Yale Psychiatry Grand Rounds, December 6, 2019

December 09, 2019

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Joan Cook, PhD, Associate Professor of Psychiatry, Yale School of Medicine: "Male Sexual Abuse Survivors: From a PCORI Engagement Award to a Competitive Effectiveness Trial"

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00:01Good morning.
00:03We're going to get started today first I just want to make an announcement you may have seen as you entered today that there's a Gale is out there and she's available to help you register for doximity. If you're a physician or faculty member of physician or a resident and if you don't know already. Doximity is the largest network of healthcare professionals with over 70% of US physicians registered.
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00:50And it let's you vote in US news and World Report Rankings. So so anyway and a vote for Yale, New Haven Hospital. If that comes up is a vote for the Department psychiatry. So I just want to let you know that that's an opportunity out there that if you want to take advantage of it. If you've not already registered. I think there are several things that you have personal benefit from doing that.
01:15So with this, I want to move on to introduce doctor Joan Cook. We're really pleased to have her today. She's a clinical psychologist an associate professor in our Department. She's a prolific writer. She has over 100 peer reviewed publications in the areas of traumatic stress geriatric mental health an implementation science.
01:38She's worked clinically with a range of trauma survivors, including combat veterans and former prisoners of war men and women have been sexually and physically assaulted in childhood and adulthood, and survivors of the 2001 terrorist attack on the former World Trade Center.
01:57She's also served as the principle investigator on 7 federally funded grants.
02:02She's a member of the American Psychological Association guideline development panel for the treatment of PTSD and she was the 2016 president of a PA's Division of trauma psychology, so she's clearly an expert. She also has another life that is highly related. But some of us are too timid to take it on, but she's not and that is. She's published over 80 OP eds. In places like CNN time ideas in the Hill, so she's getting out.
02:33Science to the public through these op Ed pieces that she's writing so with this. Please join me in welcoming doctor, Cook to the podium.
02:49Thanks for allowing me to speak today. The last time I gave Brown rounds. I think it was 6 or 7 years ago, I'm a?
02:58I'm fearful presenter not great. I don't think it public speaking. I tend to speak really, really loud an I looked really confident but it's all anxiety. I kid you not and I was telling Stephanie earlier. I far prefer to write op eds. because I can stand behind the scenes. Instead of in front. Nonetheless, when Stephanie asked me I felt I couldn't say no there's a couple things I wanted to do. Today, one was to really highlight this very underserved.
03:28And marginalized population we simply don't pay enough attention to male sexual abuse survivors. So I'd like to talk to you, a little bit about the prevalence rates of sexual abuse in boys and men and talk about the negative potential consequences and then I'd like to discuss a little a few reasons why I think and some people in the field there's relatively less on male survivors, that there is a field female survivors. But I'd like to discuss a little bit about why male survivors might not disclose these experiences.
03:59While they often don't come in for mental health treatment and what we might be able to do about that. I'd like to discuss a little bit about a picori engagement award that we had working in partnership with a nonprofit organization dedicated to working with male survivors tell you a little bit about our findings from that, and how we catapult that into a much larger comparative. Effectiveness trial and present just a little bit of data on that because the comparative effectiveness trial.
04:29We've had the grant for less than a year, an we started randomising people we started recruiting people in September.
04:38And so we're very early on in the comparative effectiveness trial. But I thought I'd tell you a little bit of why how when and the challenges that we've had with this grant. It's been unusual and innovative but very challenging. And then if it's OK with all of you. I'd like to do something a little bit different than I think most presentation. It's not because I'm thin on data up here, although you might say that is, but I'd like to roll in kindness. I like to be very kind and supportive.
05:09Not just uhm I went into psychology and many of you probably did and psychiatry to make the world a better place and not just for the populations that I study and the patients that I work with directly, but for all of us and for the world and so I'd like to share my knowledge and my wisdom and not to people that I like to mentor like Alec and Melissa. But to all of you an I specially want to do this. I was just telling Bob are that my Mommy died a couple weeks ago and so it was unexpected.
05:40And I'm processing and working through that, but all of a sudden I realized that uhm.
05:45There's no ceiling and I know I'm only middle aged and I've got a time to go. But if we work through the natural evolution of things on the next one. And if I don't share what I know it stops with me right so I'm going to sprinkle in some lessons learned particularly for UE CPS and you trainees. But I hope for more seasoned. Senior and mid career people, you see some lessons learned that you might want to take and share with your lab as well. So I hope you can indulge me and my mommy that.
06:16So.
06:18If this stadium.
06:20Were full of males approximately? How large a segment of the attendees? Would you estimate have been or will be victims of sexual abuse? I don't want you to answer that?
06:33Just we need to take that in.
06:36And think.
06:37I think you'll be surprised.
06:41So probably the best estimates that we have and again. We have relatively less on this population than we do on females.
06:48Come from the national intimate partner and sexual violence survey and why are these the best estimates well one because it's self report based on a Phone interview?
07:01And it's not derived by criminal justice reporting and all of you probably know that sexual violence rarely gets reported. We rarely go to law enforcement agencies or the FBI to tell to tell our stories. So these are probably the most accurate picture. We have nonetheless. I still think it's an underestimate but In addition, this survey did what? So few others do not only was it. Nationally, based, but it didn't just ask about rapan penetration.
07:32But it asked about a number of other sexual abuse and assault experiences as well.
07:39So there's a little bit of the data and we're going to highlight some of it for us in a minute, but I want you to just soak it in for a minute.
07:49So lifetime rape in males is 1.7.
07:54But the other sexual violence if we ask about made to penetrate sexual coercion, unwanted sexual contact, etc is much higher.
08:04So how many male survivors.
08:08A lot.
08:10At least.
08:1225%.
08:16So if we're looking at this and I made no mistake here. Everybody probably gets the reference of Penn State right Jerry Sandusky. Let's assume this is a Stadium of 100,000 mails.
08:30At least 25,000.
08:34Why is there so little research in this population? Why aren't we partnering with them more and research? Why aren't we talking about this? Why aren't they coming in for therapy to people like us? I don't know, but that's what we wanted to figure out.
08:49One of you back there is very good friends with Richard Gardner, where did she go.
08:56OK, so the senior psychiatrist in the field who is very good friends with Richard Gardner and came up and introduced me. I'm Richard is one of the key psychologists that put this the sexual abuse of boys and men on the map and has published numerous really substantive clinical books on this topic. So the fact is boys and men can be victims of sexual assault and rape and that's important for them to know it's important for all of us to know as healthcare providers, and it's certainly very important for.
09:27The public to know and is Stephanie said earlier. I've had this sort of side gig. This kind of fun passion that I have on the side which I do at night and on the weekends and is writing op eds. and I can tell you that the op eds that I've written that have the most.
09:44It seemed to have the most impact by the clicks in the Analytics. That here are the ones on sexual assault in boys and men. So I wrote one recently on Tyler Perry. He had come out very publicly and they had the article in People magazine and he talked about his significant drama history, not just sexual abuse.
10:05Numerous horrific experiences.
10:08And I use that as sort of like the lead to capture the public's attention and then to educate them and it had been shared. I don't know how many people read it. But it had been shared in social media 3000 Times Now, maybe all of you have peer reviewed publications that are shaped shared period 5. Three thousand times. But I've never had one. I've never had one. Stephanie you probably had multiple but but we have to get the word out.
10:34And we know that for a lot of these men. It's not just the experience of sexual abuse and assault, though, that's horrible enough. But we know from the Asus studies. The adverse childhood experiences studies in Poly. Victimization studies that most of these boys and men have also experienced other kinds of trauma. An I think you know, I want to challenge us not to be mean to us 'cause. They know were all great and we all do good work but to say you know they've been overlooked and stigmatized by the public.
11:06And they've internalized that and there are some studies to show that when they come in for therapy that some of us hold very negative biased attitudes. And we see that in the research and we see that in patients that I treat and we certainly see that in some of the participants where they come in and they say something like you know, I've been sexually abused or assaulted and they say no no that's possible men are perpetrators, not survivors. Yes, it is true. People say that to them. None of us of course, but people say that.
11:38So male survivors are at risk for a number of different clinical disorders from PTSD and substance abuse, suicidal aviation and behavior and they also have higher rates of sexually transmitted diseases. HIV sexual compulsivity. There's one study that shows that sexually abused men compared to men, who don't have that experience have greater educational relationship and occupational functioning difficulties and that makes a lot of sense.
12:09But we're doesn't get talked about as much or these prominent psychological symptoms and these are the ones I think that that certainly stay with me through the interviews that I've done with male survivors and certainly in the clinical work that I do, which is that there.
12:25Many of them are very angry and understandably so and they feel very betrayed and they have horrible self esteem and feel like damaged goods and they have difficulties with sexual functioning and they have difficulties with eating disorders and the list goes on and these are things we need to pay attention to clinically and help them research and find the best treatments for.
12:50So given all this, it's particularly sad for me not just that it occurs 'cause That's heartbreaking too. But that they are less likely to report abuse they're less likely when it occurs to identify it as abuse and I'll talk about that. When I talk about the Flyers that we've made for comparative effectiveness trial and they're less likely to seek mental health help. And when they do come for help less likely to link it to abusive sexual experiences in the long-term impact.
13:21And I think and not just I think, but people around the country who write about this.
13:27That this is probably fueled in part by Mail rate Miss Ann by toxic masculinity being that I'm married to a man and I birthed two. I feel like I can say you know guys have it hard and they're sort of chop that they're not supposed to feel and express their emotions and they're never supposed to be victimized and to hold in their beliefs and for the public to hold in their beliefs that men can't be raped or sexually assaulted.
13:59Or their week if they do is just a disservice and inaccurate. So traditional gender. Socialization teaches us that men and boys are supposed to always be powerful in vernal invulnerable. They should never cry. They should always welcome sexual activity. And if the perpetrator is a female now. Most of the perpetrators. I am not a perpetrator expert but most of the perpetrators of sexual violence against men and women are actually mails, but women do perpetrate and sort of one of the myths is.
14:29And some of the clients that I work with overtime and some of the participants in our study have talked about that when they come to people and they say I've been sexually abused and it's a female. People say, Oh, you should be lucky like really like wow? What a mind screw were doing to people by saying that to them.
14:48And that victims are week. Now this is not exactly a myth. I think this is this is somewhat. True is that there are fewer resources for mails when some of the males. Go to domestic violence shelters when some of the mails call in for help lines immediately hear a male voice and site no no. No, we don't treat perpetrators like OK. So we need to change that and men who have been sexually abused will either become abusers like the vampire myth or that that.
15:19Causes them to be gay and we know that case that that's not so a lot of the toxic messages that these men have internalised are things like the abuse was my fault real man would blank blank. Blank have been able to protect themselves would not have allowed this to happen would have welcome this opportunity, I'm not worthy. I feel broken. If anybody knew they would feel much differently about me if my wife knew she would feel differently about me.
15:49And that the perpetrator might hurt me which is often times why people don't tell because that's what perpetrators say I will harm you if you tell someone or I will harm someone in your family and they often feel like my body betrayed me, I will talk about this in our intervention in a minute.
16:07So a group of us psychologists at Yale decided you know, we just need to know more about male trauma survivors. We don't know right now that much about their decision to enter treatment their participation.
16:23In research their disclosure patterns and we wanted to engage with them and there was Picori. All of you probably know pick or either of these small engagement awards and I was looking for a community partner.
16:36I found a great computer community partner a lessons learned the importance of relationships. My clinical supervisor from Graduate School 20 years ago. We had a clinic on adult survivors of childhood sexual abuse and that's where I did a 2 year training before I went off to internship and he was very close to this male survivor organization and heat. She was named Steve Golden. He, too was very active in this organization. He introduced me to this organization and this is my friend Chris Anderson.
17:07A male survivor and the former executive director note the word form are going to talk about that. In a minute and how that impacted the study going forward. The executive director and this great organization if any of you know, male survivors or treat male survivors. It's a great organization.
17:26Www.mailsurvivor.org they've been around since 1998. They do clinical trainings. They do all kinds of things. But the thing that I really like most about them is that they reach a wide variety of people they get about 100,000 hits worldwide and they offer free discussion groups. Peer LED discussion groups and track forums. So they're really out there meeting the needs of people and probably.
17:53In typing an unmet need for services.
17:58So I partnered with Chris and too young psychologists and I'm going to tell you about in a minute and we put in a letter of intent, but Corey and it was rejected or we reframe that into it just wasn't accepted for further submission to a larger grants. It was rejected and.
18:21We were sad because we're like there's nothing out there and we're going to do this and we had fire in the belly to do it.
18:28And we got on the Phone with the program officer, which I think is so important as Stephanie said. I've been the peon 7 grants and as important as I think the therapeutic relationship is with our clients. I think it's very important that we have relationships with our program officers an good relationships. And so we got on the Phone with this program officer and she had already spent time on the male survivor website. She had told them she knew that this was this great group and she said. But I gotta tell you something. It was me. That was falling down. She said, You're proposing all kinds of research this is Justin.
19:00Gagement I'm not really sure what you mean there and she said. Do you know Larry Davidson and I said well I certainly know of Larry Davidson, but I don't personally know him know know probably all of you in here. No Larry Davidson in our Department big guru in pirah mental health services and recovery services.
19:20Worldwide and she said. You really should talk to him like basically like go get it. Tutorial from the Sky and come back to me. Joan and I was like I will do that. And so I wrote Tillary as soon as I got off the Phone with her and he invited me to come down to his shop and to meet him.
19:36An within minutes of me, telling him what I wanted to do, he said. Do you want to copy my grant?
19:42I was like Oh, thank you so much that I didn't have to beg. Thank you. I really appreciate that and he shared his grant just freely and openly and I got to see what engagement was because traditionally I hadn't been really doing engagement kind of research. I'll tell you about in a minute, so the lesson learned is when you're given a gift use it and show appreciation and pay it forward. I'd be happy to share my grant with you.
20:09So we reframe the proposal.
20:11To make it a more equitable partnership and use community based participatory research, to engage in Co learning to minimize power differentials and not just to meet with survivors and ask them questions. But to equally engage in dialogue and share power and have cultural humility and I think we did really, really well with that. The two psychologists that work with me, who were here and are now elsewhere are.
20:42Amy Ellis, an Vanessa some yola we were really active as Stephanie mentioned in the American Psychological Association's Division of trauma psychology and they hosted all of the products that we made as well as some of the meetings So what we did is we engage with a number of people alisa and Steven along and Rob Peter Zack and Steve Southwick and a number of people in Yale Psychiatry Department and we met with male survivors here on numerous occasions and held focus groups in discussions.
21:12We also posed open ended questions on this male survivor discussion groups. We did a small survey. It really wasn't really research Steve but you know it's kind of sort of. But we can't engagement and we went to several scientific meetings at both survivor meetings. An AP A and trauma meetings an held discussions and we collaborated on a number of different things one. One thing that I'm the most excited about.
21:40Is that we came up with the Top 10 questions that male survivors wanted to know from research and I'll share that in a minute, we did. We did publish that we also created though and disseminate and I think it's really kind of cool and if any of you are interested in you could find it on male survivors website or Division 56. Six is website is videos suggested readings on for both populations for male survivors of how they can be equal partners in research.
22:11And then one for researchers on how to share power and not just to think of male survivors as participants in our studies. But as partners, helping us figure out what questions to ask and what measures to use all the way through to dissemination an publication and we also made it brochure, which I'd be happy to share with you So what do male survivors in our engagement awards that participated over the two year period of the engagement award? I think maybe twenty five guys I should have included that up.
22:43Participate in these and So what did they want well. One was they wanted to know the impact of sexual abuse on Mens emotional functioning, including can they ever be happy.
22:58They wanted to know the impact of abuse on men sexual functioning.
23:03And what are the resilience factors that prevent distress once you're abused? What can prevent distress or help people heal. They also wanted to know how could we reach people who were struggling earlier now keep these in the back of your mind because we're going to try to take these and catapulted into our next Grant and you could see where we try to go. They asked how can we access good clinical and research information? How do I? How do I know where to go to find good stuff in a number of the sources that they were looking at.
23:35I gotta say, weren't great sources.
23:39For information.
23:41They said how are alternative forms of medison? How do they have helped men he'll what are the methods or tools that can help men he'll what's the impact of socio demographics of race and racial ethnicity and sexual orientation. In terms of providers in terms of male survivors engagement and outcome and how can we harness peer groups lot of them talked about suffering in silence for a long time, not being willing to come into people.
24:13Like and talk to people like us, but they said they were willing overtime to talk to peers on places like male survivor an men healing and etc.
24:23And then the big one, which is boy, I wish I could tackle this and maybe someday. I'll do more to do this, but is what can we do to prevent sexual abuse of boys and men, including how to identify the perpetrators.
24:38So we took these questions and we let them sort of percolate in our mind and we continued on with our engagement activities. Let me tell you a little bit more about the engagement activities and then how we married these things and took the next steps.
24:52So what do we know about male survivors engagement in treatment. Not that treatments the be all end all, I'm not pushing that as a psychologist, but I think it's a good thing. I think we can really help people and so, if they just lay.
25:07Disclosure for up to 2025 years and that seems to be the average and if they don't come in for therapy or come in less frequently. It's probably for a reason as we said earlier. It's probably for stigma. It's probably for how do they ask for help so? How do we understand this and how can we help them get the help they may need not saying everybody needs therapy.
25:32So that that is my nail and I am kind of with the hammer, but
25:37Um so we did this very small little engagement on male survivor website. 88 people responded 60% of them, said that they had that they were currently in psychotherapy. The majority had a number of adverse childhood experiences not solely sexual views, though, that in and of itself is enough to pack a punch. Many of them over half of them had significant PTSD symptoms. These were just surveys not clinical interviews.
26:09And then quite a number had mild depression and those who were in treatment.
26:14Had higher depression.
26:17And so we wondered OK. Maybe it's not the PTSD. But wondered is it depression. That is so uncomfortable for men. Or maybe therapy make some depressed. I'm not sure but is the depression so uncomfortable that that's what will push them to come into therapy.
26:34And then we also ask them what were your most and least helpful aspects of therapy. I find it telling that more people told us the least helpful aspects and helpful. But they said peer support above and beyond. Peer support has been the most helpful to me lot of them talked about individual therapy and I don't think you could think of it in terms of common factors like warmth and empathy what I read in the notes that they wrote is validation, saying someone believed me a therapist a person of authority.
27:04Believed what I was saying and then they talked about specific interventions. Mindfulness Emdr CBT. Not one really stuck out, but they talked about specific interventions and then the least helpful. We're not having trauma informed therapists and it wasn't just not having trauma informed therapist. It was people not therapist, not understanding the unique issues of male survivors and then financial or access barriers and so we
27:34Put these together and we thought, What can we do to carry on. This line of Investigation and we thought, well let's try to give them what they want and partner with them to get there. Let's try to reach male survivor sooner. Let's try to use an parnis the power of peer support.
27:53Probably depression is the point at which we might get them.
27:58And then again, going back to the program officer.
28:02We said look we've got some ideas for the next step. And she was Gung Ho at the time Picori and this is a few years ago, funded relatively little in mental health and she really liked this idea of working with male survivors and she really liked Chris and the things we were doing, but she said. You're never going to get this passed a review committee to just focus on male survivors. You have to have a health disparity group and I argued as sometimes we do, and so, but they are a marginalized group.
28:33And she said no no no, I hear you but you need to pick the group. You need to have racial and ethnic minority. You need to have rural adults. You need to have older adults. You need to have sexual and gender minority you need to pick a population.
28:46And also but I want to study all of them. I want to include all of them. I want to help all of them and we had to pick one so we went to our team and looked for resources. I'll pause on that and tell you a little bit about what happened in our group sort of lessons learned. We started to think about who did we need at the table with us to carry on. This kind of study and Chris had voluntarily decided to step down and that was a huge loss for us. He had not only become a friend in an advocate, but he really was our relationship with male survivor.
29:21And it was a lesson learned that when we do community engagement that we have to connect not with a person. But with an organization and that was painful and we could have not continued. But several people really stepped up and helped us, including Nathan Machine, Joel Fillmore, an Andrew Smiler and they're all still members of our team, so we had these key people from male survivor who are engaged and we said, OK, what population now do we do. We sort of want to work with and hang our hats on?
29:54And what had been the most prominent in the literature was discussions about sexual and gender minority male survivors. They have higher rates. Remember I told you the rates about at least 1 in 4 boys have been abused by the age of one in 6 boys have been.
30:13Abused by the age of 18, one in four across the lifespan. The rates are even higher in sexual and gender minority populations, then take on Top of that. The minority stress that they experience. The data data discrimination potential rejection unsupportive. We thought, This is the population that we'd like to sort of hang our hat and work with at least first eventually like to help everyone but at least 1st and we knew that we needed to get certain people on the bus. This was an area of expertise. This is not an area of expertise.
30:44Of mine I've got to say, although I've done pro. Bono work in Graduate School with this population. This is not what I'm sort of known for if I'm known for anything but this is something that the early career psychologist works that works with me does Amy Ellis and so I said. Let me help. Her Let me lift her voice to in her career up and we will go with this population. So we started to think about these different things. OK, we're going to focus on sexual and gender minority males. 'cause they're an increased risk. We want something that we could deliver that peers could deliver.
31:14We think we want to focus mainly on depression to get them on the door. We want to find a treatment that can be sort of scalable an affordable an easy not easy. That was not the right word scalable an low cost and we said. We want to design an intervention a comparator that could be male affirmative sexual and gender minority affirmative an trauma informed.
31:41And you have to get the right people on the bus and thank goodness for Yale. We are an amazing institution and Department as all of you know, we had 2 people right here in our Department who came on board and helped us so shrill Bellamy.
31:56Is one of the foremost experts in peer services?
32:01And Steve Martino is one of the foremost experts in motivational interviewing and they said. Sure, Joan will join your team and he said. Thank you friend and In addition, we decided.
32:15Around the time that Chris stepped down from male survivor.
32:19We weren't exactly sure there are other male survivor organizations to how well this one was going to be maintained, and we thought we better reach out to other groups as well. And so we are also partnering with another organization called men healing that they do. These weekends of retreat, which I'd be happy to tell you more about later.
32:37So we put together a proposal called peer online motivational interviewing for sexual and gender minority male survivors and it had 2 Ames and the first was to train men with lived experience in 2 versions of motivational interviewing one motivational interviewing straight up which we'll talk about in a minute and 2 motivational interviewing with trauma informed Mail affirmative sexual and gender minority affirmative care and then the second was to conduct a large randomized, controlled comparative effectiveness.
33:09Study.
33:10Now I gotta say this was also incredibly painful lesson to learn and I'm going to sound like a sack, but the day, we received our just in time information.
33:20My best friend for 20 years I'm an only child, and he was like a brother to me died. We had been research partners for 20 years and I knew he was sick with cancer. I just been with him and his wife in Texas, helping them, but when the just in time came out and they had questions for us, so they were clearly interested.
33:42I thought Oh well, OK alright I'm going to.
33:45Work through this grief hold it bottle it and respond to this and then I realized there were some questions there that you know, he had sort of developed in that area and I have not and I thought and I tried to answer some of the just some of it was easy you know, I've been in the field for awhile so I could answer some of the just in time questions. But some of them. The stat ones. I was like Oh. This is not my area anymore. and I went to several friends who trust your gut. I went to several friends and I said, can you look at this and I said Oh Joan it's fine? What you put together it's fine. I thought now. I know it's not fine. I know I am falling down in this area.
34:19And to the rescue comes Maria O'Connell. Also in our Department who freely gives me her time who said, I don't even need to be your study statistician.
34:28But yes these questions, you've answered, they need some tweaking and she helped so the lessons learned too early career folks in the room is and things I tell the male survivors and the female survivors. They work with is feel the feeling but choose the behavior and in the midst of the grief.
34:47Decided I couldn't disappoint, the team, the population. And Unfortunately like many of you. I needed the salary support. So I had to choose the behavior and get the get the just in time and to say to yourself in times of stress fall down 7 times 'cause. I kept feeling like we're falling down fall down 7 times get up 8 and never when you're in research never never never give up.
35:11Winston Churchill not Donald Trump just a joke. We we established and so we got the grant, we got the just in time information. We got the grant.
35:22And we formed a community Advisory Board to help us with a number of things and there are additional members. Nicholas Chris Andrew Jason gym. There are additional board members who didn't feel comfortable having their picture on our website or here.
35:41So our first aim let me tell you where we are our first aim was to train these peers. We posted things on listservs and discussion boards. We went to male survivor. We went to men, healing an we interview. Damian I Amy Ellis is the Copia. An we interviewed people on the Phone. We didn't ask them detailed about their mental health or their sexual abuse characteristics. I just felt didn't feel OK with that, but we did ask them a little bit about their healing and.
36:11And 20 men with lived experience came to Yale. They ranged in age from 26 to 66. None of them were in mental health and we didn't expect them to be these are not peer specialists like my friend Ankley works with these were have a lawyer and a veterinarian and nursing school student and they had no mental health experience in terms of their own training.
36:38But they had fire in the belly and they were willing to share their own pain. They were willing to learn and they came to Yale and Steve Martino. The amazing Steve Martino train them for 3 days in MI. I'm sure at some point you have to tell them maybe during the discussion about the experience 'cause I think it was pretty powerful right.
36:58Um and what the guys said to us is this is great, but we need more and they're like, we can't get out there and like this we had given books to read ahead of time on motivational interviewing written for the lay public and they were like this is too much So what they really wanted us to do the perfect solution, but our IRB understandably would not allow us to do was they ran it us to run. Mach groups so they sit as participants in Steve and Amy and Vanessa and I were to beat the therapist and like. Gosh, we would love to do that first of all I should say.
37:31These peers come from all over the USA and Canada and so our participants. So there was no way we were going to be able to meet on a face to face basis. There was no way the IRB was going to let us do this we thought, What are we going to do not a perfect solution but a good enough solution?
37:49Amy is down at a school in Florida and she got her graduate. Students who were willing to be the mock participants and so we did 6 sessions full sessions of MI 6 sessions of full MI plus we actually had. I don't know if many of you remember Oscar who was a psychology intern Oscar row has.
38:13Pereiras, who was here last year, he actually co-facilitate hated the group with Amy and these men watched these videos, they were there were 6 of them each 90 minutes each. They watched them on their own time. We didn't have enough money in the budget to pay them for them and then we did supervisions via zoom and we have had some people drop out. Just 2 out of 20. I anticipate that we might have to do some more trainings at some point this is uh.
38:45Heavy lift no doubt you know, we were thinking of to go. What primary outcomes to go for and what treatment to use and to go with motivational interviewing and depression.
38:55Now, what, if I'm known for anything, it's PTSD treatment. It's not it's trauma treatment. An I just there's nothing that I have come across in the research where peers are delivering trauma. Processing treatments like prolonged exposure. Cognitive processing therapy and I just didn't feel I felt this is enough can be triggering for them and very emotional for them. And so maybe someday down the road. Or maybe maybe never but the lesson learned was let's come up with a good enough solution to train them and give them these examples, so they could see it.
39:28And so we kept our high standards, but we had to adjust our goals. They increased their beliefs in MI from the time before they came to right after to the additional trainings. Steven I need to look over some of the other research, though the other questionnaires.
39:45But they are doing well, the most incredible wonderful men. An I feel like somebody from up above sent me a gift by sending these 20 men to us now 18.
39:56So the second aim the randomized, controlled trial.
40:00Um.
40:02Traditional MI versus MI plus it's two peer leaders running groups for sexual and gender minority men and their running groups of 6 to 8 or primary outcomes or depression and mental health engagement. We have a number of secondary outcomes and then we're also after they complete the trial following up with qualitative interviews. So this is MI and all of you probably know me so I won't go into great detail but it's essentially.
40:32Exploring current life issues targeting behaviors a change looking at decisional balance versus staying versus changing exploring values and strengths building efficacy and then importance confidence and desire an planning change and what we did on Top of that, so the regular MI group is getting this and the MI plus getting group and it's an it's an it's a heavyweight. I wish it was more than 6 sessions, but we've integrated.
41:03A number of things we've integrated sort of male rape myth, debunking sexual and gender minorities. Survivor debunking and male seeking help debunking so educating this and then asking them. How do these internalize beliefs? How of these myths impacted their lives their ability to make changes the changes that they want to make an their confidence and so this is just a little snippet. I'll give you.
41:34So this is an example of some of the sexual abuse in boys and men.
41:40NIST debunked so one is that some men believe that they can't be forced to have sex against their will and the fact is any individual can be forced to have sex against their will if you're not able if you don't want to have sex. You're not able to informally awfully give informed consent in your crushed then another one is and this is a big one that the men that I've worked with clinically over the years is men who have become sexually who become sexually aroused or having erection when assaulted must have enjoyed it that's just not true.
42:13We here again and again men often get erections in painful or traumatic situations. And so we talked to them about just like our heartbeat or shallow breathing. Physiological reactions are out of your control and just because you had one doesn't mean you enjoyed the experience wanted it ask for it, etc. So that's a little bit about the addressing the rate miss. We do the similar in a different session with sexual and gender minority male survivor rate miss that the myth is that people.
42:45Sexual and gender minorities because they were sexually abused not true.
42:50Another one is that men who were sexually abused by men must be gay. I hear that again and again from the veterans that I work with who have military sexual trauma and just not true.
43:01And then some myth, debunking in terms of male looking for support. That boys and men should not cry or experience sadness well. Of course, they showed their basic emotions manner.
43:13Humans and of course, they should have these emotions from time to time is something really awful happens to you like male sexual abuse.
43:22You might have a bigger dose of it and that seeking help makes you weak or crazy. We actually reframe that to the fact that seeking help means you recognize areas. You want to work on and you're willing to do so.
43:34So people come in and we have Flyers and I'll tell you about that in a little bit more detail but we have screening. They do the screening on line. Then they talk to Megan or research coordinator. She does the mini with them. She doesn't like a mini mental state exam with them and she assesses them in detail for suicide audiation I told you a little bit about our baseline if they meet criteria which I'll tell you right now is 18 years or older English speaking.
44:05Reporting a history of sexual abuse assault or unwanted sexual experience. Remember I told you earlier that some men won't label it as abuse or assault, so in our Flyers. It says an unwanted sexual experience at some point in their lifetime. They have to identify as male and then they have to have at least one of the following gay, bisexual trans attracted to men have sex with men. Or maybe questioning their sexuality in their gender. Experiencing some emotional distress reside in the USA or Canada and haven't been informal mental health treatment.
44:37For 60 days, 'cause That's what we want to help them do.
44:42So we've had some challenges such far we started we trained the gentleman in May.
44:49Then we did these extensive videos and supervision, which lasted through the summer. We started recruiting at the end of the summer and people were trickling in we made with the help of our advisory group and the rest of our investigative team. We made a websites called peers for Mens health study. We reached out to hundreds of organizations asking them if they would put up Flyers in our clinics. We wrote op eds blogs.
45:19We did podcast we circulated Flyers and lesson learned We thought we would build it and they would come and they didn't and 4 months.
45:312 months was enough for me to get my panties in a wad and if I gotta do something here.
45:38And so I sought consultation never be afraid to ask for help. And it takes a village to do this kind of research and so I went to John Ann Jillian and Christy all who are here at Yale. An experts in sexual and gender minority populations. Jillian had done her dissertation on sexual and gender minority men and women and sexual assault. Another traumatic experiences and she gave me a list of places to contact and I did that.
46:08And I also went to Connell up at Fenway, an you know that little Community College North of us. I think it's called Harvard and so that's only fair because when I went and talked to him. That's the same thing. He said of Jones from that little Community College down there in Connecticut. That would be Yale, so right back at Chicano. So so John Ann Connell really gave gave us a gift and one that I didn't know because I'm not a sexual and gender.
46:38Minority individual or research art. This is a newer area of expertise for me and these gentlemen have been doing this for a while and they said Joan Why didn't you build into your budget?
46:52Watt anybody have any idea.
46:55Recruitment strategies.
46:57Paying people to go on Growler.
47:00And Facebook and go on dating websites.
47:06And I was like huh, so we scraped together some money in the budget and boy Sky rocketed so.
47:17Most of the people that have come in and screamed 127 have come in since the middle of November. It's so large and many of them are appropriate for the study 36. We're still trying to catch up. But we've run one set of cohort of the groups. We have another one actively going and we're ready to randomize another and we have people waiting for this.
47:44So that's good news just in the past couple weeks. Another thing that we're actively struggling with is we are not at one location right. We're recruiting people from North America and a lot of men. Understandably are coming in with a lot of active suicidal ideations and so we really picked some items that Mega Nanami, who were doing the screenings will then pass the people to me and I'll do a more thorough screening and decide if they need to get formal mental health services and I'm calling friends and family members across the country.
48:18To find them good trauma informed and reasonably priced people who take on a sliding scale. Unfortunately, many of the men that are coming into the study have very few resources.
48:31And another thing another very interesting thing that we didn't anticipate that we're finding is that quite a number of the men were doing select as part of our screening were doing select modules of the mini and we're doing the psychosis one.
48:47And a lot of them are coming up looking like they're psychotic and the truth is that complex. People who have complex trauma often have dissociation and so it looks like you know in in if you're someone who has just sociative identity disorder or significant associations. You might be hearing voices or seeing visions traumatic flashbacks of your perpetrators or feeling like you're not quite real and it's likely not psychosis, so we also saw consultation from from a friend.
49:18In regards to that and we're being a little more lenient and who were letting in seeing it as dissociation. An we've since added associative measures so I guess one of the biggest things that I hope for of course. I hope that we have significant findings and that we help people, but one of the significant things that I really hope that we do is to communicate to males and continue to communicate to males who are survivors to know that they are not alone. That what happened to them is not their fault and that it is possible to heal from trauma.
49:48No matter how late it may seem.
49:51And my final sort of lessons learned to all of you before we take questions and have Steve talk about the amazing training. He did was to just share a few more things. I think it's really important when we do this work and we come to places like Yale and Harvard that Community College up. North is that we are, we get ahead in field and promoted by the body of work that we've created but I think it's important to that. We share the credit and we share the glory and we reach back.
50:21And help other people go forward to not just start patient populations, but our colleagues and my case for Vanessa and Amy and then be open and receptive to learning new skills. This was not the population. Again, I had done a little bit of Pro Bono, but I'm not an expert in this field, but I'm willing to learn an I want to help an think I have a big heart and I'm willing to learn and I think you know had when I started off in the field 20 years ago. If I'm known for anything, it's working with.
50:52It's all older adult trauma survivors World War 2 veterans Korean War Veterans. They're dying off and got to say. I've never found in the 70 grants. I've had. I never found. A Funding Agency that was ever interested in older adult trauma survivors and that doesn't mean you give up on that passion. If you have a passion in a population and a group. You want to work with it just means if you want to pay the bills. You might have to diversify your portfolio an not put your eggs in one basket and then most importantly, I think to all of us who are probably.
51:23Over achievers here at Yale that I think it's important, not to just make it career, but to make a life and thank you. Allowing me to be part of your community.
51:33That's it.