Working in the Field of Complex Psychological Trauma: A Framework for Personal and Professional Growth,Training,and Supervision

Participants

Purposeful sampling was utilized to invite therapists (recruited via the researcher’s own professional network) from within specialist trauma services and specialist sexual assault counseling organizations, to identify those likely to offer data relevant to both the research goals and the methodology (Finlay & Ballinger, 2006). A total of 48 clinicians were invited and 21 participants were finally recruited from mental health teams within the National Health Service (NHS), including psychology, psychotherapy/counseling, and occupational therapy professionals. The aim was to select interviewees with a background of working in the field of CPT, including (but not limited to) GBV/CSA. All participants were currently working with clients presenting with CPT. Clinicians gave written informed consent to participate in face-to-face interviews. These took place within the lead author’s own workplace, in either a private office space or clinical room, over a period of 4 months within 2014.

The sample consisted of 17 females and four males. Six participants interviewed were aged between 30 and 39 years, six were aged between 50 and 59 years, and nine between 40 and 49 years. In terms of clinical experience in this field, the majority were clinicians with significant experience in CPT/GBV with all having had a minimum of 2 years’ involvement (one therapist), seven with 3 to 5 years, eight with 6 to 15 years, and five participants having worked in this area for 16 to 40 years. Regarding the proportion of CPT/GBV clients seen by these clinicians, this varied from 10% to 19% of their workload/or all clients they saw (i.e., two clinicians), with a significant number (i.e., nine clinicians) working almost exclusively (80%-100% of their workload), in this area. A further seven participants had 40% to 79% of their caseload in this field. The three remaining clinicians reported having between 20% and 39% of clients with CPT/GBV issues. All clinicians worked in the NHS, with most having some experience of also working in either voluntary organizations or the private sector. The frequency of supervision varied between fortnightly (nine interviewees) with 12 meeting at approximately monthly intervals.

Procedure and Design

Face-to-face qualitative interviews were used to collect the data required. Because IPA is particularly suitable when exploring how participants perceive and make sense of their world, with no attempt to test out a predetermined theory (J. A. Smith, 2004; J. A. Smith & Osborn, 2007), it was important to construct the interview schedule in such a way that the questions were open ended, while utilizing a nondirective interview style (Brocki & Wearden, 2006). The goal was to generate data to answer the research question (Willig, 2008), while not imposing preconceived theories or expectations on the interviewees. As it is necessary to have a verbatim account of the data collection event (J. A. Smith, Flowers, & Larkin, 2013; Willig, 2008) to undertake a full analysis of the data, the interviews were recorded and transcribed verbatim. Transcripts were read repeatedly and then coded to identify emergent themes. Recurrent themes were then identified across transcripts. Such themes reflected shared understandings by participants of the issues under investigation. Data were compared and analyzed until we were satisfied that emerging themes adequately described the text and that final themes closely reflected the data, that is, until saturation is reached (). To ensure rigor, a cohort of the transcripts was read by two researchers in the project team (A.M.C. and Z.C.) and recurrent themes were discussed in the team (A.M.C., Z.C., and K.C.). The involvement of all team members in this process ensured that the interpretive processes were collaborative and insightful. The data were then analyzed further to unpack the situated nature of the themes, to understand them fully, and to highlight the similarities and differences in the various participants’ accounts (Lofland & Lofland, 1995). Links between emergent themes were also identified and modeled to provide a clinically meaningful framework embedded in the experiences of participants.

Rigor/Validity

IPA utilizes many of the principles of generic qualitative good practice, which, it is suggested, are quality markers in qualitative research (Elliott, Fischer, & Rennie, 1999) assisting in the production of robust and reflexive research, and increasing the likelihood of publication in professional journals (Reid et al., 2005). Within this study, the use of team consensus (whereby agreement was reached on the themes identified), the maintenance of field notes, and the keeping of a researcher’s diary were implemented to aid the reflexive process and to minimize the subjective aspect of the interpretation. In addition, a negative case analysis was identified, where the data analyzed were found to be inconsistent with the themes, which is also thought to provide evidence for the validity of the work (Creswell & Miller, 2000). Furthermore, the role of the external observer (the supervisor) was particularly helpful to provide both an understanding of the project together with an overview of the work, which was as free as possible from researcher bias.

Called to the Work

Therapists frequently spoke of CPT being a calling or vocation. Some talked of being drawn to this work.

I feel the intensity of it, of what’s coming up or what’s happened, what we are working through, but I don’t . . . I don’t shy away from it, the word enjoy is coming up for me and it’s not quite the right thing, it’s not what I want to say, I feel it is more a kind of . . . it’s kind of like a vocation really em . . . it’s like em . . . child abuse, it is everyone’s right to do something about that; everyone should be. (M211S 6/7.132-141)

There was a sense that they had already reflected on their role and that helping others in this meaningful way was an integral part of their own life journey.

I think that just through my own personal journey, an understanding of myself and homophobia and hetero-sexism I started to become interested in equality issues and then I started to look at that professionally. I started to understand about how inequality impacted on lots of different people in lots of different ways and how there can be layers of inequalities for people and I was just always really interested in that and fighting stigma . . . then through becoming a counsellor I felt that here I could actually do something to support people . . . who had been hurt in some way because of who they were (sexual orientation) or what had happened to them. (M11S 3.63-77)

Connection, Separation, and Oneness

Clinicians described the process of engaging and disengaging in a therapeutic relationship with clients, their sense of clients as “the other” or “them,” and also how they use themselves (and their own experience of trauma and emotional pain) in this work.

I guess there is a relationship built and (as) they (clients) began to trust more and felt supported they would then go into some of the graphic detail of maybe one of the incidents. I can remember the first time—one of the first times that I thought (that), I was sitting and I came back to my own chair and thought I am so overwhelmed by this story, I was really touched by it, which was a bit scary for me and I thought “oh no this is not what I am supposed to be doing! (M61S 3.67-4)

Into and Out of the Darkness

Therapists talked of developing both an awareness of and sensitivity to a darker side of life through this work, which caused them to view the world (and the adults and children within it) differently.

I was either still in placement or a volunteer so maybe about three years ago, and I can remember looking at children quite differently; looking at children as really vulnerable and that had a big impact on me because again I had to think not everybody in the world is bad and not every child is going to be sexually abuse. (M131S 6.163-166)

This sense of altered perceptions, was frequently mentioned, with participants questioning the motivations of those (men in particular) who choose to spend time with young children.

A close friend of mine met someone new and she had children and her relationship started to crumble- I had thoughts initially about both—not fleeting thoughts but those thoughts that come into your mind about what is this person’s (new partner’s) motivation and behaviours—there was no reason to feel . . . to be worried mmm about these children but I think things like that can impact on you. (M91S 8.208-214)

Chaos Into Meaning

Many of the clinicians described being part of the client’s journey to recover from CPT, on occasion as merely an observer witnessing the process, but more often as a facilitator effecting change. Therapists suggested that there was a process occurring, whereby they had a role in making sense of the often-chaotic stories presented to them, not only to create a narrative but also to further develop the meaning of the abuse in the client’s sense of themselves, and in their level of understanding of their life journey.

I help clients through the time zones, the past- where it comes from, (and) the present—how it’s affecting them now and what they want to change. (M21S 7.163-165)

This process of meaning making or of putting pieces of a jigsaw together was frequently mentioned.

For me there’s a missing piece of the puzzle and the missing piece of the puzzle I think it is in psychological way— . . . I thought that there was the only (one) missing piece now I realise that there are lots of pieces that have to work together . . . in homelessness services, I know that 90% of people have experienced complex trauma and that is a really high percentage and therefore taking into account somebody’s complex PTSD picture needs to be done before or alongside moving people into accommodation. (M81S 2.42-50)

Reparation Not Repetition

Clinicians frequently spoke of their desire to redress the balance when considering the unfairness of the trauma that their clients had experienced. In terms of the desire to right the wrong done to clients, therapists suggested that this was not only the unfairness of having been a victim of CPT, but on occasions that their client’s distress had been compounded by a lack of understanding or respect, or even by a perceived degree of resentment from professionals and services. Participants suggested that this unreceptive stance could then (together with the broader organizational issues) become a barrier to clients wishing to access services. Therapists highlighted an awareness of systemic problems, which can obstruct the clients’ pathway into therapy, and the unfairness of victims of CPT suffering once more, as a result of society’s attitudes to sexual and childhood abuse, and they spoke of wanting to make reparation.

The system is too large, it doesn’t always have the patient in mind, simple things like getting rooms; getting the same room every week; the fact that you may have 6 people who might answer the phone . . . you need eyes at the back of your head to make sure things work better for patients and that when the patient needs contact then they will know how (to get it), in some way. All the difficulties are when the lack of pathways developed to carry somebody from A to B through the system—and that’s a function of having teams that are too large (that) I am anxious about. (M41S12.301-315)

Clinician Expansion and Growth, Personal and Professional

Clinicians spoke of how they felt that they had expanded, grown, and developed through this work. Some described this work as giving their own life meaning and of developing a sense of fulfillment as a result.

I think I have developed on different levels but the simplest level it would be having more time and experience, working within the area of complex trauma has helped me to understand about how complex trauma affects people, so my knowledge has improved I think em . . . I have developed skills to help me assist people to manage those symptoms that are linked to the complex trauma so practical stuff and . . . I am most aware of the interpersonal dynamic so I guess that is an increased awareness of that and how powerful that can be . . . I I think that is a good thing certainly for me as a therapist. (M151S 10/11.254-271)

Interviewees also described benefits on a personal level, obtaining a greater level of pleasure and even contentment. Therapists highlighted improved clinical skills and an increased sensitivity to the interpersonal (therapeutic) relationship in particular, as occurring through this work, leading to overall professional progression. Others described deeper, more personal consequences.

In this work regarding post traumatic growth, I would see that as I have gone through the stages of this work in the past, any shit that I have gone through personally, and thinking “oh my God what will I do,” then thinking “I will do everything.” And there are some people, a few patients that I can think of, and do you know what actually, they have coped with much worse . . . So actually I think that I do feel very confident about that, that I know that I have really helped people, and that’s really important—knowing what I can and cannot do. And that’s really empowering too, the sense that you have got to a stage in life to be able to help like this. (M111S 10/11.238-249)

Clinician-Led Framework of Expansion and Growth in Trauma Work

Qualitative modeling was conducted by conducting thematic analysis and synthesizing of already identified themes via IPA methodology, that is, thematically analyzing already extracted themes and subthemes, treating them as original data, and identifying links and meta-themes emerging. That way, we were able to create meta-themes, which captured patterns of connections between themes. These reflected a dialogue process and consensus in the research team. This method was developed in previous published work specifically in the area of complex trauma/CSA (Chouliara et al., 2013; Chouliara et al., 2017; Chouliara et al., 2011; Chouliara et al., 2004; Chouliara & Narang, 2017). A more detailed description of this qualitative modeling method is beyond the scope of this article and will be published elsewhere.

Through this analysis, it became apparent that what was in the center of all accounts, as a common thread, was a dynamic process of expansion and growth through this type of work. As a result, we engaged in a process of modeling our themes around this key central idea to develop this framework, and identified key milestones that clinicians have to go through to facilitate this process. These milestones include clinicians being in touch with and reevaluating their motivation to this work; maintaining good therapeutic relationships in a fragile process; building capacity to tolerate all aspects of human nature, including the darker ones; and maintaining capacity to self-reflect on personal and professional levels to contain distress and maximize healing processes. The framework captures the movement in this deep, interactive process of change and growth, and also emphasizes the relational aspects in this growth process.

Contextualizing Findings Within Previous Research and Policy

Our findings propose a new extended understanding of the relational way in which clinicians engage with this client group and the how this interactive process brings benefits not only to clients, in terms of their recovery, but also to clinicians themselves through the experience of vicarious posttraumatic growth. Although since early stages of research in the field of trauma-focused work there has been the possibility that the impact on clinicians was not entirely negative (Guhan & Leibling-Kalifani, 2011; Hudnell Stamm, 1998; Pearlman & MacIan, 1995), there has been a widely held belief that the work is inherently damaging (McCann & Pearlman, 1990b; Neumann & Gamble, 1995; Schauben & Frazier, 1995; A. J. Smith, Kleijn, Trijsburg, & Hutschemaekers, 2007). This research, therefore, appears to sit out with these findings and not only presents new insight into the possibility of positive gains from the CPT work but also provides a deeper and more wholesome understanding of the meaning therapists assign to their experience of working with highly traumatized clients. Research suggesting that there may be positive outcomes for clinicians (Barrington & Shakespeare Finch, 2013; Brockhouse, Msetfi, Cohen, & Joseph, 2011; Weaver & Biggart, 2012), including a level of growth or resilience, is limited and has often related to trauma generally and CPT. It has less often been focused on those who work in the specialist area of GBV and CSA complex trauma. However, there is some connection with the findings of Samios, Abel, and Rodzik (2013) and Samios, Rodzik, and Abel (2012), who have identified a level of growth for clinicians or positive outcomes. To our knowledge, there is no precedence in the literature of a framework in which the experience of growth in clinicians, and their level of meaning makin(occurring within this fluid, dynamic, and interactive encounter), is as clealry delineated as the one proposed here. The work of Hobfoll et al. (2007), although not focused on clinicians, might be of some relevance here in support of this framework. Hobfoll and colleagues (2007) found positive associations between posttraumatic growth and posttraumatic stress. They have also suggested that posttraumatic growth is more helpful and functional if action-based and not a simple reinterpretation of traumatic events. Clinical training enhances awareness, mindful reflection, and empathy; therefore, clinicians might become more aware both of their own distress and of their motives to help others.

Another distinctive aspect of our findings is the relational way that clinicians described the positive and negative impacts of their work in the complex trauma field. This highlights the greater need for the application of relational models in this field more than in other fields of practice. The link between empathy and negative impact of such work, such as compassion fatigue and burnout, has been controversial. Recent evidence by Turgoose, Glover, Barker, and Maddox (2017) supports an association between high levels of dispositional empathy and low levels of compassion fatigue in a sample of police officers in Scotland. Thus, the role of empathy as a protective factor is advocated. Although this research was in the area of sexual assault, it did not utilize a sample of clinicians. Furthermore, the participants had not been working for too long in this area, which can explain their low levels of compassion fatigue overall. Nevertheless, empathy in the therapeutic relationship is a key factor of change within relational models. In addition, empathy’s links with trust and recovery from complex trauma (Chouliara et al., 2013; Chouliara et al., 2017; Chouliara & Narang, 2017) provide further support for more relational approaches both in practice and in self-care and consultative support.

Guidelines and systematic reviews regarding PTSD have been available for some time by the National Institute for Health and Clinical Excellence (NICE; 2013). However, there are currently no NICE guidelines for the treatment of CPTSD and—more important—there are no NICE guidelines for protecting clinicians of the impact of this work or self-care in this field of practice. The present findings highlight the need for the development of NICE guidelines and Scottish Intercollegiate Guidelines Network’s (SIGN) guidelines for good practice for those working clinically or planning services in this field (UKPTS Complex Trauma Guideline, 2016). Therefore, the findings of this research, with a new understanding of how clinicians engage in and may benefit from the work, are likely to be of value when reviewing the role of health workers, and their engagement with severely traumatized individuals and also for the safeguarding and delivery of services. Such guidelines would be paramount in prevention of detrimental impacts and promoting self-care, resilience, and growth in clinicians working in this field. Regarding policy frameworks within Scotland, the Scottish Government/NHS Education for Scotland’s (SG/NES, 2017) “Transforming Psychological Trauma: A Skills and Knowledge Framework for the Scottish Workforce” also highlights the importance of improved training and awareness for health professionals, management, organizations, and education providers to provide a “trauma informed workforce.” Nevertheless, even this framework does not touch upon the risks of vicarious traumatization and the need for self-care, growth, and personal development of the workforce in this field. Given that we live in an increasingly traumatogenic world, due to war/conflict, movement of populations, and extreme weather conditions, it is expected that professionals and services will be increasingly called worldwide to respond to individuals and groups suffering from (complex) psychological trauma. The need, therefore, arises not only for a workforce who is trauma sensitive, trauma aware, and trauma focused but also for a worldwide framework for good practice and self-care. The present findings advocate, therefore, the development of such framework potentially via the World Health organization (WHO) and for imbedding such in the official curriculum and service delivery internationally with a particular focus in countries afflicted more by high level of conflict, migration, war, and human rights violations.

Strengths and Limitations

Because the research was carried out within NHS services with specialist and highly qualified therapists, working within well-defined parameters, the results may have been quite different if participants were from other backgrounds. In addition, having taken place within Scotland, it may not be possible to generalize the findings to other parts of the United Kingdom or indeed elsewhere. However, even with these unavoidable limitations, the study provides a starting point for further discussion about the role of GBV/CSA therapists, the impact of the work on clinicians (in terms of personal and professional development), and the meaning they make of this complex and demanding work.