NPR’s Mary Louise Kelly talks with Karissa Haugeberg, assistant professor of history at Tulane University, about what it was like to get an abortion before Roe v. Wade.

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Lauren Walls had lived with panic attacks, nightmares and flashbacks for years. The 26-year-old San Antonio teacher sought help from a variety of mental health professionals — including spending five years and at least $20,000 with one therapist who used a Christian-faith-based approach, viewing her condition as part of a spiritual weakness that could be conquered — but her symptoms worsened. She hit a breaking point two years ago, when she contemplated suicide.

In her search for help, Walls encountered a psychiatrist who diagnosed her with post-traumatic stress disorder. As a result, she sought out a therapist who specialized in trauma treatment, and that’s when she finally experienced relief.

“It was just like a world of difference,” Walls says.

Seeing herself as someone with PTSD was odd at first, Walls recalls. She isn’t a military veteran and thought PTSD was a diagnosis reserved for service members. But her psychologist, Lindsay Bira, explained that Walls most likely developed the mental disorder from years of childhood abuse, neglect and poverty.

PTSD has long been associated with members of the military who have gone through combat and with first responders who may face trauma in their work. It’s also associated with survivors of sexual assault, car accidents and natural disasters. But researchers have also learned it can develop in adults who have experienced chronic childhood trauma — from physical, emotional or sexual abuse by caregivers or from neglect or other violations of safety.

Walls was fortunate to find a therapist trained to treat PTSD. Outside of military and veterans’ health facilities, finding knowledgeable help is often difficult.

A limited number of the more than 423,000 mental health counselors, therapists, psychologists and psychiatrists in the U.S. are trained in two key therapies, called cognitive processing therapy and prolonged exposure therapy. These are treatments recommended as part of a patient’s care by the American Psychiatric Association and the Department of Veterans Affairs, which has studied treatments for PTSD since it affects many service members.

There is no definitive tally of people trained in these therapies, and neither the American Psychiatric Association nor the American Psychological Association tracks those data. A 2014 study by the Rand Corp. found that only about a third of psychotherapists had the training. The VA says over 6,000 of its therapists have, though rosters for the CPT and PE organizations list just a few hundred total practitioners.

Nonetheless, the VA’s National Center for PTSD wants to expand access to these treatments, and regional groups, including those in Texas, are following its lead. Texas has a need for more PTSD providers: It ranks No. 2 nationwide in the number of human-trafficking victims; it’s the leading state for refugee resettlement; it has the most unaccompanied child migrants of any state; and it’s second only to California in the number of military service members — all factors that raise the risk of PTSD.

UT Health San Antonio, a University of Texas medical school and hospital, teaches community mental health providers how to provide the two PTSD therapies through its Strong Star Training Initiative. Funded by the Texas Veterans + Family Alliance grant program and the Bob Woodruff Foundation, the initiative has trained 500 providers since it started in 2017. Most training takes place in San Antonio, and many of the mental health professionals who participate are Texas-based, though they also come from Florida, Illinois and other states.

In February, about 20 therapists gathered in a conference room at the medical school for instruction. Calleen Friedel, a San Antonio-based marriage and family therapist, was one of them. She said she is seeing more people with PTSD and often felt inept at helping them.

“I would just do what I know and do my own reading,” Friedel said. “And what I was taught in graduate school, which was, like, over 20 years ago.”

The group learned about one of the mainstream therapies, prolonged exposure therapy, which gradually exposes patients to trauma memories to help reduce PTSD symptoms. Strong Star also teaches cognitive processing therapy, which involves helping the patients learn to reframe their thoughts about the trauma. But both therapies — often called “evidence based” because of the research backing their effectiveness — have been slow to gain traction among psychotherapists because they require the therapist to follow a script and they differ from the common therapeutic approach to mental health issues.

Edna Foa, who created prolonged exposure, said in a 2013 journal article that many psychotherapists believe delving into a patient’s inner life and history is central to their work. By contrast, the highly structured, evidence-based treatments — with their pre- and post-session evaluations and their focus on symptom relief — can seem “narrow and boring,” she wrote.

In addition, some people living with PTSD have complained that the treatments don’t work for everyone. But Foa and others say the focused approach targets the brain mechanisms that cause PTSD symptoms, and symptom relief is what many living with PTSD want.

Edwina Martin, a psychologist in Bonham, Texas, says treatments such as the ones she is learning at Strong Star weren’t mainstream when she finished graduate school more than 10 years ago. She is now employed at a VA health center after working for a decade in prisons, and she says she wants these PTSD therapies in her “tool bag.”

The push to expand the trained workforce coincides with a growing understanding of trauma’s effects. The National Council for Behavioral Health, a nonprofit organization of mental health care providers, calls trauma a “near universal experience” for people with mental and behavioral health issues.

Because so many patients think PTSD is mostly a military problem, psychologist Bira says, they encounter a roadblock to recovery.

“I get that all the time,” Bira says. “The beginning stages in treatment that I find with civilians are really about educating [them] about what PTSD is and who can develop it.”

Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation that is not affiliated with Kaiser Permanente.

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Sean Jin is 31 and says he’d not washed a dish until he was in his sophomore year of college.

“Literally my mom and my grandma would … tell me to stop doing dishes because I’m a man and I shouldn’t be doing dishes.” It was a long time, he says, before he realized their advice and that sensibility were “not OK.”

Now, as part of the Masculinity Action Project, a group of men in Philadelphia who regularly meet to discuss and promote what they see as a healthier masculinity, Jin has been thinking a lot about what men are “supposed to” do and not do.

He joined the peer-led group, he says, because men face real issues like higher rates of suicide than women and much higher rates of incarceration.

“It’s important to have an understanding of these problems as rooted in an economic crisis and a cultural crisis in which there can be a progressive solution,” Jin says.

In supporting each other emotionally, Jin says, men need alternative solutions to those offered by the misogynist incel — “involuntary celibate” — community or other men’s rights activists who believe men are oppressed.

“Incels or the right wing provide a solution that’s really based on more control of women and more violence toward minorities,” Jin says.

Instead, he says, he and his friends seek the sort of answers “in which liberation for minorities and more freedom for women is actually empowering for men.”

Once a month, the Philadelphia men’s group meets to learn about the history of the feminist movement and share experiences — how they learned what “being a man” means and how some of those ideas can harm other people and even themselves. They talk about how best to support each other.

This spring, part of one of the group’s meetings involved standing in a public park and giving a one-minute speech about any topic they chose. One man spoke of being mocked and spit upon for liking ballet as a 9-year-old boy; another spoke of his feelings about getting a divorce; a third man shared with the others what it was like to tell his father “I love you” for the first time at the age of 38.

The idea of such mentoring and support groups isn’t new, though today’s movement is trying to broaden its base. Paul Kivel, an activist and co-founder of a similar group that was active from the 1970s to the 1990s in Oakland, Calif., says men’s groups in those days were mostly white and middle-class.

Today, the global nonprofit ManKind Project says it has close to 10,000 members in 21 nations, is ethnically and socioeconomically diverse and aims to draw men of all ages.

“We strive to be increasingly inclusive and affirming of cultural differences, especially with respect to color, class, sexual orientation, faith, age, ability, ethnicity, and nationality,” the group’s website says.

Toby Fraser, a co-leader of the Philadelphia group that Jin attends, says its members range in age from 20 to 40; it’s a mix of heterosexual, queer and gay men.

Simply having a broad group of people who identify as masculine — whatever their age, race or sexual orientation — can serve as a helpful sounding board, Fraser says.

“Rather than just saying, ‘Hey, we’re a group of dudes bonding over how great it is to be dudes,’ ” Fraser says, “it’s like, ‘Hey, we’re a group of people who have been taught similar things that don’t work for us and we see not working or we hear not working for the people around us. How can we support each other to make it different?’ “

Participants are also expected to take those ideas outside the group and make a difference in their communities.

For example, Jeremy Gillam coaches ice hockey and life skills at an after-school hockey program for children in Philadelphia. He says he and his fellow coaches teach the kids in their program that even though the National Hockey League still allows fighting, they should not respond to violence with violence. He says he tells them, “The referee always sees the last violent act, and that’s what’s going to be penalized.”

That advice surprises some boys, Gillam says.

“One of the first things that we heard,” he says, “is, ‘Dad told me to stick up for myself. Dad’s not going to be happy with me if I just let this happen, so I’m going to push back.’ “

Vashti Bledsoe is the program director at Lutheran Settlement House, the Philadelphia nonprofit that organizes the monthly men’s group. She says men in the group have already started talking about how the #MeToo movement pertains to them — and that’s huge.

“These conversations are happening [in the community], whether they’re happening in a healthy or unhealthy way … but people don’t know how to frame it and name it,” Bledsoe says. “What these guys have done is to be very intentional about teaching people how to name [the way ideas about masculinity affect their own actions] and say, ‘It’s OK. It doesn’t make you less of a man to recognize that.’ “

Meanwhile, the American Psychological Association published guidelines this year suggesting that therapists consider masculine social norms when working with male clients. Some traditional ideas of masculinity, the group says, “can have negative consequences for the health of boys and men.”

The guidelines quickly became controversial. New York magazine writer Andrew Sullivan wrote that they “pathologize half of humanity,” and National Review writer David French wrote that the American Psychological Association “declares war on ‘traditional masculinity.’ “

Christopher Liang, an associate professor of counseling psychology at Lehigh University and a co-author of the APA guidelines, says they actually grew out of decades of research and clinical experience.

For example, he says, many of the male clients he treats were taught to suppress their feelings, growing up — to engage in violence or to drink, rather than talk. And when they do open up, he says, their range of emotions can be limited.

“Instead of saying, ‘I’m really upset’, they may say, ‘I’m feeling really angry,’ because anger is one of those emotions that men have been allowed to express,” Liang says.

He says he and his colleagues were surprised by the controversy around the guidelines, which were intended for use by psychologists. The APA advisory group is now working on a shorter version for the general public that they hope could be useful to teachers and parents.

Criticism of the APA guidelines focused on the potentially harmful aspects of masculinity, but the APA points to other masculine norms — such as valuing courage and leadership — as positive.

Aylin Kaya, a doctoral candidate in counseling psychology at the University of Maryland, recently published research that gets at that wider range of masculine norms and stereotypes in a study of male college students.

Some norms, such as the need to be dominant in a relationship or the inability to express emotion, were associated with lower “psychological well-being,” she found. That’s a measure of whether students accepted themselves, had positive relationships with other people and felt “a sense of agency” in their lives, Kaya explains. But the traditional norm of “a drive to win and to succeed” contributed to higher well-being.

Kaya adds that even those findings should be teased apart. A drive to win or succeed could be good for society and for male or female identity if it emphasizes agency and mastery, but bad if people associate their self-worth with beating other people.

Kaya says one potential application of her research would be for psychologists — and men, in general — to separate helpful ideas of masculinity from harmful ones.

“As clinicians,” she says, “our job is to make the invisible visible … asking clients, ‘Where do you get these ideas of how you’re supposed to act? Where did you learn that?’ To help them kind of unpack — ‘I wasn’t born with this; it wasn’t my natural way of being. I was socialized into this; I learned it. And maybe I can start to unlearn it.’ “

For example, Kaya says, some male clients come to her looking for insight because they’ve been struggling with romantic relationships. It turns out, she says, the issue beneath the struggle is that they feel they cannot show emotion without being ridiculed or demeaned, which makes it hard for them to be intimate with their partners.

Given the findings from her study on perceptions of masculinity, Kaya says, she now might ask them to first think about why they feel like they can’t show emotion — whether that’s useful for them — and then work on ways to help them emotionally connect with people.

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