Foundations: Session #2 Self care - Common effects and strategies to enhance safety and stabilisation

Structure

1	Housekeeping, announcements & check in	15 min
2	Module content Self care strategies	45 min
3	Break	15 min
4	Module Content Common effects, managing trauma & well-being PTSD - Complex Trauma & mindfulness	45 min
5	Closing session Wrap up: check out	15 min

Materials needed

Name tags.
Notepads & pens.
Whiteboard markers.
Refreshments.
Handouts.

Housekeeping & announcements

Welcome group participants. Introduce new participants to the group, if applicable. Demonstrate the weekly arrival procedures: name tags, welcome to refreshments, cell phones off.

The list of 'Hopes and aspirations' and 'Group guidelines', developed during the previously session should be displayed on wall. Preferably also typed up and made available to participants.

Check in

Facilitators to introduce the plan to start each week with a brief check in.

Check in is to include an opportunity to reflect on content covered and learning experienced, as well as current well-being. Facilitators to be sensitive to containing extended discussions of events that occurred during the previous week (taking the time to acknowledge their significance for individual participants, and foregrounding the value of returning to this topic in line with large group discussion/identified session content). Participant’s choice to provide limited check in at this time to be respected.

Optional continuum exercise, if not previously introduced in session one.

Module content 1: Self care strategies

There is no prescribed way of how men and women are impacted by child sexual abuse or sexual assault; everyone is different. We do, however, know that sexual abuse or assault can have profound effects on people's lives and relationships. The focus of this section is on identifying and implementing strategies that enhance personal well-being, and help to understand and better manage the effects of child sexual abuse. The focus is on validating the participants' knowledge and skills, strengths, and resourcefulness, as well as providing information and support to enhance coping and self care. It is about building a solid base. The group process is an opportunity to share and learn from each other, to understand ('normalise') common responses to child sexual abuse, and reduce the sense of isolation and aloneness.

Prior to commencing the topic/discussion of common effects of sexual abuse and productive strategies for coping, it is useful to facilitate individual sharing and group discussion to identify what’s working - what are the participants currently doing that keeps them on track and supports their well-being. This is about acknowledging participants' active role on a day to day basis in taking care of themselves, identifying the valuable every day routines, and the strengths, knowledge, and skills they already possess. It also provides an opportunity to share learning with other group members. Facilitators to warm up and introduce larger discussion utilising, as a dyad or small group exercise, creative resources, like strength cards, picture cards. List of strategies, knowledge, and skills to be recorded on white board or flip chart/butchers paper.

Some possible questions

What are the things that you are doing right now that are working for you in your day to day life?
What sustains you during tough times?
Are there particular routines and habits that you have developed that you know support your well being?
Are there particular people or relationships that are important in your life that provide support and encouragement?
What keeps you energised and motivated?
What keeps you on track?

The focus of this initial discussion is on identifying activities, routines and state of mind that enhance every day well-being. By developing a solid base or foundation, and knowing what contributes to it, we are in a better position to deal with problems when they do come along. There are times when all of us have difficulties or struggle with stuff. It is useful, therefore, to have an awareness of these every day activities/practices that keep us on track, and contribute to our overall well-being. Here, possessing strategies that support our well-being and assist us in dealing with problems is presented as something that is important and valuable for everyone (normalised) – not just useful for men who have been sexually abused. However, having noted this, we know that men who have been sexually abused in childhood confront additional difficulties related to the experience of abuse and that they benefit from possessing specific strategies and techniques to deal with them.

Foundations of well-being

It can be useful to refer to the Foundations of well-being handout, as well as Living Well: A Guide for Men and the Living Well app. As noted at the beginning of this session/week, there are everyday activities, habits, and routines men can put in place to enhance their personal and relational well-being. Placing a focus on developing habits that contribute to personal health and wellness are important for everyone, not just men who are dealing with the legacy of sexual abuse. However, developing and maintaining a solid base is particularly useful for men who have been sexually abused, as a healthy routines better equips them to deal with difficulties when they do arise.

The focus on making sure the building blocks that support well-being are in place, like eating and sleeping well, exercising, and having strategies to settle and calm yourself and deal with day to day stress, will not make the difficult stuff go away, but it does put you in a better place and frame of mind to deal with difficulties when they do arrive. It explicitly re orients the focus from just managing trauma to developing a fulfilling quality of life.

Facilitators to discuss and work through the different domains that support well-being.

Physical exercise.
Eating well.
Sleeping.
Staying connected.
Relaxation.
Mindfulness.

Emphasis is on strength based discussion, which acknowledges the steps participants are currently taking to support and enhance their well-being, simultaneously creating room for discussing domains requiring additional work/focus. Additional handouts to be sourced and provided to participants, e.g strategies for developing and maintaining healthy sleep routine.

Option: ‘How secure is my base?’ exercise

Participants are provided with the How secure is my base handout and invited to conduct a self assessment. The men are invited to shade in their assessment of their level of accomplishment in each of the six domains of well-being: Eating well, Sleeping well, Exercise, Staying connected with others, Mindfulness, and Relaxation from Poor through to 50-50, Good, and Excellent. This exercise provides a quick visual cue as to areas for additional attention. It is a useful means of self assessment, not a tool by which to draw comparisons with others.

Option: Mindfulness, relaxation and grounding exercises

Introduce a mindfulness, relaxation, or grounding exercise as a means to settle and support prior to break. Consider introducing the How to get grounded exercise (p. 16 of the Participant workbook, Also found in Facilitator resources).

Option: Counting your breath

This exercise is particularly useful for those participants who find their minds race or when they feel anxious. This exercise may be used for a minute or two as a brief form of relaxation, or it may be extended for 15 minutes or longer as a form of meditation.

Instructions: Sit in a comfortable position, with your back relatively straight. Keep your eyes open, and allow them to focus on the floor in front of you. Breathe through your nose. Count each exhalation silently to yourself. When you reach 10, start again at 1. If your mind wanders, and you lose track of the count (which is likely to happen), simply return to counting at 1.

A fifteen minute break is held following this exercise.

Module content 2: Common effects, managing trauma & well-being

Common effects and strategies for coping

Facilitators to support group discussion of what the common effects of child sexual abuse are, as well as useful coping strategies for managing them. Introduction to include acknowledgement that there is no prescribed or automatic way that people respond to sexual abuse, however we know sexual abuse can have a profound impact on people's lives. Focus of this initial discussion is very much on the present, in identifying common difficulties that adults who have survived sexual abuse experience and are confronted with.

What are some common effects or outcomes of child sexual abuse?
What are some useful strategies for coping with these effects?

Suggested process is to facilitate discussion and record (on whiteboard or large paper divided in two) participants knowledge of 'Common effects' and 'Useful coping strategies'. Richer, more detailed material for discussion will be generated if facilitators invite participants to include both what they may have experienced or found useful, as well as what they have read or heard from others. Participants can be reluctant to name or talk about some effects or previous coping strategies if the suggestions is only to name what they have experienced.

In facilitating and documenting this discussion, it is useful for presenters to acknowledge effects can change over time, and that what might have been some useful strategies for coping and managing in the past can themselves become problematic and require revising. Also to acknowledge complexity - how some strategies work for some people and not for others, and how some strategies can be useful in some contexts and unhelpful in others.

Facilitators to take care in exploring coping strategies in a way that avoids negative judgement, and encourages understanding and compassion, recognising that people make use of strategies that are available to them at that time (without supporting or justifying harm to others). The presenter's role is to encourage and expand options, introduce new information, and to acknowledge and validate steps taken, in a way that does not shame or set up a sense of being foolish in the participants. Facilitators to take time to notice and explore strategies that suggest greater connection with others and befriend the body and/or spirit, as well as strategies that can include elements of dissociation, numbing, or self-injury. Focus is on normalising experiences and efforts to make change, expanding participants repertoire of strategies and resources available.

Option: 'Past - Present matrix' or 'Trauma recovery awareness wheel'

Present the Past - Present matrix or Trauma recovery awareness wheel to the group. This can be utilised as an individual or group exercise. In this initial introduction of the Past – Present matrix, the focus is very much on naming the effects and strategies operating in the present. The paper/whiteboard is divided into four quadrants. The top half relates to The Past (back then) and the bottom half relates to The Present (now). On the left hand side are to be listed 'Effects' and on the right hand side 'Strategies'. The exercise can be an opportunity for the men to individually document for themselves some of the particular effects experienced and strategies they have used, and in the process be a warm up for the larger group exercise. However, there is no suggestions that participants need to share all that they have recorded with the larger group.

Presentation of the 'Past – Present matrix' and 'Trauma recovery awareness wheel' also provides an opportunity to note how:

Effects, back then, can't be changed.
Strategies used back then can be learnt from, but can’t be changed.
Effects, in present, can be worked on and addressed (this is one of the objectives of Foundations).
New strategies of managing effects and enhancing well-being can be introduced and learnt (this is the emphasis of Foundations).

Common effects list

In order to stimulate and further develop discussion, information detailing some of the known impact of childhood sexual abuse on men can be introduced by facilitators.
Some common effects:

Guilt, shame, humiliation.
Isolation, self blame, low self esteem.
Depression/anxiety, mental health problems.
Overwhelming emotions/anger.
Flashbacks/nightmares/disassociation/memory difficulties/hyper vigilance.
Numbing/avoidance.
Decreased appetite & weight loss.
Suicidality/self harm.
Relationship difficulties.
Sexual difficulties.
Sleep difficulties.
Abuse of drink and drugs.
Physical health difficulties, somatization.
Increased risk of re-victimisation.

In presenting the list of effects, care is to be taken not to suggest these are inevitable long term outcomes of sexual abuse. Facilitators are to flag to participants where there will be opportunities for more extensive discussion of particular impacts, and strategies for managing, will occur in the coming sessions/weeks.

Facilitators to introduce and reinforce the following principles that support participants:

You are not alone – support is available.
Men who have experienced sexual abuse sometimes struggle to do things to care for themselves.
Throughout this group, we want to remind you that you deserve to take care of yourself and to live a fulfilling life.
Sexual abuse can have a range of different effects on people’s lives.
It's ok to ask for and accept help from other people, and to offer and give help to other people who need it.
While we can't change the past, we can change the present.
We can develop and choose new ways of coping.
People who have been sexually abused can go on to live healthy connected lives.

Module 3: PTSD and Complex trauma

Option: Aftermath of trauma

Many of the participants will be familiar with the term post-traumatic stress disorder (PTSD) and some may have been diagnosed as having PTSD. It can be useful, therefore, to discuss the characteristics (diagnostic sequelae) of PTSD. Distribute the handout The Aftermath of trauma – for presentation notes please refer to Facilitator resources. Outline some of the identified traumatic impacts.

Understanding flashbacks, dissociation, flooding, & numbing

It is useful to support participants to discuss, understand, and better respond to flashbacks, dissociation, flooding, and numbing, as common impacts of childhood sexual abuse. A short, focused presentation and discussion that identifies and 'normalises' these traumatic impacts of child sexual abuse can help men to allay fears that they are 'going mad' or that there is 'something really wrong with me'. Facilitators can work with the men and the group in developing knowledge of practical, useful strategies for managing each of these difficulties. See the handout Understanding flashbacks, dissociation, flooding & numbing in the Facilitators Resources, and the relevant sections in the Living Well Guide for Men and the Living Well app.

PTSD – Complex trauma

It is also useful to introduce and discuss what is referred to as Complex Trauma. Some researchers and professionals working with people who have been sexually abused in childhood have found it useful to make a distinction between PTSD and what is called Complex Trauma or Complex PTSD. PTSD is fundamentally based on the model of an adult with an established sense of self, who experiences a contained traumatic event or events that impact on their well-being. The interpersonal nature of childhood sexual abuse can produce complex psychological trauma, due to traumatic stressors that:

are repetitive and prolonged;
involve direct harm and or/neglect and abandonment by caregivers or ostensibly responsible adults;
occur at developmentally vulnerable times in the victim's life, such as early childhood; and
have great potential to compromise severely the child's development.

The complex interpersonal nature of sexual abuse can leave a child/adult struggling to self-regulate (i.e. to feel in control of his or her feelings, cognitions, beliefs, intentions and actions), to achieve a sense of self-integrity (i.e. the feeling that one is a unique, whole, coherent, and worthy individual), or to experience relationships as nurturing and supportive.

The below quote can be a useful discussion starter in that it foregrounds how trauma can start to shape and limit people's lives - where lives become organised around responding to traumatic impacts, rather than the hopes and aspirations people have for their lives:

“What distinguishes people who develop PTSD from people who are merely temporarily stressed is that they start organising their lives around the trauma.” (Van Der Kolk & McFaulone 1996).

There is a delicate balance here for facilitators in taking time to acknowledge how trauma, and managing its effects, can come to 'take over' or 'consume' someone's life. It is important to take care not to build a totalising account that leaves no room for noticing people's everyday actions and choices unrelated to the experience of sexual abuse. Given that many men would not have had an opportunity to consider and talk about the multiple ways that sexual abuse has impacted on their lives and sense of self, it is important that there is adequate room for this before inviting alternative accounts. When opportunities arise, it is useful to invite the men to identify and reflect upon successes and mistakes they have made in their lives that are unrelated to trauma and child sexual abuse, as well as to open up a discussion that acknowledges the ways men have distanced themselves from trauma and taken steps to build a life beyond trauma.

The below quote is a useful reorienting tool and discussion point in that it empahsises a focus beyond managing the impacts of trauma, towards developing a fulfilling quality of life (an objective of Foundations).

“Recovery and resilience do not reflect simply the absence of problematic symptoms, but rather a zest for life; a positive conceptualisation of ones self; the ability to form positive, supportive, and safe relationships; and the ability to achieve a fulfilling quality of life.” (McMAckin RA, Newman E, Fogler JM, & Keane TM, 2012, Trauma therapy in context: the science and craft of evidence based practice. American Psychological Association: Washington.)

Mindfulness exercise

It is recommended to spend 15 minutes introducing and practicing a mindfulness breathing exercise. Followed by a discussion of the experience, its usefulness and how the participants might establish a mindfulness routine. The Time2Breathe function on the Living Well app is a useful starter for some men.

Wrap up: Check out

Review: Processes/content covered/reflections

Wrapping up session #2

Mindfulness, relaxation or grounding exercise

If a short Mindfulness exercise has been introduced prior to wrap up and check out, then no need to repeat. If not, consider mindfulness or:

Provision of handout or resources

Group feedback/evaluation

Introduce upcoming session content

Next session, the focus is on naming and discussing some of the pressures men can face in relation to 'being a man', and confronting the barriers to men’s disclosure of child sexual abuse.