Although the findings by Hasin et al. are compelling, the study had limitations, which could have affected the outcome of the study. The researchers did not assess for a previous history of psychiatric disorders in the sample with the exception of the participants disclosing any past information. Hasin suggests that this limitation could potentially explain the higher levels of post-traumatic stress symptoms in the participants. Hasin indicates from this limitation on the study that pre-existing psychiatric conditions can possibly exacerbate problems individuals have in coping with traumatic stressors. Additionally, the study used an instrument that is self-report and relies on the truthfulness of the reporting of information by the participants. Information regarding behaviors that would be deemed socially unacceptable (i.e., excessive alcohol consumption) could potentially be adjusted to an acceptable way and reported to the researchers without benefit of verification of other sources.

The study by Hasin et al. is also a quantitative study, which compared to qualitative designs, have limitations. Quantitative studies can only provide overall generalized information that has been inferred from a sample. The information taking from a quantitative study such as this one provides a limited amount of information, which, compared to a qualitative study that provides more in-depth material about the experiences of participants. For clinicians, this can be helpful to understand the experiences of their clients. Additionally, in seeking treatments to assist in active coping strategies, a qualitative study would be able to provide specifics as to what types of strategies have proven successful with clients of other clinicians and researchers.

Sciancalpore and Motta (2004) examined Post-Traumatic Stress symptoms and coping style in both men and women following a terrorist attack as well. The results presented by Sciancalpore and Motta support the need for the introduction of positive proactive coping skills with those who have experienced traumatic or negative life events.

The researchers examined the differences in PTSD symptoms and coping in 123 people (71men and 51 women) who had experienced a terrorist attack. Sciancalpore and Motta suggested that there would be differences in coping between men and women with women more likely to develop symptoms of Post-Traumatic Stress Also, it was posited that such differences would be mediated by gender role. The researchers used several instruments to measure the constructs under investigation. The Modified PTSD Symptom Scale was used to measure PTSD symptoms, the Bem Sex-Role Inventory was used to measure social roles related to the sex of the participants, Response Styles Questionnaire was used to measure the ways in which individuals respond and cope, and the Post-Traumatic Cognitions Inventory, was used to examine cognitive thought processes typically associated with PTSD.

Sciancalpore and Motta found gender differences in PTSD development. Females tended to have a higher rate of PTSD symptoms than did the male participants in the study. Additionally, a ruminative coping style (i.e., dwelling on the event) was also associated with high rates of PTSD than not. Results from the Bem Sex-Role Inventory suggested that those who did identify themselves as having feminine characteristics had a higher rate of PTSD symptoms.

The research by Sciancalpore and Motta is in agreement with other research (Hasin et al, 2007) in that it supports a more active approach to coping with traumatic events and life stressors. Sciancalpore and Motta posit that a ruminative style is highly associated with Post-Traumatic Stress Disorder. It can be inferred from this research that a more proactive coping style would not inversely associated with PTSD. If interventions are to be used to aid in the recovery of trauma, according to the work of these researchers, having a more active approach to coping, would be associated with a more likely chance at recovery from the traumatic or negative life event.

This study, while supportive of the previous studies, has potential problems that threaten its validity. The number of participants for this study, compared to other studies, is relatively small (n=123). The researchers have made inferences and generalizations about the larger population, specifically that among the population, when faced with a traumatic event, an active coping response will yield a lower rate of post-traumatic stress symptoms. Although this is a very interesting finding, the researchers are making these generalizations based on a small population and in one geographic area. It can be asserted that it would be difficult to propose those specific assertions based on the small n-size. According to the Central Limit Theorem, smaller populations are not as reflective of the population as a whole, thus larger sample sizes are easier to infer about the population because they typically contain the characteristics of the whole population.

Additionally, the sample size of this study regarding sex is lopsided. The sample size has comparably more males than it does females. This could potentially have an effect on the outcome of the study if the participants reported a high level of sex-role association on the Bem Sex-Role Inventory. The researchers also did not account for the possibility of a high level of racial and ethnic identity in this sample as well. Due to the cultural norms of many non-White minority groups, the results could potentially be subject to challenge by other scholars. For example, in many Asian cultures, there is a taboo regarding mental illness and the seeking out of related services. An individual who has a high level of identification with Asian culture, may be less likely to answer questions surrounding psychiatric illness and mental health due to a specific cultural norm. The answers he or she could give due to this taboo surrounding mental illness could potentially skew the data that would be collected from the participant in the study. This effect could possibly be lessened in a qualitative designed as the researcher, when collecting data from participants in the research, would most likely become aware through verbal indications or non-verbal language that would suggest a discomfort with the topic or direction of the interview.

Although the tragedy of September 11^th was traumatic to those who had experienced the event, those events such as automobile accidents can prove to be traumatic as well. Bryant and Harvey (2003) examined gender differences and the relationship with trauma-related psychopathology such as Post-Traumatic Stress Disorder and Acute Stress Disorder in the context of experiencing a car accident.

The study by Bryant and Harvey aimed at studying the effect of gender on Acute Stress Disorder and Post-Traumatic Stress Disorder. For this study, 305 motor vehicle accident survivors were studied using the Beck Depression Inventory, the Impact of Events Scale, the State-Trait Anxiety Inventory, Acute Stress Disorder Interview, Composite International Diagnostic Interview Post-Traumatic Stress Disorder Module, and the Abbreviated Injury Scale. The accident survivors were assessed for ASD one month after the event and were then assessed for PTSD six months after the accident. The results from Bryant and Harvey’s study found that ASD was diagnosed in 8% of males and 23% in females. Post-traumatic stress disorder was diagnosed in 15% in males and 38% in females. When the researchers did a follow up assessment on the participants at 6 months post-trauma, 57% of males and 92% of females who had met the diagnostic criteria for ASD subsequently were diagnosed with post-traumatic stress disorder. Females displayed more adverse effects to the motor vehicle trauma than did males.

The study clearly indicates the impact that a traumatic event, such as a motor vehicle accident, can have on the mental health of an individual. The results also show that gender differences may play an important role in the effects of the traumatization as well. These results are similar to research done by Sciancalepore and Motta (2004).

This information can be useful to those in the helping professions because the results show the importance of working with trauma survivors early on as opposed to several months later. In the case of this study, many of the participants who had been diagnosed with acute stress disorder went on to develop post-traumatic stress disorder, which can, with time, become the case. Bryant and Harvey’s work also illustrate that motor vehicle accidents, like terrorist attacks, can be just as traumatic and result in similar psychopathology.

However, this study does have a limitation. As discuss earlier, quantitative studies, as opposed to qualitative studies, sometimes lack enough information to be practically useful. This study indicates gender differences in trauma experiences between men and women, but does not go into length as in exactly how men and women are different. Bryant and Harvey suggest that women experience fewer negative effects from the traumatic experience than do men, but does not elaborate as to what kinds of experiences the women or the male participants have. A qualitative study, such as the one being conducted, would allow for rich data that would be able to elaborate on what exactly those experiences were.

Research by Freedman, Gluck, Tuval-Maschiach, Brandes, Peri, and Shalev (2002) also indicates that there are gender differences in the response to a traumatic or negative life event. Freedman and colleagues completed a longitudinal study, which recruited participants from an emergency room following a motor vehicle accident. The number of participants for the study was 275. Both male and female participants were included in the study. The participants were administered the Structured Clinical Interview for DSM-IV, the Clinician-Administered PTSD Scale, Impact of Events Scale, Mississippi Scale for Combat-Related PTSD, Peritraumatic Dissociative Experiences Questionnaire, State-Trait Anxiety Inventory, Beck Depression Inventory, and the Trauma History Questionnaire Self-Report. The researchers interviewed the participants one week, one month, and four months after the traumatic event. The findings of this study, as opposed to Bryant and Harvey (2003), suggests that there were no gender differences in the prevalence or recovery of PTSD or in its symptom levels at the one and four month periods. The results also indicated that women had a prevalence of lifetime and post-accident generalized anxiety disorder (GAD) than did men.

The study, while useful to the field of the study of trauma, provides information that is susceptible to bias. Many of the instruments such as the Mississippi Scale, the BDI, the Trauma History Questionnaire, and the Clinician-Administered PTSD Scale rely on the self-reporting of individuals. Additionally, instruments such as the Mississippi Scale is a likert-type scale, which makes the accuracy of the instrument for clinical research suspect in its validity.

The research by Freedman and colleagues is important to the mental health professions because it indicates that gender can be an important factor in how the individual may interpret and respond to the event because of the socialization of gender roles and stereotypes in society. This is important when working with clients as some may not feel that a specific event was traumatic, while another may feel that the event may have been quite severe. These results suggest the importance of knowing and understanding the experiences of clients who have dealt with a traumatizing experience, which makes the case for the need for qualitative studies examining the experiences of survivors of traumatic events. Qualitative research, as opposed to a quantitative approach, is not as widely done and would be helpful in providing helpful information on experiences related to trauma, trauma-related psychopathology, and the experiences of women and men.

Research on Trauma and Gender

Research has indicated that there are differences in the way that individuals of different genders cope and respond to traumatic events. However, research exploring the trauma responses of men and women separately, has focused less on collective events that men and women typically experience as a group and rather on experiences that are associated with each specific gender. Research on the trauma experiences of women are typically examined in the context of sexual assault , sexual abuse, and domestic violence (Gibson & Leitenberg, 2001). Research on men in this particular arena is lacking. This can be attributed to the social stigma and attitudes attached to men being the victims of sexual assault and domestic violence (e.g., “real men” do not let their partners beat them. “Real men” do not get raped by other men.). The social stigma surrounding these types of events could potentially cause most male survivors of these types of trauma to not report these incidents or to not participate in research out of shame and embarrassment.

However, when research is undertaken on male trauma survivors, the research is typically done on men who have served in the military and have experienced combat. Prigerson, Maciejewski, and Rosenheck (2002) studied the effects of combat trauma on U.S. men. The aim of this study was to determine the outcome of adverse effects that can be attributed to combat exposure. For this study, a representative sample of 2,583 men, ages 18-54 who had experienced combat, were assessed. The instruments used in this study were the Composite International Diagnostic Interview and the NIMH Diagnostic Interview Schedule for DSM-IV. The results of the Prigerson study revealed that 27.8% had met the criteria for PTSD, 7.4% met the criteria for Major Depressive Disorder, 8% had a substance abuse disorder, 11.7% experienced job loss, 8.9% were currently unemployed, 7.8% were currently in the process of divorce or separation, and 21% of the participants were involved in spousal or partner domestic abuse.

The results from the study suggest that these adverse effects are attributable to combat exposure. However, Prigerson and colleagues do not indicate as to the type of coping responses that facilitated these types of diagnoses, and further, the types of coping responses of those who did not meet the diagnoses for any of the criteria for PTSD, MDD, or substance abuse. This information would be clinically relevant to those who work with this population in way of understanding coping behaviors associated with men and what can be done by means of clinical interventions to prevent complications resulting from combat exposure.

This study provides information on the effects that traumatic experiences can have on men. While most of the available research on sexual abuse, incest, and domestic violence is done on samples of females, this research reports that men are also adversely affected by traumatic events such as the experience of combat. This study also makes a persuasive case for the need for further research on the responses of men to traumatic experiences

Recent research by Arnold (2006) examined the coping responses of males who had different backgrounds in respect to trauma experience including automobile accidents, vicarious trauma, physical abuse, sexual abuse, and domestic violence. Arnold examined undergraduate males administering the Beck Depression Inventory, the Behavioral Attributed of Psychosocial Competence-Condensed, the Keirsey Temperament Sorter, and the Life Stressors Checklist. Results from the study indicated that there was no relationship between the types of trauma experienced and levels of depression on the BDI suggesting that the type of trauma is an irrelevant factor in the development of depressive symptoms. Additionally, the research also suggests that active coping, as opposed to a ruminative style of coping is associated with fever symptoms of depression, which is consistent with the literature presented.

The study had several limitations, the most important being that many of the instruments were self-report and were subject to potential biased responses by the participants. This study attempted to generalize it’s results to the wider population, which is a challenge to it’s validity in respect that all of the participants were from a university population and did not take into account those in the population who are not.

Despite problems with its validity, the study provides insight into the coping responses of men. Specifically, active coping responses in men and its association with lower levels of psychopathology regardless of the traumatic event. This is helpful in understanding what is helpful in working with this population. Working with men to be proactive in their coping will most likely lessen the effects of a traumatic experience. However, what has not been helpful is that Arnold does not address what specifically can be done in regards to active coping (i.e., techniques to be used with this population).

In conclusion, research suggests that active coping is associated with fewer symptoms of trauma-related psychopathology as opposed to ruminative styles of coping (Sciancalpore & Motta, 2004). Research also suggests that there are gender differences in coping, indicating that men and women experience and cope differently with traumatic events (Bryant & Harvey, 2003). Additionally, there is a need to understand the experiences of men. A majority of research in the field of trauma focused on men in the context of extreme situations such as combat (Prigerson, Maciejewksi, and Rosenheck, 2002). Recent studies have suggested that, in men, active coping is associated with fewer symptoms of psychopathology regardless of the type of trauma that has been experienced. This study, which is an extension of the Arnold (2006) study, will examine active coping in men and will explore the types of coping responses men have when exposed to a traumatizing event.

Jason Arnold, PhD, from Waltham, Massachusetts currently is a mental health practitioner in the metro Boston area. Originally an Illinoisnative, he moved to Massachusetts seven years ago with his husband of now 20 years. Professionally, he has a PhD in psychology from Southern Illinois University. He’s done post doc work in clinical studies at Harvard University. He’s worked in outpatient psychiatric practices, intensive outpatient programs, substance abuse as well as in VA veterans’ programs. He is currently a clinician the Boston area. Jason Arnold holds current areas of interest in psychosis, depression, anxiety disorders, and Bipolar Disorder as well as men’s health. If there is an issue you think he may be able help with, please do feel free to contact him.

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