UBC Theses and Dissertations

UBC Theses Logo

UBC Theses and Dissertations

Preventing vicarious traumatization of mental health therapists: identifying protective practices Harrison, Richard Lawrence 2007

Your browser doesn't seem to have a PDF viewer, please download the PDF to view this item.

Notice for Google Chrome users:
If you are having trouble viewing or searching the PDF with Google Chrome, please download it here instead.

Item Metadata


24-ubc_2008_spring_harrison_richard_lawrence.pdf [ 8.76MB ]
JSON: 24-1.0054403.json
JSON-LD: 24-1.0054403-ld.json
RDF/XML (Pretty): 24-1.0054403-rdf.xml
RDF/JSON: 24-1.0054403-rdf.json
Turtle: 24-1.0054403-turtle.txt
N-Triples: 24-1.0054403-rdf-ntriples.txt
Original Record: 24-1.0054403-source.json
Full Text

Full Text

PREVENTING VICARIOUS TRAUMATIZATION OF MENTAL HEALTH THERAPISTS: IDENTIFYING PROTECTIVE PRACTICES by RICHARD LAWRENCE HARRISON B.A., The University of California, Berkeley, 1979 M.S.W., McGill University, 1996 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY in THE FACULTY OF GRADUATE STUDIES (Counselling Psychology) THE UNIVERSITY OF BRITISH COLUMBIA August 2007 © Richard Lawrence Harrison, 2007 11 Abstract This qualitative study was designed to identify protective practices that mitigate risks of Vicarious Traumatization (VT) among trauma therapists. The sample included six peer- nominated experienced therapists, trained at the masters or doctoral level, who self-identified as having managed well in this work. Narrative data was collected through interviews with individual co-participants, who were asked, "How do you manage to sustain your personal and professional wellbeing, given the challenges of your work with seriously traumatized clients?" Data analysis was based upon Lieblich, Tuval-Mashiach, and Zilber's (1998) typology of narrative analysis, with a primary focus on thematic content analysis within and across participants' narratives. The research findings yielded twelve major themes that describe protective practices engaged by exemplary trauma therapists: countering isolation (in professional, personal and spiritual realms); developing mindful self awareness; consciously expanding perspective to embrace complexity; openness to the unknown; sustaining and renewing hope; active optimism and problem solving; holistic self-care; maintaining clear boundaries; invoking imagery, metaphor, and ritual; exquisite empathy; professional satisfaction; and creating meaning. The novel finding that empathic engagement with traumatized clients appeared to be protective challenges previous conceptualizations of VT and points to exciting new directions for research and theory, as well as applications to practice. Participants also described experiences of vicarious post-traumatic growth. The findings confirm and extend previous recommendations for ameliorating VT and underscore the ethical responsibility shared by employers, educators, professional bodies, and individual practitioners to create time and space to address this serious problem. Participants recommend opportunities for regular supervision, support and validation (including group-based interaction), self-care (including 111 personal therapy, as needed), and developing self-awareness within and beyond the workplace. They think taking care of the caregivers is an organizational responsibility as well as a personal one. Although the research design precludes generalizing from the data, the knowledge generated herein may be helpful to others in the fields of psychology, psychiatry, social work, psychiatric nursing, and related health care disciplines, at the levels of education, training, and practice. iv TABLE OF CONTENTS Abstract^ ii Table of Contents^ iv CHAPTER I: Introduction^ 1 Background 1 Purpose of the Study 1 Research Questions^ 2 Research Design 3 CHAPTER II: Review of the Literature^ 6 Vicarious Traumatization 6 VT versus Countertransference 7 VT versus Burnout^ 7 Transforming VT 8 Costs of VT 10 Elements that Impact on VT^ 11 Secondary Traumatic Stress 12 Treating the effects of VT and STS 16 Prevention^ 17 Compassion Satisfaction^ 20 Counsellor Sustainability, Expertise, and Posttraumatic Growth^21 Master Therapists 22 Sustaining Professional Wellbeing^ 24 Psychologist Well-functioning 25 Managing Countertransference 27 Coping with Stressful Clients^ 28 Posttraumatic Growth 29 Personality and Successful Coping 31 Resilience^ 32 Vicarious PTG 33 Vicarious Adversarial Growth^ 34 Gaps^ 35 CHAPTER III: Method^ 37 Research Problem and Relevancy^ 37 Research Questions 38 Research Design^ 38 Situating Myself as Researcher^ 39 Rationale for Using a Narrative Approach^ 41 VSample (Locating Co-participants)^ 42 Screening^ 43 Data Collection Process^ 44 Transcription 44 Data Analysis^ 45 Criteria of Worth 50 Verisimilitude 50 Consensual validity ^ 51 Polyphonic Vitality 52 Pragmatic Resonance 52 Issues of Representation^ 53 CHAPTER IV: Findings 55 Dear Clare:^ 56 Conscious Self-Care: An awakening^ 56 Embodied Response to a Different Level of Engagement^ 57 Body Stuff - Running and Processing: An Interior Journey to Acceptance^57 Processing^ 58 Being Held 58 Planting Seeds 59 Getting Warm^ 59 Mind-Body Stuff: Touching the Spirit^ 59 Reconnection With and Through the Light 60 Invoking the Light^ 61 Nature as Middle Ground 61 Checking Bounds 62 Releasing Emotions: The Role of Advocacy /Moving Emotion into Action^62 Preserving Self and Others: Release as Ethical Practice^ 62 The Gift Side of Loss^ 63 Mystery as Purpose 63 Touchstones: Safety Through Connection^ 65 Edgy Humor: Another Form of Connection and Release Through Acceptance ^65 Other Self-Care Strategies^ 65 Prevention^ 66 Dear Yvette 68 Training: Rigid Adherence to Clear Boundaries ^ 68 Satisfaction in Assisting^ 69 Recognize Professional Role and Scope of Influence 69 Goodness of Fit: Theoretical Perspective, Professional Responsibilities, & Worldview^ 69 Moment-to-Moment Awareness As Part of Responsible Practice^70 Presence: Here and Now Process^ 70 Facilitating Shifts^ 71 Exquisite Attunement to Self & Others 71 vi Expanding Perspective to Embrace Complexity^ 71 Faith & Ritual^ 72 Openness to the Unknown^ 72 Enduring Relationships: Inner & Outer Presence^ 73 Dialectical Living^ 73 Practice What You Teach 74 Continuity & Letting Go 74 Breathing^ 75 Other Protective Practices^ 75 Perspective on Life: Awareness and Optimism^ 75 Ongoing Learning & Curiosity 76 Protective Practices that You Recommend for Other Helpers^76 Dear Joy^ 78 Countering Professional Isolation / Finding Like-Minded People^78 Vision and Purpose/ Making a Difference^ 78 Organizational Support ^ 79 Balancing Realistic Expectations and Sustained Hope/ Change as Incremental^79 Loving Connections in Professional and Personal Life^ 80 Consistent Interpersonal Boundaries and a Perspective of Enduring Compassion ^80 Variety of Professional Responsibilities^ 81 Practicing What You Teach^ 81 Letting Go^ 82 Mindful Self-Awareness and Active Self-Care^ 82 Communication Skills^ 83 Relational Self-Healing: Supervision, Peer Support, Personal Therapy^83 Maintaining Boundaries Between Personal and Professional Realms of Life ^84 Maintaining Temporal, Spatial, and Relational Boundaries within the Work Place ^84 Informed Acceptance^ 85 Spiritual Care of the Self: Engaging Your Belief Systems^ 85 Nature, Present-Focused Joyful Awareness, and the "Work" of Spirituality^86 Potentially Protective Practices at the Organizational/Systemic Level^87 If I Had to Sum it Up^ 87 Dear Abigail^ 89 Acknowledging and Accepting the Inevitability of VT^ 89 Caring Supportive Community Helps Mitigate Risks 89 Giving Experience a Name^ 90 Self-Awareness + Pro/Active Problem Solving^ 90 Embracing Paradox: Enduring Optimism and Cynical Perspective^90 Beauty In: Expanding and Refreshing Your Perspective^ 90 Countering Isolation: Connection With Ordinary Folk 91 Diversity of Professional Activities^ 91 Community, Interconnection, and Sense of Greater Meaning^92 Positive Feedback^ 92 Love of the Work/ Vicarious Posttraumatic Growth^ 92 vii Making a Difference: Realistic Appraisal of Your Sphere of Influence^92 Sense of Purpose & Acceptance of Work Role^ 93 Clarity About Expectations for Change and Bounds of Personal Responsibility ^93 Imagery of Interconnection: A Thread in the Web of Life^ 94 Imagery to Reinforce Compassionate Presence^ 94 Nature Affirms Resiliency^ 94 Mindfulness^ 95 Community Building 95 Continuity In Relationships^ 95 Supportive Partner^ 96 Practices That Mitigate Risks of VT for Others^ 96 Summary^ 97 Dear Frank 99 Balance: The Medicine Wheel^ 99 Emotional Health: Family 99 Separation between Personal and Professional^ 99 Physical Health^ 100 Creating Time and Space for Personal Pleasure 100 Intensity of Engagement in the Present^ 100 Enjoy Work: Intimate Honest Connections with Clients^ 101 Goodness of Fit: Mental and Spiritual Wellbeing 101 Walking Your Talk: Self Awareness, Personal Growth, and Enlightenment^ 102 Letting Go and Active Problem Solving^ 102 Professional Effectiveness, Satisfaction & Sense of Accomplishment^ 103 Meaning and Purpose: Social Responsibility and Making a Contribution 103 Sustaining Hope Through Expanded Perspective: Part of a Larger Movement^ 103 Entering Discourse: Increased Public Discussion of Abuse^ 104 Enduring Hope^ 104 Embracing Paradox Around Progress^ 104 Change as Incremental/Recognizing and Accepting Limits of Personal Influence ^ 105 Accepting and Appreciating Small Successes as Adequate^ 105 Positive Feedback^ 106 Integrated Spirituality 106 Ritual and the Practice of Spirituality^ 107 Vision: Seeing Beauty and Making the Extraordinary Ordinary^ 107 Embracing Complexity/Seeing Both Sides of the Story 108 The Drift: Adjusting to the Bad Days^ 108 Practice Optimism Through Awareness and Conscious Shifts in Perspective^ 108 Personal Therapy^ 109 Recommendations 109 Dear Ernest^ 110 Exquisite Listening and Empathic Attunement^ 110 Co-Presence 110 Being Effective and Good at What You Do 111 viii Personal Experience of Traumatization/ Post-traumatic Growth^ 111 Clarity of Boundaries Between Self and Other^ 112 Imagery: Wind through a Screen Door 112 Peer Supervision^ 112 Physical Exercise 113 Holding and Being Held 113 Community^ 113 Religion, Tradition, and Belonging^ 114 Spirituality 114 Contemplating Nature^ 115 Witnessing Client Change: Vicarious Post-traumatic Growth^ 116 Invigoration: Love for Work and Clients^ 116 Recommendations^ 116 In Closing 117 CROSS NARRATIVE THEMES 118 Counter Isolation^ 119 Professional Community^ 119 Supervision: Relational self-healing^ 119 Training, professional development, and organizational support^ 120 Multiple professional roles ^ 121 Therapetic connections 122 Personal Community^ 124 Countering Isolation Through Spiritual Connection^ 127 Develop Mindful Awareness: Integrated Practice of Spirituality^ 128 Consciously Expand Perspective to Embrace Complexity 133 Remain Open to the Unknown^ 138 Sustain Hope and Trust in People's Capacity to Heal^ 144 Active Optimism and Problem Solving^ 146 Holistic Self Care^ 148 Maintaining Clear Boundaries and Honor Limits^ 152 Invoke Imagery 154 Exquisite Empathy^ 156 Professional Satisfaction 157 Creating Meaning 158 Summary^ 161 CHAPTER V: Discussion^ 162 Contributions to the Literature^ 162 Implications for Research and Theory 174 Implications for research 174 Implications for theory^ 176 Implications for Practice 177 Limitations of the Study 179 Conclusion^ 180 ix References^  182 Appendix: Consent Form^  191 Chapter I Introduction Background Over the past 15 years, researchers and theorists have given increasing attention to the construct of Vicarious Traumatization (VT), which has been defined as the cumulative transformative effects upon counselors and other helpers that result from empathic engagement with traumatized clients (McCann & Pearlman, 1990; Pearlman & Mac Ian, 1995; Pearlman & Saakvitne, 1995a). The risks of working directly with traumatized individuals on a regular basis are well documented within the literature. Counsellors and other mental health professionals may experience physical, emotional, and cognitive symptoms, (e.g. physical pain and agitation, emotional distress, disrupted beliefs, nightmares, and intrusive thoughts and images) similar to those of their traumatized clients (Arvay, 2001; Figley, 2002; McCann & Pearlman, 1990; Sexton, 1999). However, there is consensus in the field that we do not know through empirical research the definitive factors that contribute to VT and the practices that may prevent or ameliorate its harmful effects (Arvay, 2001; Figley, 2004; Pearlman, 2004; Pearlman & Saakvitne, 1995b). Purpose of the Study Although research and theory have begun to emerge about VT vulnerability and treatment, it is equally important to understand what protects and sustains helping professionals in their work with traumatized populations. To date, very little is known about the success and satisfaction of trauma therapists who are able to manage in the workplace despite the potentially noxious demands of their work. Who are the respected, experienced professionals who succeed in this work and remain healthy? How and why do they carry on? Salston and Figley (2003) state 1 2that the most important and least studied variables predicting VT are "a sense of satisfaction for working with the traumatized and the ability (or competence) in creating distance between the worker and the work . . . both physically and mentally." (p. 172). My study expanded on current research (and filled a gap in the existing literature) by offering an in-depth exploration of experienced trauma therapists' narratives of individual and organizational practices that contribute to their professional satisfaction and wellbeing and to the sustainability of their efforts in the workplace. The purpose of the study was to gain and share knowledge about these protective practices. The ultimate goal of the study is to contribute to the prevention of VT. This research has implications for the training, counselling practice, supervision, and support of counsellors who are working with increasingly complex client populations. Many people enter the fields of counselling, social work, and psychology without ample awareness of the costs of caring. Curricula in the helping professions rarely impart adequate knowledge regarding the harmful effects of VT and the potential risks to the health and wellness of trainees. When individuals trained in the helping professions abandon the field, due to a perceived burden of caring and an insufficient ability to balance work with other aspects of life, this constitutes an enormous loss of resources and potential. When therapists continue working, despite suffering from the damaging effects of VT, this constitutes a tremendous disservice to both clients and helpers, and the health of our community is undermined. It was imperative to address these concerns on ethical grounds, as practitioners and researchers alike must strive to provide appropriate, effective care for traumatized clients as well as those who work with them. There is a social cost to ignoring these issues. Research Questions The questions that I explored are: 31) How do exemplary (i.e., healthy, effective, satisfied) trauma therapists experience and practice sustainability and personal wellness in their work with traumatized clients? 2) How might protective practices best be engaged at the individual, organizational, and systemic levels in order to mitigate risks of VT for therapists who work with traumatized populations, thus sustaining their efforts in the workplace? Research Design I used a narrative method of inquiry and analysis to explore these research questions (Arvay, 2003, Freeman, 1997, McLeod, 2001). This approach to research involves "in-depth study of particular individuals in social context and in time" (Josselson, 2003, p.4), and integrates a careful, systematic study of phenomena with the literary deconstruction of texts and hermeneutic analyses of meanings. Narrative analysis combines a discursive emphasis on how meanings are constructed through language and utterances along with an attention to the participant's personal agency and self-awareness in their efforts to attribute meaning and achieve fulfillment in their lives. It is concerned with the multiplicity of voices within texts, the co- constructed nature of interviews, figurative use of language, analysis of story structure, and the identification of cultural narratives. It also makes use of reflexivity and multiple readers (McLeod, 2001). Narrative ways of knowing are compatible with my personal research epistemology, which hovers and shifts between a post-structuralist and social constructionist framework (the very notion of fixed categorization here is antithetical to my epistemological orientation towards research). I believe we humans come to know through narratives, through stories (including cognitive schemas, which I construe as narratives), and that these are always relationally co- 4created (Siegel, 1999). Furthermore, I maintain that language, thought, and much (if not all) of human experience are inextricably interwoven together (Burr, 1995; Riessman, 1993). Metaphorically speaking, I want to expand the story of VT by conducting research with trauma therapists who are "doing well" in their work rather than succumbing to the risks of VT. In formulating the research questions, I intentionally avoided terms such as resilience, hardiness, and coping, because each of these are already linked to theoretical measures and constructs; whereas, I preferred to first hear from my co-participants how they name their ability to manage in the work. My initial interest in exploring this "counterplot" to VT was informed by my training in White and Epston's (1990) narrative ideas and practices of therapy. When considering the problem of VT, I found myself curious about the influences of VT over the lives of affected trauma counsellors, as well as the influence that counselors and other trauma therapists have over "the life of the problem." However, my curiosity extends beyond the realm of individual influences over the problem of VT. In addition to personal practices and individual differences or attributes that may mitigate the harmful effects of VT, I am equally curious about organizational and societal practices that can help prevent or reduce the damaging effects of counselling traumatized clients. I do not aspire to write autobiography as research; however, I believe it is important to recognize and declare, as well as possible, my own subject position(s), because perspective informs what is seen (Burr, 1995; Geanellos, 2000; Josselson & Lieblich, 2003). Undoubtedly, my interest in this subject is informed by my professional experience (between 1998-2003) as a 5child and family counsellor to children exposed to domestic violence' and my work as a child, youth, and family therapist for a community mental health team in a particularly challenging and impoverished cachement area where many clients had experienced significant abuse and neglect. Experiences from my childhood and family-of-origin also inform my approach to this study (both in terms of my choice of topic and my research epistemology); however, it is beyond the scope and intent of this dissertation to further address these personal, historical influences. Nonetheless, this awareness on my part is an aspect of researcher reflexivity, which comprises an important and vital component of the narrative research process in which I engaged throughout all stages of the study. Moreover, I look forward to continuing to engage in ongoing reflexivity, as the findings from this study are disseminated and invite further research conversations in future arenas (e.g., between readers and myself as researcher or presenter). I Typically, this "domestic" violence was , in fact, woman abuse, perpetrated by an adult male; however, I recognize and acknowledge that DV also takes place in same-sex relationships, and that women perpetrate abuse directed towards men. 6Chapter II Review of the Literature My research questions concern counsellors who are doing well despite the known risks of VT. In order to establish a theoretical foundation and context for my research question, I have reviewed literature related to VT. Consistently, this literature highlights the need to better understand practices and attributes that are protective of counsellors and others who work with traumatized clients. However, to date there does not appear to be an existent body of knowledge on this important subject. In order to build a rationale for my study, I have had to review research studies in other areas. Therefore, I have looked to research and theory on counsellor wellbeing, expertise, and the construct of posttraumatic growth. In a sense, my research question is located in the liminal, interstitial spaces between these areas that I have cobbled together (for each of which there appears to be only a paucity of research). For these reasons, I am confident this study of qualities and practices that protect and sustain counsellors in their work with traumatized clients addresses an important gap in the literature that is indeed deserving of exploration and study. Vicarious Traumatization Over the past 15 years, researchers and theorists have given increasing attention to the construct of Vicarious Traumatization (VT), defined by Pearlman and Mac Ian (1995) as "the transformation that occurs within the therapist (or trauma worker) as a result of empathic engagement with clients' trauma experiences and their sequelae" (p. 558). McCann and Pearlman (1990) first identified and conceptualized VT as an interactive, cumulative, and inevitable process, distinct from burnout or conntertransference. They posited that all therapists working with survivors of trauma experience pervasive and enduring alterations in cognitive schema that impact the trauma worker's feelings, relationships, and life. Whether these changes are destructive to the therapist and to the therapeutic process, depends, according to these authors, largely on the extent to which the helper is able to engage in her or his own process of integration and transformation of clients' horrific traumatic material. VT versus countertransference. Unlike countertransference, which is typically construed as a short term response that occurs and is contained within the context of a therapy session, VT involves "long term alteration in therapists own cognitive schemas, or beliefs, expectations, and assumptions about self and others" (McCann & Pearlman, 1990, p. 132). Furthermore, the therapist is the locus of origin for countertransference, which is based upon preexisting personal characteristics of the helper (inner qualities, psychological makeup, etc.) and is understood to be an intrusion of a therapist's own unresolved material, including previous trauma experiences, retaliatory or aggressive fantasies, etc. In contrast, traumatic experiences in the client's life account for therapist VT. According to Pearlman and Saakvitne (1995a; 1995b), VT increases therapist susceptibility to some countertransference responses, which may be less recognizable and hence more problematic in therapy. VT versus burnout. McCann and Pearlman (1990) suggested that there is some overlap between conceptualizations of VT and burnout, inasmuch as "symptoms of burnout may be the final common pathway of continual exposure to traumatic material that cannot be assimilated or worked through" (p. 134). In burnout, the nature of the external event is the source of distress (as contrasted with countertransference). Burnout is related to the work situation (e.g., a high stress work environment with low rewards, in which minimum worker goals are unachievable) but not to the interpersonal interactions specific to VT (Pearlman & Saakvitne, 1995a; 1995b). Burnout 7 8lacks the specificity of therapist exposure to the emotionally disturbing images of suffering and horror characteristic of serious traumas (McCann & Pearlman, 1990). Transforming VT. McCann and Pearlman (1990) drew upon their own work experience to posit strategies for the transformation of VT. According to these authors, helpers must acknowledge, express and work through painful experiences in a supportive environment. Otherwise, therapist numbness and emotional distance risk interfering with ongoing empathic engagement with clients. Therapists own salient schema and related needs could make it harder for them to work with certain trauma clients. McCann and Pearlman suggested that weekly case conferences and other groups for trauma professionals can counter professional isolation and provide emotional support by helping to normalize and elucidate therapist reactions to client trauma. Furthermore, they recommended that trauma therapists balance caseloads with victim and non-victim clients, balance clinical work with other professional responsibilities, such as teaching and research, and maintain balance between personal and professional life. They identified other coping strategies, including: advocacy, enjoyment, realistic expectations of self in the work, a realistic worldview (that includes the darker sides of humanity, acknowledging and affirming the ways in which trauma work had enriched lives (of others and their own), maintaining a sense of hope and optimism, and a belief in the humans ability of to endure and transform pain. Although I personally agree with the coping strategies recommended by Pearlman and McCann (1990), these need to be further researched. My sense is that the authors may have generalized their recommendations, which appear to have been based upon theoretical inference and personal experiences of informal observation that "emerged" from weekly meetings. Furthermore, some of the terminology used by these authors troubled me. They wrote of 9therapists who are "not immune to the painful images, thoughts, and feelings associated with exposure to their clients' memories" (p. 132, emphasis added), using terms that appear to be grounded in a medical model. They subsequently referred to Jung's concept that "an unconscious infection' may result from working with the mentally ill" (p. 136). I question whether the concept of therapist immunity (to implied infection) is the most helpful way of framing a healthy or adaptive response to interactions with traumatized clients. I wonder whether VT can be conceptualized as over-involvement (that ultimately necessitates distanciation), whereas burnout is a form of disengagement. Hence burnout would be the ultimate common pathway for VT, because over closeness eventually is unsustainable and leads to distancing. According to Pearlman and Saakvitne (1995b), VT arises out of the interaction between a therapist's characteristics and the work environment over time. Both the nature of trauma work and personal characteristics of individual therapists contribute to vicarious traumatization of therapists. The latter include: therapists' high ideals, over-identification with clients, over- investment in meeting clients' every need, rescue fantasies, inadequate self-care, and inadequate training and supervision, all of which can contribute to VT. These authors maintained that the phenomenon of VT is consistently observed in therapists who work with traumatized clients, and that it is both cumulative and permanent, involving profound changes in "core aspects of the therapist's self, or psychological foundation" (p. 152). These changes include shifts in: identity, worldview, and sense of meaning or spirituality; ability to manage strong affect; ability to connect interpersonally and with self; and ability to maintain positive sense of self. I question whether VT is indeed "ineluctable" (Pearlman & Saakvitne, 1995a, p. 295) and inevitable, as suggested by McCann & Pearlman (1990), who stated: "It is our belief that all therapists working with trauma survivors will experience lasting alterations in their cognitive 10 schemas, having a significant impact on the therapist's feelings, relationships, and life." (p. 136). Clearly, there is a need for clarity and precision in definitions of VT, which frequently is conceptualized as something harmful. Personally, I am not convinced that there are inevitable, permanent, and deleterious effects for all those who engage in work with traumatized clients. Even the idea that there are inevitably permanent changes, whether these be positive or negative, for all who work with the traumatized, seems to me to be an overly-assumptive and totalizing statement. I also question the notion that there is a unitary core aspect of a therapist's self or psychological foundation. At the same time, I recognize the importance of identifying and communicating the risks and potentially harmful effects of working with traumatized persons. Costs of VT. According to Pearlman and Mac Ian (1995), VT "implies changes in the therapist's enduring ways of experiencing self, others, and the world, " and its effects "permeate the therapist's inner world and relationships" (p. 558). VT "takes a serious toll on both the therapist and the client, as well as on the organizations and society that provide the context for their work together" (Pearlman & Saakvitne, 1995b, p. 156). Costs to therapists can include: depression, cynicism, despair, professional impairment (often leading to premature job changes), alienation from family, friends, and colleagues, and physical and psychological responses similar to the symptoms of untreated trauma survivors. At a broader level, VT poses a risk to the profession (Pearlman & Saakvitne, 1995b; Sexton, 1999). When therapists suffering from VT become disillusioned and/or mistreat clients, their failures can demoralize colleagues and open the mental health profession to criticism, censure, and potential fiscal liability for harm to workers. Furthermore, when therapist hope turns to cynicism, this constitutes a loss to society. According to Pearlman and Saakvitne (1995b), disruption of frame of reference (identity, worldview, and spirituality) may be the most fundamental disruption experienced by a trauma 11 therapist. Disruptions in spirituality (defined by these authors as a belief system, whether theistic or not, that provides a context for meaning, connections, hope, awe, and joy) may be the least explored and most troubling aspect of VT (Pearlman & Saakvitne, 1995b). Elements that impact on VT. Pearlman and Mac Ian (1995) conducted a quantitative study of the effects of trauma work on self-identified trauma therapists. They found that therapists who were newer to the work and unsupervised experienced the most disruptive beliefs (which they reported to be consistent with the burnout literature). Therapists who had less training also reported increased disruptions in beliefs, as did those who worked in a hospital setting. Increased exposure to client trauma correlated with greater disruption in self intimacy (connection to one's inner experience) and general esteem for others. In their review of the literature, Pearlman and Mac Ian (1995) also reported Schauben and Frazier's finding that a larger number of directly traumatized clients on a therapist's caseload was correlated with more severe disruptions in schemas/beliefs, increased PTSD symptoms, and increased likelihood of self-identifying as experiencing VT. Similarly, Munroe found that increased time spent working with clients traumatized in combat correlated significantly with intrusive symptoms. Pearlman and Mac Ian (1995) further found that the personal trauma history of therapists was significantly correlated with increased negative effects from their work. The survivor therapists in their study who expressed the most positive beliefs about relationship with self had been doing work the longest. The authors offered interesting speculation about their finding that these survivor therapists had experienced fewer disrupted beliefs with the passage of time. They queried whether, through their work, survivor therapists might find meaning in their own trauma and achieve resolution in previously disrupted beliefs, thereby contributing to their own healing by helping clients. They further hypothesized that a longer work history may have afforded these 12 therapists more experiences of continuing education and consultation which possibly helped them maintain clearer boundaries between self and clients. However, "longer work history" appears here to be a very general and ambiguous variable, inasmuch as it tells us very little about the characteristics of the work history. Pearlman and Mac Ian (1995) drew the following clinical implications from their study: there is a need for increased supervision of all trauma therapists, increased training for those new to the field, and more support for those therapists who are themselves survivors. The authors made suggestions regarding therapist self-care and the importance of supportive professional relationships. While I agree with these recommendations, it was not clear to me the extent to which they had researched whether these strategies were helpful. I believe there is a need for further research in the area of therapist self care and other organizational practices that sustain professionals in their work with traumatized clients. Furthermore, because Pearlman and Mac Ian (1995) was a quantitative study, it could only yield limited, more thinly described (i.e., less in- depth) knowledge about trauma therapists' lived experiences of the complex phenomenon of vicarious traumatization. We need to learn more and in greater depth about therapists who are doing well despite the risks of VT, such as those therapists who had a personal history of trauma, but whose beliefs appeared to be less disrupted with the passage of time. Secondary Traumatic Stress Figley (1995. 1999, 2002) described Secondary Traumatic Stress (STS) as a natural, treatable, and preventable consequence of empathic engagement with suffering people. He also popularized the term Compassion Fatigue (which was previously employed by Joinson to describe burnout among nurses); however, the terms STS and Compassion Fatigue are used interchangeably. Figley (1999) defined STS in terms of the "behaviors and emotions resulting 13 from knowledge about a traumatizing event by a significant other" (p. 10). In contrast with VT, which presupposes a constructivist model of personality in which relationship and meaning are integral parts of all human experience, STS focuses on symptoms with lesser attention given to etiology and context (Pearlman & Saakvitne, 1995b). According to Figley, both direct and indirect exposure to traumatic events can be traumatizing and lead to a similar set of PTSD-like symptoms. He proposed the existence of secondary traumatic stress disorder (STSD), a syndrome of symptoms that parallel those of PTSD, among those who care for victims of trauma. In the case of STSD, the primary exposure to traumatic events by one person becomes the traumatizing event for the second person. Figley (1995) equated STS with "the 'cost of caring' (Figley, 1982) for others in emotional pain" (p. 9) that has led researchers and therapists to abandon their work with traumatized persons. STS encompasses and transcends the construct of countertransference and overlaps with that of burnout. However, STS can have a faster onset of symptoms and quicker recovery than burnout, which is a process (Figley, 1995, 1999). In this regard, STS can be somewhat further differentiated from VT, inasmuch as VT is defined in terms of a cumulative process. Figley recognized the importance of warning therapists in training of the risks associated with caring for the traumatized. He also recognized the potential for trauma professionals suffering from STS or compassion fatigue to find a renewed sense of hope, joy, and purpose. At times, Figley (1995, 1999, 2002) used metaphors from industry and biological or physical science that reinforced and risked reifying the conceptualization of STS (and VT) as a communicable disease. He speculated about the mechanism "that accounts for this 'spread' of the 'virus' of PTSD" (2002, p. 3) among helping professionals, and he employed metaphors of 14 trauma infection, contagion, transmission, and absorption; stress breeding (in the manner of a virus); and empathic induction (Figley, 1995, 1999, 2002). These metaphors from physical science and biological illness may have been helpful in focusing awareness on the problem of STS or VT; however, they can also be limiting and may preclude other ways of understanding and addressing VT. I personally question whether VT and STS might not be better conceptualized as a form of a situated learning (Lave & Wenger, 1991) or unintended, reverse apprenticeship rather than as the transmission of a toxin or virus (Harrison, 2005). Arvay (2001) provided an overview of research findings on STS, most of which involved the use of surveys and standardized instruments. She suggested that VT and STS are the same phenomenon. VT is based on constructivist self development theory, whereas STS is subsumed under DSM-IV diagnostic criteria for PTSD. The position of the stressor accounts for the fundamental difference between STSD and PTSD. Arvay's review of the literature suggested "although important factors in the development of secondary traumatic stress have been examined, there appears to be an absence of agreement in the research findings to date" (p. 291). The number of traumatized clients in a therapist's caseload appeared to be a factor related to development of STS, according to Arvay's review. Working exclusively with traumatized clients was found to be positively correlated with development of STS symptoms, as were years of experience in the field and level of education. Younger therapists, and those with less than a master's degree were found to be more vulnerable. The research was inconclusive (or contradictory) with regard to whether therapist personal history of trauma is correlated with the risk of STS. There was a consensus that VT is distinct from burnout. There did not appear to be much research in the areas of self-care and support. 15 Arvay (2001) concluded that: "We do not yet know all the factors contributing to the development of secondary traumatic stress, nor do we know the conditions that protect trauma counsellors from becoming traumatized" (p. 286). Scholars in the field concurred, "the self of the counselor is the fundamental tool in trauma work" (p. 291). Arvay concluded that because trauma counsellors frequently work in isolation, without sufficient professional and social support, or the practical training and conceptual background needed to do the work safely, it is morally and ethically imperative that they be provided regular opportunities for supervision or on-site debriefing with professionals who are knowledgeable about the effects of trauma counseling and STS. Educators, supervisors, and trainers have both a duty to warn trainees of risks and to implement protective practices (including proper education and support) that minimize the risks of harm to counsellors who work with traumatized clients. I agree with her conclusions, and this article helped me recognize the paucity of qualitative research in the area of STS. Collins and Long (2003) reviewed the literature on the psychological consequences for mental health workers of interacting with seriously traumatized clients. Along with Stamm (2002), these authors acknowledged both the grave risks and the potential for remarkable resiliency associated with trauma work. "This raises the question: what are the protective factors that trauma workers use . . . what is it that protects humans as they steer the path between helping people heal following a traumatic event and developing prolonged psychological difficulties themselves?" (p. 422). The authors cited Stamm's hypothesis that compassion satisfaction (see below) mitigates VT, and they referred to research findings by King, King, Fairbank, and Adam that good social support and hardiness were associated with fewer psychological problems in 16 caregivers of the traumatized. I agree with Collins and Long's recommendation for further investigation into both positive and negative consequences of trauma therapy for therapists. Treating the effects of VT and STS Saakvitne and Pearlman (1996) identified the need for treatment interventions to address both stress (e.g., self-care) and demoralization (e.g., transformation of despair). These authors recommended mindfulness practices (such as those described by Kabat-Zinn, 1994, or Thich Nhat Hanh, 1976), as well as group and team-based treatment. Figley (2002) recommended the use of a desensitization program (e.g., EMDR) combined with relaxation to treat VT. Westwood has developed Therapeutic Enactment (Westwood, Keats, & Wilensky, 2003), a group-based, multi-modal treatment for trauma repair that has been used for practitioner renewal (research findings are currently being prepared for publication). Pearlman and Saakvitne (1995b) offered recommendations for treating VT and STS, based upon personal experience and suggestions from workshop participants. These included personal and professional practices. Personal practices for ameliorating VT included: recognizing the importance of maintaining a personal life, with a balance of work, play, and rest; engaging in personal psychotherapy; having a commitment to restorative self-care; and the development of a spiritual life (reconnection with and restore faith in something larger than oneself). Professional strategies included: regular supervision or consultation with an experienced trauma professional; developing connections to professional community; establishing a balanced work life, both in terms of variety of professional activities and diverse clientele on caseloads; and engaging in conscious reflection on the value and meaning of trauma work. The authors named organizational strategies, which they acknowledged could be construed as ideals toward which organizations might strive. These included: providing a safe, 17 comfortable physical setting; adequate provision of resources (including regular supervision, case conferences and consultation, professional development, employee health and mental health benefits, and vacation time); maintaining a respectful environment; offering trauma-specific professional training and education; and informing trainees and junior colleagues of the risks of VT. It is unclear what research design and methods underlie the authors' claims that these recommendations are effective in ameliorating VT. Although they may indeed be valid treatment strategies, the stated recommendations appear to be based upon informal observation and anecdotal accounts. Pearlman (1999) reviewed quantitative studies that suggested that self-care practices might mitigate VT in trauma therapists and psychologists. She identified disrupted frame of reference (worldview, identity, and spirituality) as a hallmark of VT, and suggested that increased awareness, on the part of trauma therapists, of the importance of remaining connected with self, both physically and emotionally, and with other people could sustain helpers in their work. Pearlman reported that formal education has been associated with fewer psychological disruptions. She identified the following "antidotes" (p. 54) or coping strategies: a) balancing work, rest, and play; b) engaging in creative and physical activities; c) maintaining interpersonal connection with family and friends; d) engaging in activities that increase affect tolerance and reconnect people with their feelings; and e) receiving professional support to mitigate the isolation that accompanies working within the demanding ethical requirement of client confidentiality. Again, the use of the word antidotes here suggests that VT is a poison or a toxin. Prevention There is consensus in the field that we do not yet know enough about the factors that contribute to VT and the practices that may prevent or ameliorate its harmful effects (Arvay, 18 2001; Figley, 2004; Pearlman, 2004; Pearlman & Saakvitne, 1995b). Yet, authors have consistently made recommendations about prevention. Yassen (1995) employed an ecological conceptualization of prevention that incorporates the interrelationship between individual persons and their physical, social, and psychological environments. She reviewed research and guidelines on stress reduction, burn out, and prevention, and applied these to STSD. Prevention was conceptualized as occurring at three levels: 1) primary prevention to address underlying social causes; 2) secondary prevention, which emphasizes risk-reducing activities and planning; and 3) tertiary prevention involving care and remediation in the aftermath of crisis. Studies exist in the area of crisis response (e.g., Boscarino, Adams, & Figley, 2005; Myers & Wee, 2002), but I will not expand on these at this time. According to Yassen's (1995) ecological model, there are individual and environmental components of prevention. Policy makers, administrators, and educators, as well as individual helpers, share the responsibility for comprehensive prevention planning. Individual preventive practices were identified as occurring within personal (physical, social, and psychological) and professional realms; whereas, environmental prevention interventions are directed toward the work setting (including physical environment and less tangible elements such as workplace value system) and society at large. Personal realm prevention identified by Yassen (1995) included: care for the physical body (body work, nutrition, sleep, exercise), life balance, relaxation, contact with nature, creative expression, meditation or spiritual activities, skill development (including assertiveness training, time management), self-awareness, humour, social support, accessing help, and engaging in social activism. Individual preventive practices in the professional realm included receiving professional support, and training, establishing balance in quantity and quality of work tasks, 19 (including proportion of work related to treatment of trauma), setting boundaries and limits (including time boundaries, therapeutic or professional boundaries, separation of work and home, and realistic appraisal of limits in personal ability to help), and experiences of professional replenishment. "We must be sensitive to our own needs for professional, as well as personal, replenishment" (Yassen, 1995, p. 199). Environmental interventions include: education strategies, coalition building, legislative reform, social activism, and attention to workplace setting (physical setting, value system, professional support, and collegiality). Although, Yassen's ecological model is commendable, in that the locus of responsibility for prevention is not situated solely with the individual, it is at times unduly complicated by efforts to delineate personal, professional, and societal realms. Furthermore, it is not always clear when the author is offering personal opinion, as contrasted with the application of research findings or theoretical implications. Stamm (2002) drew on the research of King and colleagues that suggested that hardiness (characterized by control, commitment, and change as challenge) and good social support are associated with decreased PTSD. Stamm proposed that caregivers are at increased risk of developing negative reactions to patients' traumatic material when the professional's control and competency were at risk. She suggested that questions of competency arose, at least in part, from caregivers' feelings of lack of control of the traumatic material. This led her to propose that competency and control could be both enhanced and sustained by collegial support, which is an important element of structural and functional social support. She found that caregivers who had more time to sustain relationships and engage in basic self-care seemed to be less at risk for experiencing negative effects of their work. 20 Salston and Figley (2003) stated that "a sense of satisfaction for working with the traumatized and the ability (or competence) in creating distance between the worker and the work (including the clients with whom they work) - both physically and mentally" (p. 172) are among the most important and least studied variables predicting VT. However, they did not identify how they came to this conclusion. Sexton (1999) highlighted the importance of "creating an organisational culture that acknowledges and normalises vicarious trauma reactions and offers practical support" (p. 402). According to Sexton, organizations must ensure the availability of adequate resources to help counselors to process disturbing aspects of their work. This can be accomplished in a variety of forums, including: clinical supervision, case conferences, peer process groups, regular organizational team meetings, external consultation, personal psychotherapy, and training and professional development. Furthermore, organizations can assist counsellors to maintain realistic boundaries and limits in relation to their work: Clear and manageable caseloads must be formally set, and excessive commitment to work should be discouraged. Above all, organizations should avoid being bureaucratic, impersonal and disempowering, since this leads to feelings of helplessness which exacerbate the experience of vicarious traumatization. (Sexton, 1999, p. 399) Compassion Satisfaction Not everyone exposed to a traumatic stressor develops PTSD. Stamm (2002) described a study in which 50% to 60 % of a random sample of American adults reported having experienced a traumatic event that met PTSD diagnostic criterion A 1 (APA, 2000); however, the estimated lifetime prevalence of PTSD among American adults is only 7.8% (Stamm, 2002). Acknowledging the risks of work-related secondary exposure to trauma, Stamm asked: "What 21 sustains a person in the face of potential distress . . . how do people stay sufficiently healthy to do their work?" (2002, p. 108). Recognizing both the vulnerability and the resiliency of the human spirit, she identified compassion satisfaction (CS) as a possible factor that mediates the risks of VT. She developed a CS subscale, composed of positive questions that parallel the negative aspects of caregiving, as a complement to Figley's Compassion Fatigue Self-Test (1995). She suggested that "CS may be the portrayal of efficacy: Indeed, CS may be happiness with what one can do to make the world in which one lives a reflection of what one thinks it should be" (2002, p. 113). This stands in contrast with burnout, which is characterized by emotional exhaustion and a lack of efficacy. "Burnout... seems to make it impossible to envision a world in which one is not overwhelmed by an inability to be efficacious (Demerouti, Bakker, Nachreiner, &Schaufeli, 2001; Lee & Ashforth, 1990)" (Stamm, 2002, p. 113). I think that compassion satisfaction is a valuable concept, but I am not convinced that it can be fully gleaned, let alone measured, by a quantitative scale. Nor do we know enough about how compassion satisfaction interfaces with the negative consequences of caring for the traumatized. Counsellor Sustainability, Expertise, and Posttraumatic Growth The VT literature consistently highlights the need to better understand practices and attributes that are protective of trauma therapists, given the demands, challenges, and risks of their work with clients who have experienced serious trauma. Yet, there does not appear to be an existent body of knowledge on this important subject. For this reason, I have looked to research and theory that addressed wellbeing and expertise among therapists in general, as well as the construct of posttraumatic growth. 22 Master Therapists Jennings and Skovholt (1999) conducted qualitative research to identify the cognitive, emotional, and relational commonalities among a cohort of peer-nominated master practitioners of therapy. Their findings led them to hypothesize that master therapists have developed cognitive, emotional, and relational skills to a high level, and draw on each of these domains in their work with clients. Jennings and Skovholt found that master therapists attended to their own emotional wellbeing and were aware of the ways that their emotional health affected their work. These therapists took preventative action, including daily quiet time, personal therapy, exercise, and spiritual practices to protect the self of the therapist, which they regarded to be their most valuable therapeutic tool. These therapists were voracious learners who valued cognitive complexity, ambiguity, and ongoing learning. They were open to experience, non-defensive when receiving feedback, and comfortable dealing with complexity and ambiguity. They valued client self-determination and respected their clients' capacity and ability to change. They recognized the importance of the therapeutic relationship or working alliance and had highly developed relational skills, which they used to create both safety and challenge. Master therapists were both gentle and strong, and they did not fear clients' strong emotions. They created an environment where clients can visit pain and count on the therapist to be there. They were predictable, and maintained consistent, reliable boundaries, with regard to time and space. Master therapists had strong support systems, including longstanding close friendships, peer support, supervision, and personal therapy. They experienced congruency between their personal and professional lives. They were reflective and self-aware. This included an awareness of the limits of their own self-importance, as well as awareness of their own unfinished business. Nor surprisingly, the therapists in Jennings and Skovholt's (1999) study were skilled at empathy; 23 they had a highly developed capacity to imagine clients' lived experiences, which helped them to be empathic towards themselves, as well. Based on their findings, the authors encouraged therapists to: a) seek opportunities for ongoing learning, feedback, and reflection; b) keep an open mind in the face of ambiguity and complexity; c) continue to hone relational skills; d) attend to their own emotional wellbeing, and e) seek personal therapy when needed. Jennings and Skovholt (1999) acknowledged that their findings could not be generalized beyond their sample because their research method focused on an information-rich rather than representative participant pool. Furthermore, they recognized that their sample lacked diversity. This study is significant to me because it is one of the very few examples of qualitative research available on therapists who are doing well. However, it is unclear to what extent the participants worked with traumatized clients. Therefore, its relevancy to my own research question is ambiguous. However, I very much like aspects of the authors' research design which sought to get at the lived experience of exemplary practicing therapists. In particular, I liked their purposeful sampling strategy in which they asked key informants (well-regarded therapists) to nominate colleagues whom they considered to meet criteria for being a "master therapist" (e.g., a therapist whom they considered to be the best of the best and to whom they would feel comfortable referring a dear friend, family member, or themselves for psychotherapy). These nominated master therapists were then asked to nominate other master therapists using the same criteria. It is not clear whether those selected actually regarded themselves to be master therapists. For the purposes of my study, it was important that co-participants saw themselves the way that others do (i.e., that they self-described as doing well or managing in the work) in order to be included in the sample. I did not want to interview people who look to others as though they are managing well but did not feel that way themselves. One drawback to this kind of 24 sampling strategy is that the researcher's own bias may inform the initial selection of key informants; however, I believe that researcher bias is inevitable and that it must be openly acknowledged and included in the analysis (see Chapter II p. 39). Sustaining Professional Wellbeing Mullenbach and Skovholt (2001) also conducted qualitative research on the ways that mental heath practitioners sustain professional vitality and emotional wellness. They used the same sample of 10 peer-nominated experts from Jennings and Skovholt's (1999) study on master therapists to identify components relevant to their wellness and professional resiliency. Although client experiences of trauma were not explicitly named in the professional stressors identified, examples included feeling "tapped out" (p. 166) by clients' level of distress and the cumulative effect of clients' stories about "what people are able to do to people that causes pain and distress" (p. 166). This latter quote sounds very much like VT. The authors discussed their findings within a career-development framework. Establishing boundaries and limits helped therapists manage the effects of continuous exposure to suffering, as did understanding their own limits as a practitioner. Therapists who held the belief that the attachments and separations inherent to therapeutic relationships are part of a natural process that mimics life, or the belief that these relationships continue beyond separation (either on an internal level or because they have the potential to resume) appeared to "insulate...from the potential distress of repeated attachments and separations" (p. 171). Furthermore, participants developed a deep understanding of suffering through their work. This included an awareness of painful aspects as well as the potential for growth. Skovholt, Jennings, and Mullenbach (2004) proposed that master therapists are often anchored by a profound spiritual or religious dimension, which may have been enhanced by numerous experiences of 25 having encountered human suffering as expressed by clients (i.e., vicarious experiences of human suffering). Mullenbach and Skovholt (2001) identified aspects of a positive work structure and environment that helped mitigate professional stressors and contribute to resiliency, including: diversity of professional responsibilities (teaching, supervision); freedom to design one's practice/caseload; mentor support early in professional life; ongoing formal and informal peer relationships; and health-promoting, safe, comfortable work settings. A strong commitment to self-observation and self-care, combined with a proactive style of directly confronting stressors in professional and personal life further contributed to wellness, as did a high level of skill in accessing helpful resources (including personal therapy); openness to learning; comfort with ambiguity; and engagement in a wide array of restorative activities. Participants expressed the importance of immersion in enriching activities and relationships apart from their work environment. They built and maintained fortifying (nurturing, challenging) personal relationships and a sense of connection with others who provided consistent, ongoing support and enabled a realistic perspective of self. They also valued connection with nature, creative undertakings, and fostering "an essential relationship with the world at large... in terms of a spiritual awareness or seeking a greater sense of connection with others" (p. 185). Psychologist Well-functioning Coster and Schwebel (1997) researched psychologist well-functioning (which they originally called unimpairment), defined as "the enduring quality in one's professional functioning over time and in the face of professional and personal stressors" (p. 10). Content analysis of interviews with six practicing psychologists with 10 years' postdoctoral experience yielded 10 themes as important contributors to well-functioning: Peer support, stable personal 26 relationships, supervision, a balanced life, affiliation with a graduate department or educational institution, personal psychotherapy, continuing education, family of origin as source of personal values, awareness of cost of impairment, and coping mechanisms (such as vacations, relaxation, rest, exercise, spirituality, and time spent with friends). Self-awareness/monitoring for early signs of potential impairment and personal values rated as the top two reasons for psychologists' well-functioning on a questionnaire in a second study. Based on their findings in the two studies, the authors advocated a strong role for professional organizations in the promotion of professional wellbeing. In addition to interpersonal support and intrapersonal activity (self- awareness/monitoring), Coster and Schwebel (1997) emphasized the value of professional and civic activity: By joining with others in purposeful action to contend with professional challenges related to social and global policy, psychologists can benefit from peer group interaction, support, and empowerment, while promoting their own welfare and/or that of the broader community. These authors stressed the importance of normalizing vulnerability to impairment: Accepting signs of impending impairment (as normal) is crucial to prevention of more serious problems. They called for further investigation to correct an existing imbalance in professional education, wherein prevention of impairment does not receive ample emphasis. I appreciate their emphasis on the potential preventative role of training. Furthermore, I value how these authors do not position responsibility for psychologist wellness solely at the individual or intrapersonal level of action. Coster and Schwebel clearly identified a gap in the research literature, because there had been "no research on factors that are presumed to be related to well- functioning" (p. 5) prior to their article. However, there are limitations both in terms of the design and selection of participants (i.e., criteria for inclusion). 27 Managing Countertransference Hayes, Gelso, Van Wagoner, and Diemer (1991) conducted a survey study, informed by their psychodynamic theoretical perspective, and designed to provide an initial empirical basis for understanding the management of countertransference from the perspective of experts in the field. Their conceptualization of countertransference as potentially harmful to clients but not to therapists stands in distinction with VT, which can be harmful to both parties in the therapeutic relationship. Hayes and colleagues suggested that countertransference stems from a therapist's inability to disengage from identification with a client, rather than from empathy itself, which involves a process of partial or trial identification balanced with relative disengagement (standing back and observing). Their findings suggested that therapist self-integration and self- insight, including cohesion of self, self—understanding, and differentiation of self from others, played the most important role in managing countertransference. I think this article is important, in terms of its conceptualization of the risks inherent in over-identification with clients. I am curious whether clarity of boundaries between self and other may play an important protective role for therapists who are managing well despite the potential harmful consequences of VT. However, the research design (a 50 item likert-scale questionnaire) did not yield much information about the lived experiences of participants. Furthermore, participants were chosen because the authors considered them to be in prominent positions of authority on the subject of countertransference, but it is not clear whether authority here equated with greater experiential (practice-based) knowledge as opposed to greater power and influence in their field. The subjects were known for their journal publications and conference presentations. This raises the question whether there might be a difference between academic expertise and expertise based in the practice of therapy. It is possible that this study measured theoretical perspectives more than 28 lived practice, and the authors did not appear to acknowledge their own bias and the extent to which this may have informed their sampling procedure and findings. Van Wagoner, Gelso, Hayes, and Diemer (1991) surveyed 93 experienced counselling professionals who perceived that, when compared with therapists in general, expert therapists: a) have greater insight into the nature and basis of their feelings; b) have increased capacity for empathy; c) are better able to differentiate between client needs and their own; d) experience less anxiety both in session with clients and in general; and e) are more adept at case conceptualization, all of which were theorized to contribute to better management of countertransference or over-identification. However, this quantitative study was based on experienced therapists' perceptions of imagined excellent therapists. To their credit, the authors recognized that "much caution must be exercised in generalizing from perceptions to actual behaviors of excellent therapists" (p. 420). The results did not directly indicate that expert therapists are actually better at managing countertransference than are therapists in general. Instead, they suggested that experts were perceived to possess more attributes related theoretically to effective management of countertransference. This research is germane to the question of how trauma therapists manage well in their work, inasmuch as Figley (1999) suggested that STS (and by implication, VT) included, but was not limited to what these researchers viewed as countertransference. Coping With Stressful Clients Medeiros and Prochaska (1988) identified six coping strategies used by psychotherapists to deal with stress experienced in working with difficult clients. They employed a quantitative study to measure the perceived success of these strategies when used by psychotherapists to deal with what they termed client-generated stress. However, neither diagnosis of PTSD nor client 29 stories of victimization and traumatization were among the explicitly named stressors (which included descriptors such as borderline, depressed, suicidal, psychotic, passive, substance abusing, as well as unspecified other diagnoses, many of which may have masked experiences of trauma). All of these client-related psychotherapist stressors appeared to locate pathology at the level of the individual client, which I find limiting, inasmuch as individuals are socioculturally situated, and the authors' perspective apparently fails to take into consideration that the source of stress could have been conceptualized, more inclusively, as socially, systemically, or interpersonally situated. Findings suggested that optimistic perseverance was correlated with self-perceptions of successful coping more than self-reevaluation and wishful thinking, humor, seeking social support, seeking inner peace, or contingence control and avoidance. The more psychotherapists relied upon self-reevaluation and wishful thinking, the greater the intensity and duration of stress experienced. However, these correlations were not causal, and equal consideration must be given to the possibility that more successful coping resulted in increased optimism and perseverance, rather than the converse. The authors identified the need for further longitudinal study in this area. Posttraumatic Growth O'Leary, Alday, and Ickovics (1998) reviewed eight models of life change. In each, there was a period of chaos or decreased baseline functioning immediately following a disruptive or traumatic event, as well as the possibility of subsequent growth or enhanced outcome, following change. Personal and social resources may enhance the likelihood of positive outcomes. Constructed meaning (positive appraisal), self-efficacy, active coping style, hardiness, and past experience were the personal resources cited by most theorists. Social support was the most frequently mentioned social resource. Several of the models propose that positive "growth occurs 30 as a result of finding meaning in uncontrollable events" (pg. 136). In their model of resilience and thriving, O'Leary and Ickovics' identified three possible outcomes after unintentional change: survival, recovery, and thriving. Thriving involves vigorous growth beyond original level of psychosocial function, possibly to the point of flourishing, and can include affective, cognitive, or behavioral transformation. Availability of individual and social resources enhances the likelihood of thriving. Social resources include access to and use of institutional, community, and/or religious resources. However, little empirical evidence validated these models. The authors identified methodological challenges and the need for further research; they proposed qualitative research for future inquiry in this area. Calhoun and Tedeschi offered a model of Posttraumatic Growth (PTG), characterized by positive changes in interpersonal relationships, sense of self, and philosophy of life, subsequent to a seismic or traumatic event that shakes the foundation of an individual's worldview (Calhoun & Tedeschi, 1998, 1999; Tedeschi & Calhoun, 1995). Common aspects of PTG change include: deepened relationships; increased compassion for others: greater ease in expression of emotions; increased sense of vulnerability coincident with greater sense of self-reliance and experiences of self as capable; enhanced appreciation of life; changed priorities; and positive change in the spiritual, religious, or existential realm. According to these authors, PTG is not uncommon and may co-occur with negative sequelae of trauma. Active coping is an important complement to the construction of new meaning that occurs in the process of positive change following a crisis, and the emotional support of others is held to be influential in an individual's passage from rumination to growth and wisdom. Preexisting personality characteristics may affect the likelihood of PTG: individuals who are hopeful, extraverted, cognitively complex, and generally open to feelings and new experiences appear to be slightly more likely to experience growth than persons who do not share these qualities. Calhoun and Tedeschi (1999) offered the caveat that they conducted their research in the traditionally religious southeastern USA, which may have informed their findings; their 1999 book is intended as a clinical guide, based on a "small body of empirical research" (1999, p. ix) and the authors' extensive practical experience. They asserted that clinicians and scholars in the field of traumatic stress need to consider the possibility of PTG, and they highlighted the need for qualitative research methods in this area (Calhoun & Tedeschi, 1998). Personality and Successful Coping Tedeschi and Calhoun (1995) considered personality characteristics that appear to accompany successful coping after traumatic life events. These included: a) having an internal (versus external) locus of control; b) good self-efficacy; c) hardiness; d) optimism; e) sense of coherence; f) resilience; and g) creativity. A complex interaction between environment, personality, and coping skills was held to be responsible for growth and perceptions of benefits in crisis. However, the authors conceptualized personality as innate (as did the related research upon which they drew). This runs counter to a constructionist conceptualization of self/personhood, such as that proposed by Burr (1995), in which personhood is understood to arise out of social processes. Sometimes the identified personality qualities were, however, defined in terms of personal practices, as opposed to innate traits, (i.e., choosing when to approach or withdraw from a threatening situation may result in development of self-efficacy). This kind of attention to practice is of more interest to me because practices can be developed, learned, transferred, and honed. In my opinion, many of the personality traits posited as intrapsychic are actually contextually situated social practices. 31 32 Resilience Citing Rutter's work on resilient children, Tedeschi and Calhoun (1995) understood resilience to be the result of environmental influences as well as individual temperament, which is itself relationally defined and plays out in practices, inasmuch as resilient children produce "responses to difficulties that engage others rather than create further interpersonal difficulties" (Tedeschi & Calhoun, 1995, p. 51). Resilience appeared to involve an ability to maintain a caring relationship while recognizing the boundaries of personal responsibility for and influence over problem situations, which I imagine to be relevant to managing VT. Resilient children's ability to relinquish responsibility for parental mental illness and the hope that they could change it was especially important. This reminds me of the tenet of radical acceptance espoused in Linehan's Dialectal Behavioral Therapy, which has been empirically validated as effective in working with people diagnosed with borderline personality disorder (Linehan, Cochran, & Kehrer, 2001). Resilient children "seemed able to find the strength to care for other people in need while also separating themselves from their troubles by engaging in pastimes they found enjoyable" (Tedeschi & Calhoun, 1995, p. 50). This is in accord with recommendation for VT prevention, such as balancing personal and professional life, engaging in self-care and recreation. This ability is also compatible with Salston and Figley's (2003) belief that the most important and least studied variables predicting VT are "a sense of satisfaction for working with the traumatized and the ability (or competence) in creating distance between the worker and the work (including the clients with whom they work) - both physically and mentally." (p. 172). Green suggested that resilient children have a flexible attributional style that is a central element in their ability to manage life's difficulties: They can hold contradictory notions about their 33 power and its limits (Tedeschi & Calhoun, 1995). This fits with Skovholt and Jennings' (1999) findings regarding master therapists' tolerance of ambiguity and complexity of thought. In my own professional experience working with children traumatized by exposure to domestic violence, I had to gain clarity about the boundaries and limits of my responsibility and influence in relationship to these clients' traumatic experiences and their sequelae. On a more personal note, in order to flourish as an adult, I have had to learn how to sustain a caring connection while establishing and maintaining personal boundaries in relationship to a troubled parent who consistently blurred such boundaries at my own expense. I believe these personal experiences inform both my journey in the profession of counselling psychology and my interest in the subject of this research. Vicarious PTG Given the evidence that some trauma survivors experience positive changes subsequent to seismic life events that disrupt their foundation, it is plausible that PTG might also occur through vicarious exposure to such events, which is commonplace in the practice of counselling psychology. Calhoun and Tedeschi (1999) recognized that "the potential negative effects of clinical work with traumatized clients have been identified and studied (Figley, 1995; Pearlman & Saakvitne, 1995), but no similar body of inquiry exists for the potential vicarious positive effects of working with clients in crisis" (1999, p. 129). In their chapter on Issues for Clinicians, Calhoun and Tedeschi (1999) suggested that therapists could learn vicariously from clients about their own vulnerability and the paradoxical, dialectical nature of being alive (i.e., that we humans are more vulnerable and stronger than we might have imagined possible). They suggested that, as a result of their work with traumatized clients, clinicians might reexamine their own philosophies 34 and priorities of life, experience enhanced connection to close others, and gain a greater sense of purpose through advocacy for social justice. Calhoun and Tedeschi (1999) offered recommendations for therapist self care, such as the importance of recognizing the limits to amount of positive change that clinicians can help clients attain. They endorsed Rotter, Chance, and Phares' (1972) concept of minimal goal level, which can be applied to trauma work: Unrealistically high expectations of client improvement can lead to increased likelihood of therapist negative self-evaluation, which could contribute to VT/burnout. Instead therapists should actively work to notice small changes in clients' growth or adaptive coping. Like many others, Calhoun and Tedeschi also stressed the importance of regular supervision, even if only working with one client who has experienced extreme life stress. Furthermore, they recommended that therapists engage in practices that reinforce boundaries between personal and professional realms (e.g., eating lunch, changing clothes upon arriving home after work, or other activities that delineate the transition between work and home); spend time in nature; pursue recreational activities (it is not necessary to be good at these); and embrace humor by seeking it out and utilizing it as self care. Vicarious Adversarial Growth A quantitative study by Linley, Joseph, and Loumidis (2005) provided preliminary evidence for the construct of adversarial growth in therapists as a result of their work with traumatized people. PTG research has shown that adversarial growth in people directly exposed to trauma can lead to positive changes, such as improved self-perception, increased valuing of interpersonal relationships, and changed philosophy of life. However, there is a paucity of research on posttraumatic or adversarial growth resulting through vicarious exposure, particularly in therapists. The authors hypothesized that Sense of Coherence (SOC) personality 35 construct (comprised of comprehensibility, manageability, and meaningfulness) may be a useful way of conceptualizing factors that influence positive and negative changes after dealing with others' traumatic experiences. Previous reviews suggested that SOC encapsulates key elements of related constructs, such as locus of control, self-efficacy, and hardiness. SOC has previously been shown to be associated with less secondary traumatic stress of lay counsellors Linley and colleagues found that trauma therapists with higher SOC scores self-reported more positive changes and fewer negative changes as a result of their work, on a likert scale questionnaire. The authors called for further, longitudinal research using a wider range of measures to better understand vicarious posttraumatic growth, which could, in turn, help and protect trauma therapists in their work helping others. Their research is important because it appears to be one of the only studies that purposefully looked at positive as well as negative changes in trauma therapists. However, I was interested in accessing more in-depth knowledge about this important topic than is afforded by the information provided on a likert scale questionnaire. Furthermore, I was more interested in therapists who were managing well in their work with traumatized clients than in the construct of vicarious PTG, per se; although, there may be a relationship between these two areas. Gaps Apart from the last mentioned study, positive sequelae to vicarious experiences of trauma, and more specifically, those of counselors whose clients who have been directly traumatized, do not appear to have been investigated to date. Furthermore, virtually no research appears to have been conducted to explore the experiences, qualities, and practices (both individual and organizational) of trauma therapists who are doing well despite the harmful risks of VT. Nor has there been adequate inquiry into the effects of working with traumatized clients 36 as part of a varied caseload (Sabin-Farrell & Turpin, 2003). Additionally, most of the VT research published, to date, has been quantitative. Few studies have employed well designed qualitative methods to further deepen our understanding of therapists' lived experiences of this important phenomenon. In particular, there is a compelling need for qualitative research exploring the lived experiences of therapists who are managing in work with traumatized clients, in order to identify individual, organizational, and societal protective practices that mitigate the risks of VT. My research was designed to seek out exemplary practitioners who are doing well and learn what they have to offer about that which sustains them in the challenging and important work of counseling traumatized clients. 37 Chapter III Method In the following pages, I discuss the rationale for my choice of a narrative method of inquiry, in relation to both the research topic and my personal research epistemology. I describe the process of data collection and analysis of the research narratives. In addition, I identify and define criteria for evaluating the worth of the research study. Finally, issues of representation are discussed. Research Problem and Relevancy This research study was designed to identify and explore practices that protect mental health therapists from the vicarious traumatic effects of their work with traumatized clients. The risks of working directly with trauma victims on a regular basis are well documented within the literature (Arvay, 2001; Figley, 1995; McCann & Pearlman, 1990; Pearlman & Mac Ian, 1995). Trauma therapists may experience physical, emotional and cognitive symptoms similar to those of their traumatized clients (e.g. physical pain and agitation, fear, rage, confusion, intrusive images and nightmares) (Pearlman & Saakvitne, 1995b; Sexton, 1999). Pearlman and Saakvitne (1995a) defined Vicarious Traumatization (VT) as: The transformation in the inner experience of the therapist that comes about as a result of empathic engagement with clients' trauma material. This material includes graphic descriptions of violent events, and exposure to the realities of people's cruelty to one and other. (p. 31) Pearlman and Mac Ian posited that the effects due to VT are "cumulative across time and helping relationships" and include "changes in the therapist's enduring ways of experiencing self, other, and the world." (1995, p. 558). 38 Although research and theory have begun to emerge about VT vulnerability and treatment, it is equally important to understand what protects and sustains helping professionals in their work with traumatized populations. To date, very little is known about the success and satisfaction of trauma therapists who are able to manage in the workplace despite the potentially noxious demands of their work. My study expanded on current research (and filled a gap in the existing literature) by offering an in-depth exploration of experienced trauma therapists' narratives of individual and organizational practices that contribute to their professional satisfaction and wellness and to the sustainability of their efforts in the workplace. The purpose of the study was to gain and share knowledge about these protective practices. The ultimate goal of the study is the prevention of VT. Research Questions 1) How do exemplary (i.e., healthy, effective, satisfied) trauma therapists experience and practice sustainability and personal wellness in their work with traumatized clients? 2) How might protective practices best be engaged at the individual, organizational, and systemic levels in order to mitigate risks of VT for therapists who work with traumatized populations, thus sustaining their efforts in the workplace? Research Design I used a narrative method of inquiry and analysis to explore these research questions (Arvay, 2003, Freeman, 1997, McLeod, 2001). Narrative research methods are situated within a postmodern paradigm of science and a social constructionist epistemology that stand in contrast to modernist era, positivist and post-positivist traditions of science. Some of the epistemological assumptions that inform narrative approaches to research in the social sciences include the following: 39 • Truths are multiple, subjective, overlapping, and situated, as opposed to objective and universal; • Knowledge is contextual, relational, and fluid; • Power relations get played out through language processes (language has constitutive power, as well as oppressive power); • Lives are multiply storied and multiply voiced. A narrative research design presupposes a dialogical meaning-making process, in which knowledge is co-constructed by: a) researcher and co-participants, b) researcher and readers, and c) research co-participants and readers. This approach to research is concerned with the multiplicity of voices within texts, the co-constructed nature of interviews, figurative use of language, analysis of story structure, and the identification of cultural narratives. It involves "in- depth study of particular individuals in social context and in time" (Josselson, 2003, p.4). Narrative analysis combines a discursive emphasis on how meanings are constructed through language and utterances along with an attention to the participant's personal agency and self- awareness in their efforts to attribute meaning and achieve fulfillment in their lives (McLeod, 2001). Narrative research methods embrace researcher subjectivity as inevitable: the role of the researcher cannot be separated from the research process or product. Researcher reflexivity is an important and valued aspect of a narrative research design. Situating myself as researcher. Narrative research is compatible with my personal research epistemology, which shifts between postmodern and poststructural paradigms (the notion of fixing my position here, categorically, is antithetical to my epistemology). I embrace a dialogical ontology in which the social and individual are mutually constitutive. I believe that agent, activity, and world co-create each other (Latour, 1996; Lave and Wenger, 1991). I very 40 much value recognizing the limits of what we can know. In this regard, I am agnostic (and something of a skeptic); however I embrace this position in the service of being open to, rather than foreclosing upon, the unknown and avenues of possible knowledge not yet known to me. I do not think that there is a one-to-one correspondence between words and their meaning, between sign and referent in the world. The ideas of Bakhtin (Wertsch, 1991), Foucault (1965, 1972), White and Epston (1990), and Arvay (2002) inform my understanding of the complex interplay between language and personal/relational realities. I very much believe in the constitutive power of language, and I think there is a language/knowledge/power continuum that is socially, culturally, and historically situated. We are born into cultural tales. Similarly, some stories do not make it into dominant discourse: We live in linguistic habitats and are influenced by the discourses available to us. These discourses may enhance our experiences or hinder our self-expression and personal agency. Language is the living medium where human action is performed and narrative is the form we use to make our actions understood. Human agency and action are languaged forth. (Arvay, 2002, p. 119) I appreciate Bakhtin's concept of ventrilloquation, as described by Wertsch (1991), which "presupposes that a voice is never solely responsible for creating an utterance or its meaning." (p. 70). For Bakhtin, all texts, whether written or spoken, necessarily involve multiple authorship. Speech is always circulating, and consequently, language is never neutral, as individual speakers do not have total freedom in the use of words to implement their intention. Instead, the construction of meaning through language is always both (and contradictorily) an original act of individual agency and an appropriation of borrowed, recycled, ever-circulating phrases, voices, and language already imbued with meaning. In this sense, the speaking 41 consciousness expresses "self" through utterances with a point of view inflected/infected by the other: The word in language is half someone else's. It becomes 'one's own' only when the speaker populates it with his (sic) own intention, his own accent, when he appropriates the word, adapting it to his own semantic and expressive intention. Prior to this moment of appropriation, the word does not exist in a neutral and impersonal language (it is not, after all, out of a dictionary that the speaker gets his words!), but rather it exists in other people's mouths, in other people's concrete contexts, serving other people's intentions: it is from there that one must take the word, and make it one's own. (Bakhtin, as cited in Wertsch, 1991, p. 59) Furthermore, meaning, for Bakhtin, is doubly socially constructed, in the sense that any utterance is informed not only by preceding utterances, but also by how it is received and construed by its recipient or addressee. Meaning requires the voice of the listener (or reader) responding to the voice of the author/speaker. I value the complexity of these ideas, which I consider to be highly compatible with narrative research methodology. Rationale for using a narrative approach. My conceptualization of the "object" of research as an intersubjective, contextually situated construction led to a research method that embraced the co-constructed, dialogical, intersubjective nature of interpretive research. Furthermore, my interest in the research topic evolved out of a narrative conceptualization of VT as a problem -- and my curiosity about unique outcomes (White & Epston, 1990). We already know about VT as a problem and its influence in the lives of individuals and communities. I was interested in exploring the influence we have as individuals and communities over the life of VT as a problem. Ultimately, the current research study offers my interpretive, narrative account (co- 42 constructed with participants and readers) of participants' narratives of lived experiences (that were co-constructed with other agents in the world). I conceptualize the research as a retelling (of a retelling). For these reasons, I believe that a narrative research method is particularly well suited to my study. Sample (Locating Co-Participants) I used a purposive sampling procedure to recruit 6 peer and organizationally nominated practitioners, trained at the masters (or equivalent) or doctoral level, each of whom had a minimum of 10 years' professional experience with traumatized clients and self-identified as having managed well in this work. This sample size allowed for an in-depth, rich exploration of the lived experiences of the research co-participants, and it is in keeping with previous narrative research studies on related subjects (e.g., Pearson, 2004). The selected participants came from the disciplines of in Counselling Psychology, Clinical Psychology, Social Work, or Nursing. They ranged in age from 49 to 59 years old and included female and male therapists of diverse sexual orientations (heterosexual, lesbian, and gay) who came from a range of religious backgrounds, including Judaism, Catholicism, Christianity, and Native American spirituality. The participants all lived and worked in western Canada; one was of First Nations heritage, another was of Latin American origin, and two were originally from the USA but identify as Canadian. Individual participants had between 10 and 30 years of experience working primarily with traumatized clients in organizational (e.g., hospital, community mental health, residential program for alcohol and drug abuse) and/or private practice settings. Their clientele included survivors of sexual and/or physical abuse perpetrated during childhood and/or adulthood; pediatric and adult palliative care patients and their families; survivors of torture and natural disasters; refugees from countries at war; firefighters; bank tellers involved in robberies; and 43 people dealing with poverty, racism, substance abuse, and suicidal ideation, in addition to a history of abuse. Screening Potential co-participants were invited to an initial, structured, screening interview, in which I explained the purpose of the study and confirmed that they met all eligibility criteria. I also asked them to complete a short quantitative measure, the Professional Quality of Life: Compassion Fatigue and Satisfaction Subscales, R-III (Pro-QOL) (Stamm, 2003). This measure was used for screening purposes only. Individuals who scores were below average on the Burn Out and Compassion Fatigue subscales of the Pro-QOL (i.e., who appeared to suffer less burnout and VT than the average practitioner) and who self-identified as eligible were invited to participate in the study. The Pro-QOL was not designed for diagnostic purposes, and I do not regard the score on this quantitative measure as a definitive objective truth claim about the potential co-participants. Rather, I view it as a subjective, situated, co-constructed, text. However, because much of the prior research and theory on VT sits within a post-positivist research epistemology, it is my hope that including this measure as a screening criterion might contribute to a greater dialogue between the findings from this study and the research that has preceded it. Moreover, the inclusion of this screening criterion could make findings from my study more accessible to readers and researchers who embrace more modernist/traditional research epistemologies than my own. Furthermore, it potentially could have helped to screen out potential participants who did not recognize or acknowledge the extent to which VT had affected them. Co-participants' scores on the Pro-QOL were not included in the data analysis. 44 Data Collection Process The data collection consisted primarily of interviews, which took place in three phases. In the initial structured interview, I explained the research approach, clarified roles and responsibilities, addressed ethical considerations, such as ownership of the research narratives (Smythe & Murray 2000), and confirmed appropriateness for participation in the study. During this first stage, I also initiated the process of informed consent, which I revisited repeatedly with participants throughout the ongoing research. I also gathered information about each co- participant's age, work setting, caseload, years and range of experience with traumatized clients. The second phase of data collection involved open-ended and semi-structured interviews with individual co-participants, in which I invited their stories of sustainability and personal wellness in their work with traumatized clients. After eliciting and hearing participants' narratives, I asked the second research question (i.e., participants' recommendations for practices that could mitigate other therapists' risk of VT). These interview conversations were recorded in analogue (audiotape) and/or digital audio. I subsequently arranged a third interview as a follow-up/ member check, after having shared with each co-participant my interpretive analysis of our interview transcript, in the form of a letter (more below). Depending upon the preference of the participant, this exchange took place either in person, by telephone, or email. In all instances, it afforded an occasion to ask co- participants whether there was anything they would like to add, change, or remove from my account. Throughout the entire data collection process, I kept a research journal. Transcription Transcription is necessarily partial, selective, incomplete, and interpretive (Arvay, 2003; Lapadat & Lindsay, 1999). When transcribing, I attended to paralinguistic elements of the 45 narratives, such as tone of voice, rhythm, volume, pauses, and inflection. I also considered non- verbal language and context and created a transcription key that included these elements of the narratives. For example, BOLD TYPE in the interview transcripts represents increased volume and italic type conveys emphasis and increased emotional intensity. Furthermore, I listened to tape recordings of the research conversations while reading the written transcripts to check the "accuracy" of these (i.e., the correspondence between written transcriptions and the audio recordings of the research conversations). Immediately after each interview, I reflected upon my awareness of contextual, paralinguistic, and non-verbal components of the co-constructed interview narratives and recorded these in my research journal. Data Analysis My data analysis was based upon Lieblich, Tuval-Mashiach, and Zilber's (1998) typology of narrative analysis, with a primary focus on thematic content analysis within and across participants' narratives. Through multiple readings of the text, I selected passages relevant to the research questions and coded these according to emergent themes. I do not believe that the content of the narratives can be truly and completely separated from their form, and my analysis also explored participants' choice of words, metaphors, and other language resources used to convey meaning. Moreover, I am interested in the meanings of the research stories and those of the storying/telling. Consequently, I engaged the whole text to explore the interplay between the parts and whole (Pearson, 2004). In this way, my analysis moved among the quadrants of Lieblich, Tuval-Mashiach, and Zilber's (1998) typology of narrative analysis, with a focus on holistic and categorical content analysis. My analysis also drew upon researcher reflexivity. Even the act of listening involves thinking and consequently subjective interpretation; therefore, my process of data analysis (and to some extent, coding) began in vivo during the 46 research conversations, at which time I made notes in my journal about my initial impressions of emergent themes. This minimal note-taking was first and foremost a strategy to allow the participant to lead the interview and simultaneously ensure that I did not miss opportunities to invite thick description at opportune moments that did not interfere with the flow of the telling, by revisiting topics that might have initially been mentioned only briefly (i.e., jotting notes during the interview allowed me to keep track of words or phrases that I wanted participants to expand upon, without my interrupting or directing their narratives). At times during the interviews, I checked with participants to clarify whether a latter part of the research conversation was thematically related to an earlier portion. I also documented my initial, holistic impressions of each research conversation immediately after the interview, with attention to any aspects of the telling that stood out as unusual or contradictory. For example, after my research conversation with Yvette, I wrote the following journal entry, which highlights my initial impression of salient themes and metaphors that emerged (categorical content) within the interview context, as well as my global impression (holistic content): The Kaleidoscope. The Dialectic. Life is full of holes. Goodness happens... The kaleidoscope of her office/ wall hanging — its border like flames behind her head. Cover on the couch — patchwork mosaic of colours and mirrored surfaces. I am in the presence of cool passion. When we started one of her eyes was more closed than the other. By the time we finished, both eyes were equally wide open. It was as though she were putting a damper on her passion at the outset... I am aware that when she started to talk about faith, the sun came through and shined on my face (she got up to adjust the blinds) which seemed like something participant #1 had talked about the day before — the light in room 47 changing at important points. This interview was like cracking a nut with a hard cognitive shell to get to the sweet soft meat (of faith, of releasing to the unknown, of optimism and conviction that things shift and get better) within. I worry that I am leading the interview by responding/engaging: By naming themes I hear when they seem to recur. Prior to conducting my next interview, I showed the transcript of the above-mentioned interview two committee members, with whom I shared my self-reflexive concerns about my own voice and presence during the research conversation, in order to ensure that my engagement with the participant was not leading the interview. My process of data analysis continued and expanded during transcription. While attentively listening to and transcribing the interviews, I also typed reflexive researcher memos in parallel to the interview dialogue and used colored fonts and markers to highlight segments of "verbatim" text that illuminated various themes. In so doing, I attended to both content and process of the research conversations; In addition to identifying narrative episodes and themes, this analysis took into consideration choice of words and meanings of metaphors, as well as sequence, rhythm, flavour, and shape of the storying. Furthermore, I journaled while transcribing, and also drew numerous concept maps (on average three per participant narrative), both while transcribing and throughout multiple readings of the interview transcripts. As a strategy for engaging with the text in depth, I conducted multiple interpretive readings for: 1) holistic content; 2) research question; and 3) a critical reading for issues of power). This strategy was based upon an adaptation of Arvay's (2003) method; however, I did not employ her collaborative process of analysis nor did I read for subject position of the narrator. Rather, I did these interpretive readings on my own, and then shared my interpretive 48 account with each participant in the form of a letter (described below). Throughout a process of reading, rereading, and listening while rereading, I coded each segment of transcript that pertained to any of the above-mentioned three categories. Although my research question focuses on practices that are protective and sustaining of trauma therapists' efforts in the workplace, I also sought to identify practices that impinge upon their wellbeing. Definitions of content categories arose "from an ongoing interpretive dialogue with the text" (Lieblich et al., 1998, p. 127). Initially, I coded each transcript independent of the other research stories (although I concomitantly wrote memos in my journal about any cross narrative themes that were emerging, as well as about any links to the research literature I had reviewed). Subsequent to the multiple readings, coding, and concept mapping described above, I wrote a letter to each participant, in order to articulate and check the validity of my understanding of the participant's response to the research questions. In these letters, organized by codes, I explained, to the best of my ability, the interplay between the themes that emerged during analysis of the respective research conversation, thereby sharing my interpretive narrative account of each participant's research story. After incorporating any feedback from participants (in the manner described above), I conducted a categorical content analysis across participant narratives, by reading and rereading the six letters, and subsuming the various codes under twelve major themes. In doing so, I looked for commonalities rather than universal truth claims about the research questions. The six individual letters and twelve common themes comprise the research findings presented in Chapter Four, below. I also wrote poetry about my process of analysis, examples of which follow: I hear the rhythms: pitch, flow, and halting tones of utterance Paralinguistic ear Paralinguists, here, hear: What volumes might the silences speak? finding my way Stretching praying/ playing with data drinking tea always eating always hungry drinking wine dreaming worrying procrastinating reading/yawning wanking/working loving living being writing research finding my way VentrilloQuilting I am weaving story strands 49 50 A patchwork quilt of lived, embodied, storied knowledge My account of their accounts, interwoven, all and each in relation to a vast network of others' storied lives. The web of social construction is myriad. Criteria of Worth I have articulated four criteria I used to discern the strength and value of the study. Below, I define each of these criteria, and the actions taken to ascertain that they have been attained: Verisimilitude. Does my interpretive account resemble the narratives that the participants and I co-constructed in the interview conversations? Is the research text a simulacrum of our conversations and their experiences? Although I can never capture or seize their situated truths, is there ample overlap between my account of their experiences and their own? This criterion allows each participant to determine whether my interpretive narrative account of our respective research conversation was a sufficiently trustworthy (Reissman, 1993) or faithful representation of the practices they described. I have relied upon the member checks to ascertain that this criterion of worth has been met. Each participant in the study reviewed my narrative account (in letter form, as described above). I incorporated all requested revisions into my interpretive accounts of the research conversations included herein. However there were very few such revisions requested. Three of the six participants approved of my account without any modification. The three other participants requested only minute changes for purposes of clarification. For example, Ernest wrote: "Well done. I figure you've captured it! No edits on my part." Whereas Abigail responded: Hi Richard. looks very good a couple of teeny, tiny points under Nature affirms resiliency it should read walking at the seashore (the ocean persists) Waves don't! Continuity in Relationships should be "board of directors of volunteer organization In this way, all six participants validated that these co-edited letters are resonant with their experiences of practices that mitigated risks of VT. Verisimilitude has been endorsed as criterion of worth by Bruner (1986) and Polkinghorne (1988). It is also commensurate with Reissman's (1993) criterion of trustworthiness, which stands in contradistinction to the idea of a fixed and unitary truth to be seized and replicated. Consensual validity. Lieblich et al. (1998) consider consensual validation, which they described as "sharing one's views and making sense in the eyes of a community of researchers and interested, informed individuals," to be "of the highest significance in narrative research." My research design addressed and fulfilled this criterion in numerous ways. Research participants were collaboratively involved in reviewing and editing the narrative accounts, as described above, thereby ensuring de facto consensual validity within one community of interested, informed individuals (i.e., the research sample). Moreover, I actively invited and received feedback from my supervisory committee, who offered combined expertise in narrative research, VT, trauma repair, workplace wellness, and occupational satisfaction. All feedback received supported this criteria of worth. Furthermore, by including my own voice in 51 52 representations of the research findings, I have sought to further attain consensual validity through researcher transparency in sharing with readers and other researchers the process of dialogical meaning making in which co-participants and I engaged, and which formed the basis of my interpretative analyses. Polyphonic vitality. Is the text spacious and lively, allowing for a multiplicity of voices (i.e., those of co-participants, readers, and my own)? Does the research acknowledge the co- constructed natures of the narratives? I employed researcher reflexivity (journaling, self- reflection, discussion of my role with participants, conversations with my research supervisor and committee); transparency; inclusion of participants' voices/narratives, as well as my own voice in dialogue with co-researchers; and acknowledgement of the reader's role in the co- construction of the text (Fiske, 1989) to achieve this criterion, which is commensurate with Whittemore, Chase, and Madley's (2001) criteria of vividness, sensitivity, and, creativity, which together call for thick description and mutivocality of possible textual positions in the presentation of the research. Pragmatic resonance. Is my interpretation evocative in a useful way? Can it be applied to the field? Is it potentially generative? Might it inspire change or instill purpose? This criterion was established in relationship to participants' responses to the second research question, about how protective practices might best be implemented to mitigate other therapists' risks of experiencing VT. All of the participants believed that other practitioners would benefit from many of the practices described in the findings, some of which they spoke about with great passion and perceived as being crucial to sustaining ethical practice. Moreover, upon reviewing excerpts from our research conversation to be included in this dissertation, which I had shared with Clare (along with her co-edited letter), as a part of the ongoing process of informed consent, 53 she wrote to me: "I have read both the attachments and feel fine with you submitting them without changes regarding the issues of identity and confidentiality. It is lovely to be reminded of your work, the depth and breadth of what you are seeking, it is very important work I think. I am glad someone like you who has the capacity to deal with both the depth and breadth has conducted this kind of research [emphasis added]." This criterion is compatible with Reissman's (1993) concepts of pragmatic usefulness and resonance. Ultimately assessment of whether I have fulfilled these latter three criteria of worth is an ongoing process that depends upon how this research is taken up by readers, audiences at future conference presentations, and others. Issues of Representation However ambiguous or polysemous our discourse may be, we are still able to bring our meanings into the public domain and negotiate them there. That is to say that we live publicly by public meanings and by shared procedures of interpretation and negotiation. (Bruner, 1990, p. 13) Having recognized the importance of public representation of research, I have presented the research findings in a variety of forms, including written narrative accounts (i.e., letters to participants), excerpts from research conversations (including transcriptions of dialogue between participants and myself as researcher), thematic analyses, and examples of researcher reflexivity. It is my intention and my hope that co-participants voices, stories, and lived experiences are honored by these means of representing the research findings. Moreover, I aspire to a transparent approach to power relations. I fully acknowledge that the research is my own interpretive account. By presenting the research findings in the form of letters that I wrote to participants, I purposefully bring to the foreground the hermeneutic composability of narratives, a concept articulated by Bruner (1991), which I understand in terms of the inevitable space and difference between what a speaker intends to express in a text and the meanings taken up by a listener or reader. I concur with Bruner, who wrote: The word hermeneutic implies that there is a text or a text analogue through which somebody has been trying to express a meaning and from which somebody is trying to extract a meaning. This in turn implies that there is a difference between what is expressed in a text and what the text might mean, and furthermore that there is no unique solution to the task of determining the meaning for this expression. (1991, p. 7) Furthermore, I agree with Riessman's astute observation that: "decisions about displaying talk are inseparable from the process of interpretation." (1993, p. 51). At times, I have chosen to represent findings as transcribed dialogue between participants and myself, in order to show the co-constructed nature of the knowledge generated in and through this research. This strategy reflects my desire to be as transparent as possible about my process of interpretation. Finally, I consider research co-participants, readers, and audience members at future presentations to be co-creators of the research retellings. I aspire to perform/circulate my interpretive research text before audiences in these multiple arenas because I want the research to have its own full life, one that is honoring of the participants' stories and lives, as well as those of the readers (and myself). 54 CHAPTER IV Findings Overview In this chapter, I represent the research findings in two different forms. First I present letters that I wrote to the research participants (one letter each to six participants). I sent these letters as a validity check, in order to share my emergent understandings based upon my participation in and subsequent analysis of audio recordings and transcriptions of the research conversations. As described in the methods chapter, I have incorporated any changes requested by participants (e.g., clarifications and additions); however, there were few such requests and any changes were minute. Following the letters, in the second half of this chapter, I present an analysis and description of themes that emerged across participant narratives. 55 56 Dear Clare, I have decided to write this letter as a means of sharing with you my initial understanding of our research conversation about how you manage to maintain your personal and professional wellbeing given the challenges of your work with clients who have experienced serious trauma. I understood that awareness and connection, on many levels (connection to self and other, to mind, body, spirit, nature, and the mysterious transcendent) are at the heart of how you maintain your wellbeing in relation to your work. Conscious Self-Care: An awakening Over time, you have become aware of the importance of consciously caring for yourself in this work, in order to not do harm to self or others, which would be untenable for you. During your social work training, your first practicum supervisor invited you to look at and notice the impact of the work on you, personally, and this was new to you. This supervisor recognized that part of professional training involved the development of awareness, through reflective practice, of the impact on self of being exposed to other people's experiences of suffering, and that there are both positive as well as negative aspects to this. He effectively encouraged you to be curious and pay attention to what you "got" from the stuff you see everyday, to notice both the "gift" and the "down side" from your professional encounters with people who were suffering. His invitation to attend to this was the very beginning of a process of becoming aware that when you are exposed to things that initially may look horrendous, there are usually good things and there are usually really difficult things. You recognize that you have a personal responsibility to figure out what you are going to do about the difficult stuff and its impact upon you. This was a big realization for you: An awakening. 57 Embodied Response to a Different Level of Engagement You believe that what you get from these experiences cannot be dealt with solely through intellectual, cognitive, "head stuff" because this stuff actually goes into the body. Seeing people suffer is not solely an intellectual experience. Your empathic response to their pain is a felt experience, an embodied response. You came to recognize that holding and containing this new understanding of life (as encompassing the undeniable existence of suffering) can weigh you down. While supervision addressed aspects of this concern on a mental level, you found yourself still left thinking, wondering, or worrying about some things that translated into a kind of tension felt in your body. Body Stuff - Running and Processing: An Interior Journey to Acceptance You began running to or from work as way of purposefully dealing with these leftover feelings. You developed a "mechanism" or strategy of playing a little interior movie about people at work (clients or their family members) with whom you felt unfinished. You used these active, imaginative visualizations in order to finish the story for some of these people, in a way that you were unable to do in "real time" or "real life." This resolution was often something like the thought that "it was meant to be incomplete." You had a running partner who worked in the same setting, and each of you would put things "into the hopper" and process as you ran, sometimes talking to each other about what you were "processing" in ways that respected client confidentiality, but often in silence. Simply recognizing that these things were unfinished and still present in your being, and attending to this, helped you to accept and contain them and not stay caught up or stuck in them. From what I can tell, this processing was, for you, your journey (both physical and mental) to acceptance without judgment. It was a means of releasing (and paradoxically 58 embracing) what felt incomplete but which, in reality, was complete in its incompleteness, even though you might have preferred it to be otherwise. You also learned to take time and space for yourself to emote and to cry, whether while running or later at home. Processing When you use the word "process", you refer to a form of attending. This involves checking in; being present and figuring out what you are going to do with whatever is lingering and calling you to attend to it. Sometimes no action is called for beyond appreciating it for what it is. Other times you may reframe whatever experience or circumstance has evoked your attention in this way, in order to consider it from a different perspective, one that encompasses the things that transcend our conventional explanatory systems of observable phenomena. Or you may decide that you need to say something to someone about the situation. Being Held Another way of processing these feelings involved sitting with your partner, in silence, while he held you in his lap and rocked you in a chair. This provides you the chance to counter some of the isolation of the kind of work you do. It is a way of reconnecting with your partner when you feel tender (in the sense of bruised or delicately sensitive) without having to burden him with specifics (thereby protecting him and client confidentiality as well). Being held provides you a physical kind of connection that you value. One of your strategies for maintaining your wellbeing involves creating environments in which you can take the time and the space to be accompanied and held while you contain and experience your responses, in a way that is honoring of clients, yourself, and your loved ones. 59 Planting Seeds Another self-management strategy involves being future-focused: consciously initiating plans to which you look forward with pleasurable anticipation. This provides comfort to you. As soon as you finish one thing, you deliberately "create the seeds of something more". You plan for travel, running in a big race, and activities that you find self-nurturing and peaceful. The latter include time spent in nature, where you feel very well fed, spiritually and opportunities to be in the sun and warmth, which are also healing forces for you. Getting Warm When struggling with dark stuff (pain and hardship of others), you try to get warm by taking hot baths, hot waters (Jacuzzis, hot tubs, hot springs), trips to Mexico, or simply by sitting inside on a sunny winter day in a chair positioned so the sunlight warms you. During the winter months you often light a fire in the fireplace and burn candles upon arriving home after work until the time you go to bed. Mind-Body Stuff: Touching the Spirit At some point you became aware that you could also do for your mind what running does for your body. Because you engage your reasoning and cognitive capacities as a way of assessing difficult situations (i.e., how can I make sense of this? Can I even make sense of this?), you recognized that you needed to attend to the mind, and not just the body, in terms of "processing." Attending to the mind allows you to get in touch with the spirit, which you do through mindfulness practice (Organized religion was not part of your upbringing, although your family did attend church twice yearly, on Christmas and Easter — and while you have trained in Buddhist meditation in a group setting, you do not consider yourself to be a Buddhist). Meditation gives you a sense of connection between your body and the natural world: heartbeat 60 to waves, body to earth, sunlight to air. However, these days, you need not sit to meditate. Instead you meditate when you move. This flexibility allows you to actually meditate more than when you used to sit with a group. Your meditation/mindfulness practice begins with a process of focusing on your breath, and attending to what unfolds. Often before going to bed at the end of the day you will do a little meditative practice to connect with what's the day's messages have been for you, and attend to what you walk away with and what you carry forward. Similarly, during quiet moments at work you reflect upon your experience of the day and the present moment. Once in bed, you also take time to attend to your breathing in order to experience a sense of release and your gratitude for being alive, as you go to sleep. These practices help create a sense of spaciousness that frees you up in order to be as present as possible when you face the coming day, and the unknowns it brings. Reconnection With and Through the Light For the first time in your professional life, you have a window in your office that gets direct sunlight, which allows you to experience connection to the natural world, through the light, without having to go out into nature. Light is important for you because it counterbalances darkness. At work, you spend a lot of time with people dealing with death, and that can bring up your own anxiety about death. You sometimes are a witness to people who struggle at the end of life, "because not everybody dies peacefully. So those are quite dark places" and the counterbalance to that is to then go into the light. One of your self-care practices involves a vision of just seeing things move from the dark to the light, and knowing that you can go back and forth. Often when you meditate, you will see yourself allowing the energies that pull you into the dark being released and as that happens, you experience a kind of floating sensation that you get closer and closer into the light and then you 61 are up and free of the darker energies. You can always go back, but there are times when you need to go and tap into the light just to make sure that its there. To remind you that the light is a part of it all. Invoking the Light In some ways, this is similar to a practice of intentional, conscious, dissociation, one over which you have agency. You are able to invoke this experience at will by closing your eyes and thinking about the light. In doing so, you create a mental image that is like a picture of the sun's rays, flowing with reverse directionality (from earth towards the sun). You envision a smaller version of yourself sitting beneath the light, covered with light, and moving closer to the light. Simultaneously you feel the light: a glowing, physical sensation of being warm, light in body, and lifting or moving. This is a lovely, comfortable experience. It is not scary. On occasion you have had a similar sensation (without invoking it) when in a very warm place. Nature as Middle Ground Reconnection with light as part of life -- as part of the continuum of existence that gets eclipsed or "covered off" by experiences at work (where you are in frequent and close proximity to people's pain and suffering) —brings extremely pleasant, exhilarating feelings of lightness, wholeness, genuineness, and joyful release. So for you, there are also extremes in the light; whereas, nature is more of a middle ground. Consequently, you view nature as a place of replenishment and rest where you can rebalance the extremes of life. Although you are mindful in planning occasions to be in nature, you also believe that there is a bigger connection, one in which nature calls you when you have not been there long enough or often enough. Nature is a source of providence for you, in the sense that it provides care and benevolent guidance. 62 Checking Bounds In our second conversation you talked about going up into the light as a way for you to "check bounds" — to check in with a felt sense, a tacit knowledge, as to how to best be in relationship to someone else's pain, agony, or loss. I sense this is a practice that helps you see where you stand in relation to self, other, and the mysterious energy ("life force") that interconnects. That going up into the light helps you be in contact with multiple levels of resonance (mind/body/spirit) In our earlier conversation, I was aware that you differentiate between sympathy and empathy, and implicitly, delineate boundaries between self and other: between clients' feelings and your feelings about their feelings. It is not that you feel their pain, but rather that you feel a pain because you see them in pain. At the same time, something passes between you and the people with whom you work. You seem to be aware of interpersonal boundaries and conscious of the extent to which these can be porous, and therefore need to be protected or at least mindfully respected. Releasing Emotions: The Role of Advocacy /Moving Emotion into Action You believe in expressing emotions as a form of release, and you employ advocacy as a means of redirecting rage that is unfocused. It is important to direct anger into advocacy so that it becomes useful, And so that you can move emotion into action. Preserving Self and Others: Release as Ethical Practice You are aware that there is a risk of harm to self and others if you become stuck in angry emotions. You feel a professional responsibility to be present as a witness in a way that does not add to a client or family's burden. In this way, you impress me as a highly conscientious and ethical practitioner. You value release because when you are stuck or attached to anger (beyond 63 the necessary or optimal amount of time), this prevents you from being connected to the larger (spiritual) realm, and puts you at risk of causing harm to yourself (through burnout or VT) or others by practicing when you are not fully available and connected. The Gift Side of Loss You told me about how some of the worst of the worst, the most horrific exposure to others' experiences of suffering that you could ever expect to see, have a gift side, because they are reminders of the general resilience of human kind. This is helpful to you to know, because you too will have to (and have had to) face the inevitable difficulties that are part of being alive. You recognize that this is part of the human experience of life, and it is not unique to you or the people with whom you work. From your perspective, there is "a kind of inherent balancing of the forces in life, where there is sort of good and sad, good and sad, that go in and out through life over and over again, and so that even though a circumstance may look very sad and it is very sad, that other part of that experience is that there is something else that comes from it besides just the sadness." Your belief that there is more to it than the manifest sadness makes it more tolerable, more endurable. Mystery as Purpose The belief that things have a "purpose" and that someone exposed to a difficult experience did or will get the purpose (regardless whether you eventually do)frees you. This explanatory system is crucial to your ability to do what you do for a living. One of your explanations is "that it may always be a mystery, but that is a purpose in and of itself." Mystery helps you to realize that not knowing is part of being in the world, and that not everything has a neat and tidy answer. Mystery has significance that you find enriching, and in which you take solace. I gather this Mystery is gleaned through sensed experience or tacit knowledge that 64 transcends and defies science and understanding, and awareness of it is about connection — with another realm (the next level of consciousness or the divine, or whatever it may be). You lack the words to explain this form of communication or contact with that which we cannot know (the mystery and purpose). Yet, it is positive, and sometimes its goodness is apparent or manifest through light. When this occurs, it is usually comforting because you know you are not alone in the bigger mystery of it all. You take solace in mystery and have trust that it is attached to meaning and purpose, in order to make sense of your experiences of those things that eclipse conventional, rational or scientific explanation. This interpretation comforts you and ultimately helps sustain you in your work and in your life. [I am reminded of James Hollis' use of the term "transpersonal mysterious agency" in Under Saturn's Shadow. He writes: "But always, whenever healing occurs, it is due to a transpersonal mysterious agency, experienced as grace." (1994, p. 115). Hollis also cites Kafka who "warns us against placing our faith precisely where the twentieth century has placed it — in the external, quantifiable world. Our wounds are to the soul and only that which reaches it can heal." (p. 112) — do these words fit with your sense of purpose?] Mystery and purpose are also manifest in the ways that significant teachers or guides came into your life and invited you to self-heal. Working through your own pain and witnessing others doing the same in a group-based format has been very meaningful. Through this kind of in-depth personal work you gained awareness of personal resourcefulness, and this discovery leads you to believe that, because you are not so unique, every other person must also have these resources. Your belief that "we are meant to have experiences that challenge us and cause us pain, but ultimately it is about the goodness" sustains you in your work, because it generalizes to other people's experiences and the belief that clients will ultimately be able to look back and say, 65 "That was really terrible and awful, and ...It's not the whole story." There is more to it. And that more is about the goodness. Touchstones: Safety Through Connection Relationships with your children, husband, and friends play a protective role, by helping you keep life balanced and pleasurable. Loved ones also help you gain awareness of how work is affecting you, by speaking up when they see you are working too hard or otherwise preoccupied with work. Because you have connection and community outside the work place, you don't have to always be self-vigilant. Edgy Humor: Another Form of Connection and Release Through Acceptance Another thing that has sustained you has been the use of humor in work environments. Brutal, seemingly disrespectful talk that confronts bodily functions and decline can be a means of connection for workers in health care settings where there is rarely time to connect otherwise. This kind of edgy black humor simultaneously embraces levity and weighty depth. However, you are careful to shelter patients and family members from overhearing this type of talk, which can serve as an important form of release. You consider isolation to be a huge risk factor for people who work in health care. Therefore it is imperative that people find a way to connect in this work, whether it is through this kind of edgy, black humor, or by being more authentic about one's feelings. Other Self-Care Strategies Since you turned forty, you never work on your birthday. For the past six years you have chosen to work part-time in two different work environments, which allows you to maintain a better balance between work and life and a better balance between work with death and work 66 with life issues. You have maintained regular personal therapy and supervision for the last 10 years. You have also regularly been involved in continuing education focused on self-reflection and personal growth and learning in relation to working with trauma. You believe these are essential components to maintain professional work quality and engagement, as well as personal self care and growth. Prevention In our conversation, you spoke quite passionately about your desire to see early training in self-care promoted as part of professional practice. You think we have a professional responsibility to incorporate self-awareness in all of our training programs, and to say to people, as your supervisor did, "Your job, is not only to learn about the patients and what they need, but also to look at yourself and learn what you need to do the work." We need to start to talk about people's need for connection with spirit, connection with physical resources, and connection with people, including wise leaders and mentors in their community. Clearly, there is a personal cost, as well as a societal cost when "highly trained professionals are unable to work because of workplace trauma, and the company has to pay disability benefits for them." Furthermore, you think people who work with clients who have experienced traumatic events need to deal with their family of origin issues and their pain, in order to reduce risk of burn out, compassion fatigue, and vicarious traumatization. Our professions need " to encourage, to invite, to sometimes demand that people take that responsibility seriously. Because without that they [helping professionals] can do harm to self and others." Taking care of caregivers needs to become a higher priority in health care. You think this is an organizational responsibility as well as a personal one. This will require institutions implementing some kinds of practice that make space and time available for people to look after 67 themselves. You recommend opportunities for supervision, support, group-based interaction and validation within the workplace. This would allow health care workers "to talk about what the impact is for them and how they are helping themselves. Or how they can help one and other." You spoke passionately about the need for limits to overtime in hospital work (such as nursing), instead of the current practice of asking employees to pick up extra shifts, which is frequently done in a way that can be very coercive, and it must stop. Instead, hospitals need to hire more people to cover, so staff can actually take time to engage in practices that allow them to tend to their own needs both within the workplace and during time off. You hope that one day these kinds of changes will happen, that institutions like universities and learning centers as well as work place environments will make it a priority to provide funding and staffing necessary to implement these protective practices, which could be beneficial and productive. Right now, however, you think we need to do a much better job in this area of prevention, the lack of which angers you. And I sensed that you don't expect the kinds of changes you envision to happen soon, because, as you quietly said, "at the moment, it's just so limited." As we ended our conversation, you told me one of your "missions in the next while" is going to be to make sure that in your current work environment, "we do a better job. Even if we don't do it in all environments although that would be the ideal " This resonated for me with your description of advocacy as a way of moving emotion into action, and it brings to mind your conscious practice of planning ahead – planting seeds—perhaps, in this context, seeds of hope. Thank you again for entrusting me with your heartfelt vision, and your wisdom. Warm regards, Richard 68 Dear Yvette, I am writing you this letter to share my initial understanding of our research conversation about how you manage to maintain your personal and professional wellbeing given the challenges of your work with clients who have experienced serious trauma. In this letter, I first address practices specific to your professional role, then move to the personal realm; however, my sense is that there is tremendous congruence between your approach to wellbeing in both personal and professional life. Below, I describe the rich, interrelated, and often overlapping themes that emerged from my review of our conversation. Training: Rigid Adherence to Clear Boundaries You received good clinical training in the country of your birth (which included being a client in psychotherapy), and you learned to maintain consistent, unbending boundaries between your personal life and those of your clients. You are strongly committed and adhere rigidly to this (which is ironic given that you tend to be quite flexible in other realms of life), because you believe consistent, unbending boundaries are crucial to effective practice, which you consider to be both an art and a craft. Your professional integrity requires clarity about who you are and what you know, as well as what you have to offer, which is a present-oriented relationship strictly within the context of the therapeutic hour in your office. You do not do therapy outside the four walls of your office and you do not engage in dual relationships or otherwise try to help clients beyond the parameters of their sessions (e.g., you do not cook for clients or lend them money although you are very generous in your personal life and cook for everyone else you know) because this would not be helpful to clients or to you. Clear boundaries also include cognitive clarity on your part that stories of previous traumatic events in a client's life are part of the client but not part of your relationship with them. You empathize with clients' accounts of 69 painful experiences but what you share with clients is a present-oriented relationship. This clarity about boundaries between self and other is helpful to clients and protects you. Satisfaction in Assisting You take great satisfaction in being effective in your work as a helper, and you think it is a tremendous privilege to assist people, and to do work that is meaningful. You like your work and your clients, for whom you feel compassion. You are honored and empowered by your professional role, not vicariously traumatized by it. Recognize Professional Role and Scope of Influence You recognize the limits of your professional role and know that the best you can do is to assist clients by offering an important kind of attuned presence during sessions, which helps them to expand their perspective to encompass both the past (including traumatic experiences) and the present, and to differentiate between these. This helps clients become unstuck and accept both what has happened to them and new possibilities, both current and future. Goodness of Fit: Theoretical Perspective, Professional Responsibilities, & Worldview You embrace a model of "care" rather than a model of "cure": you understand your job is to help clients raise awareness (e.g., of the permeability between internal and external realities), become more flexible, and cope, rather than to "cure" them of trauma. This is a goal that you can help them accomplish, whereas if you were attempting to "cure" clients (e.g., rid them of traumatic memories), you would be at greater risk of depletion and burn out, because traumatic memories may stay with a person for life. Moreover, your worldview encompasses the bad things that happen to people; however, these do not eclipse all future possibility. Your theoretical perspective has evolved over the years, and you have adapted your practice accordingly. Being 70 well grounded in theory is protective, provided there is a congruence or goodness of fit between clinician and theory that allows for artful practice. Moment-to-Moment Awareness As Part of Responsible Practice You attend to (i.e., strive to remain continuously aware and curious about) how you respond to client material, particularly those times when client stories stir up your own "internal reality." At such times, you focus on your breath and stay with the client in the here and now. If need be, you seek help in the form of consultation with colleagues. In addition, you read a lot about issues of counter-transference and boundaries. You also participate in a peer supervision group made up of mental health professionals who discuss Buddhism and Psychology, and you are involved in a structured Buddhist life practice group; both of these groups are of great support to you in your work as a therapist. You also value group as a treatment modality for trauma survivors because this affords clients opportunities to have present-oriented relationships (with each other) that are free of the hierarchy and asymmetry that clients may perceive in the therapist-client relationship (due to therapist's training and role). Presence: Here and Now Process From your early training, you learned to stay with the here and now process when a client abreacts. This strategy helps you maintain clarity that the trauma story is part of the client (and not part of you), and that what you share with them is a here-and-now relationship in the present, which itself facilitates healing. You think that your "presence with a person who is in the present is the most relevant and essential part of therapy" (p. 3). Your know-how and ability to offer clients a new, present-oriented experience is meaningful and helpful to both you and clients. Working in the here-and-now with clients, and helping them shift between trauma memories and here-and-now experience is protective for you (and helpful for clients), because it allows you to 71 be fully present and exquisitely attuned to clients, to witness, empathize, and assist without ever confusing their experience with your own. This clarity is beneficial to clients and also sustains you in the work. Facilitating Shifts You may do very pragmatic and directive things at those times when you sense that a client is stuck (in a traumatized internal reality), such as direct them to breathe and talk to you about what they are experiencing, or to attend to their physical posture, gesture, embodied experience, or something in the present environment, as a way to help the client shift into a present-oriented experience in relationship. Exquisite Attunement to Self & Others You rely on your own here-and-now self-awareness in relationship with clients as a guide to determine when to facilitate shifts for them (and for you). If you are feeling stuck, you invite a client to shift, because you see clients as more than TRAUMA, and you want to help them expand their story of self and the world (their "life conclusion"). You use your interpersonal sensitivity and ability to get very close to others as a way of sensing when a shift might be beneficial (i.e., when you feel stuck this is an indication that the client is stuck in an unhelpful place). Expanding Perspective to Embrace Complexity Drawing on a metaphor from a Buddhist parable, you want clients to experience more than the holes in which they have fallen — you help them to become flexible and see that life comprises both the holes and the road. Your view of life encompasses complexity, both the good and the bad. This perspective ultimately helps protect you from potentially harmful effects of your work. 72 Faith & Ritual You have faith that goodness evolves, that life is more than what has happened before (e.g., the trauma, the holes that people get stuck in), which is not the whole story. This faith, in combination with your ability to use the here-and-now therapeutic relationship to assist people in expanding and correcting their incomplete "life conclusions" helps sustain you in your work. You were raised Catholic, and think that religious rituals helped you learn discipline. self-love, and trust. However, you no longer are a practicing Catholic. Now, you are interested in Buddhism as a practice of life. You practice meditation with a group that practices Pure Land Buddhism. You also have personal rituals. You never work on your birthday. This practice helps you to stop and think about yourself independent of work and to celebrate your "cherished life." You clean house annually in December as a way of letting go of the past and things you don't need. You approach cooking as an activity that involves ritual: it is about alchemy and transformation, mixing and transforming something into something else. Rituals involve belief in something that one cannot fully understand, and you find inherent value in the practice of rituals, regardless of the belief system from which they derive, because they open you to the unknown, that which transcends our capacity to know, but which is part of existence. Openness to the Unknown You trust in the unknown, and are not interested in "knowing it all". You hold the belief that by shifting and expanding perspective what is unknown can enter increasingly into awareness, and the result is greater acceptance of the present, which is GOOD. By shifting perspective, you invite and invoke the fullness of life through increased awareness, and you believe this yields increased contentment. Partial stories are painful, but the whole story (the road and the holes) is good and it gets better. You offered the metaphor of a kaleidoscope, in 73 which all the elements are ever present, and yet multiple, purposeful shifts in perspective are needed before its universe is revealed in its most integral (and pleasing) constellation. Enduring Relationships: Inner & Outer Presence Personal relationships help you to expand your own perspective and life conclusions. With age, you have grown increasingly non-judgmental and accepting of difference in politics and values between friends. You draw on the presence of loved ones, whom you "contain in your heart", even when these people live far away in another country (or are no longer living). Presence does not need to be physical. These interpersonal (and intrapersonal) connections provide continuity in relationships. The presence of loved ones in your heart bridges ruptures in physical and temporal proximity and sustains you. In this way, you have a "multicultural" (and postmodern?) internal world. Dialectical Living You engage in a dialectical "practice of life" that protects and enhances your wellbeing in both personal and professional realms of experience. My sense is that despite maintaining good boundaries between professional and personal identity in relation to clients, when it comes to your approach towards living and being well in your own life, personal and professional practices are interwoven; they are all of a piece, and interconnected for you. You consistently dissolve borders between things that could be construed as binary opposites (e.g., good and bad). Instead, you embrace these as polar resonances, as totality rather than dichotomy. You are simultaneously aware of the interplay between inner and outer reality, prior learned experiences and new current contexts, self and others, as well as presence and absence. You are passionate, non-linear, and fluid, yet (simultaneously and paradoxically) you consistently maintain well- delineated, rigid boundaries between self and others. You recognize boundaries and their 74 permeability. Embracing the complexity of this "dialectical" perspective allows you to be well in your personal life and to be effective in your work. In fact, these realms of wellbeing inform each other reciprocally: When you live well (embrace complexity and practice dialectical living) you can better practice your work artfully, which gives meaning to your life, and contributes to your wellness. Practice What You Teach Furthermore, you strive to practice in your personal life the same kinds of things that you help clients learn to do in their lives. This involves embracing complexity and paradox in multiple realms of life with the intention of practicing acceptance of the present in all its fullness. You highly value flexibility and purposefully facilitate shifts in your routine in order to expand perspective. These external shifts (in pattern, in habit) invoke "move[s] within" that yield fuller "life conclusions" and greater acceptance of what is. You aspire to embrace life in its totality and complexity, because you believe that life is good and the more fully you can accept and embrace life, the better it gets. Furthermore, you live simply, which builds discipline and acceptance of where you are and what you have. You create opportunities for practicing this kind of discipline. Continuity & Letting Go You practice letting go in your personal life. This involves a balance of constancy and fluidity. Periodically, you purposefully move to a new living space but ironically then set up your new home in a similar way to your previous dwelling. You try not to hold on to material possessions. At the end of each calendar year, you ritually clean house and throw away unneeded things. You maintain continuity in friendships over time, but these evolve and change. Also new friendships enter your life, some of which evolve and then pass on. These external shifts occasion internal shifts, "a move within" (like a kaleidoscope shifting its configuration), which 75 ultimately expands your perspective and leads to contentment, because the whole story, the bigger picture, is good. Breathing Conscious focus on your breath helps you to let go. This leads to release, acceptance, awareness, focus and new expanded perspectives. You practice breathing (e.g., while driving). Breath opens you to fullness of experience, which involves a flow of give and take. You understand breathing to be a form of exchange with life (you take something in and let something out) that ultimately yields something better (what you take in is better than what you release). Other Protective Practices You also find it renewing to travel for leisure, meditate, laugh, do art, and cook. Perspective on Life: Awareness and Optimism You are an optimist. You maintain faith that positive change happens, and this sustains you. You believe that the more awareness we can take in through embracing different perspectives (through shifting the kaleidoscope to refigure the constellation), the closer we are to the whole story, the big picture of life, which comprises beauty and pain, past and present, internal and external realities. The more we are able to perceive the entire story, the better it gets, because life is good. You told me: "What is my definition of optimism? It would be open your eyes and you're ALIVE that's optimism." You described feeling "blessed" by your temperament and the way your life has unfolded, including multiple tragedies experienced during childhood. You told me: "Maybe I am peculiar, maybe I am...uh... saved from a lot of things because I see more the positive stuff... I tend to see positive things. I'm not a cranky person. I wake up very happy you know." And even though, upon waking, you immediately think about tragic 76 experiences of clients or other people whom you know, you dwell in gratitude and focus on how honored and empowered you feel to be asked to assist people, which is a thought you "grab like... a real light switch." You have faith that something good will happen "even from very bad, difficult circumstances." You recognize that this kind of faith is a hard thing to teach others. It has nothing to do with resilience or coping skills. You think people either have it or they don't. However your optimism is tempered by realism. You are not an idealist, and you work with systems rather than trying to change the world (at the systemic level). This is a position you have come to with age and maturity. In your youth you were angrier (and less accepting of flawed systems) than you are today. However, you think that well-intentioned people with unrealistic and utopian expectations, who aspire to change systems and rid the world of suffering and injustice, burn out easily. Your perspective is informed by having grown up outside North America. In your country of birth, people are less idealistic and are more accepting that trauma happens to people. In this way, you are optimistic but accepting that both suffering and joy are part of life. Ongoing Learning & Curiosity You also value opportunities for ongoing learning and new sources towards which you can direct your curiosity, in order to become a better helper. This renews your faith that life evolves (in good ways). Protective Practices that You Recommend for Other Helpers You are involved in training other therapists and find that people are very refreshed by the workshops you lead. You think that providing forums to talk about VT and educate helpers about the risks that come with their work is an important form of prevention. You recommend the following to mitigate these risks: 77 People must remain open to the fact that they are vulnerable to VT, rather than thinking that being a psychologist or other mental health professional makes one impervious to its effects. People doing this work need to know that it can take a toll on their life, and they need a plan for how to address this, which may entail the need for supervision or a group to work with. They must have clarity around their professional role and recognize that the client is ultimately responsible for change (and that there are limits to what they can do to help). They must develop the ability to practice effectively and artfully, to balance being present in a helpful way with the containment necessary to avoid overstepping limits of ethical practice, being over protective of clients, or otherwise depriving clients of opportunities for discovery. This kind of containment is a discipline, and requires careful self-monitoring in the moment-to-moment practice of therapy. Organizations need to be aware of people who are burning out (for example, teachers, nurses, and other helpers missing work due to occupational stress). Furthermore, therapists must have significant meaningful relationships in their personal lives and find a sense of meaning in life (e.g., through work). They must like their work and the people whom they assist. Finally, while you recognize the risks of VT and support increased education about practices that minimize these risks, you are wary of fostering an industry of compassion fatigue, where people capitalize off of the problem and make it into more of an issue than it need be. Like therapy and cooking, I believe that our research conversation was also a form of alchemy (mixing elements and transforming these), and I look forward to hearing your thoughts about whether the meanings I have made out of our discussion are well suited to what you intended to say. Warm regards, Richard 78 Dear Joy, I am writing you this letter to share my emergent understandings of our research conversations about how you manage to maintain your personal and professional wellbeing given the challenges of your work with clients who have experienced serious trauma. In talking with you, I got the sense that awareness, focus, and presence within each unfolding moment, accompanied by a strong commitment to personal responsibility, well-developed abilities to check in with yourself and self-regulate as necessary, your rich relational life, and your enduring belief in both people's ability to heal and the inevitability of change, all play an important role in your ongoing, evolving practice of personal and professional wellbeing. You have developed strategies and opportunities to care for yourself emotionally, physically and spiritually, and you actively and consistently engage in these with commitment and purpose. This allows you to experience profound and sustained interpersonal contact and connection (with self and others), while maintaining a clear sense of personal perspective and boundaries in relationship to others. I will elaborate on these and other themes below: Countering Professional Isolation / Finding Like-Minded People Initially, when you first began working with people who had experienced traumatic events, it was important to find others who recognized that social factors contributed to diagnosable psychopathology. Finding "people of like minds" and building a community and network of supportive colleagues helped counter isolation. Vision and Purpose/ Making a Difference Political and social justice events within the broader community (marches, conferences, feminist movement, etc.) further allowed you to develop your vision and to give voice to concerns about sexual abuse, domestic violence, witnessing violence, and other social 79 components of mental illness. These forums helped you feel a sense that "we were moving ahead", progressing and making change, which was hopeful. You subsequently developed further opportunities to raise awareness and educate colleagues (and clients) about these concerns. Organizational Support You feel supported in your work, and valued, by members of the local and upper management of your organization, and this contributes to a sense of belonging, even though you are the only person doing the kind of work you do there. They give you physical support (space to do your work, a salary) and convey to you that your work is valued. This acceptance is crucial. Your employer provides further support in the form of supervision and co-leaders for groups (which you are not expected to lead on your own). Because you are afforded a lot of autonomy in your job, you are able to work with clients on a long-term basis. This in turn allows you to witness more client change (such as increased interpersonal trust extending beyond the therapeutic relationship into interactions between group members), which reinforces your conviction that people have a capacity to heal, and this belief is sustaining of your efforts. Balancing Realistic Expectations and Sustained Hope/ Change as Incremental You recognize that change is a process for which you are not wholly responsible. Rather than "taking on the impossible task" of convincing everyone to support your convictions, you are willing to work with small groups of like-minded people. Similarly, you do not entertain utopic expectations of ridding the world of pain and suffering. You recognize the limits of your sphere of influence, while sustaining hope for a better world. This involves differentiating between client responsibility for change and your responsibility to be a good therapist. You also keep 80 your caseload down to a manageable number, despite the pressures to always take on one more client. Loving Connections in Professional and Personal Life You love what you do, and care deeply about the people with whom you work. You respect your clients (including their autonomy and ability to heal) and are honored by their trust in you. You view them as relational partners rather than objects of clinical interest, and you described this deeply empathic, loving connection with clients as "the heart of my work... it's that moment of true connection and understanding, which doesn't happen every session, but it happens at times, and I'm sure it's what carries us both through." In this sense, your ability to engage empathically (in an I/thou relationship) is itself protective, as well as rewarding. Yet these are asymmetrical relationships, inasmuch as you are careful not to allow clients to assume responsibility for your personal wellbeing. However, your personal life is rich with reciprocal caring relationships (e.g., your friends and partner). Consistent Interpersonal Boundaries and a Perspective of Enduring Compassion Paradoxically, you maintain clear consistent boundaries that are permeable enough to allow you to be deeply touched by the other's reality, without ever losing your own perspective. You maintain a trusting belief in the general goodness of people, which endures, even though your work involves empathic engagement with clients who have suffered greatly from acts of human cruelty, and who have come to believe that people are generally bad, dangerous, or untrustworthy. You have developed the ability to be consistently trustworthy and patient with clients, and your awareness that this kind of presence is helpful (e.g. that what you do makes a difference) helps you continue in your work. Holding onto your "belief in people's ability to heal and move forward" helps you to intimately understand clients' worldviews and be very 81 relationally present and connected with them "yet not have to enter their world and carry it" with you. You view your clients as more than the product of the bad things that happened to them, and you do not believe they are capable of "contaminating" you; although many express the fear that they will do so. Similarly, you believe that people who perpetrate acts of abuse, however misguided, are not evil, but rather, people deserving of compassion (who have often been victims themselves of acts of cruelty). You also recognize that adults are responsible for their own choices, and you remind yourself, "it's their lives, right? And it's their choices." (At the same time you recognize that they may not be aware of the full range of choices available to them, so that is part of the work you do). In these ways, you maintain clear, consistent boundaries, and a loving core. Variety of Professional Responsibilities In addition to practicing individual and group therapy, there is an educational component to your job, which you find protective because it allows you "to have some variety and get out into the world". You also seek out opportunities for further training and professional development. You give yourself permission to read at work in order to keep up to date in the field. Practicing What You Teach The VT Prevention workshops that you give provide an opportunity to check in with yourself on a regular basis, which has been very valuable to you in terms of maintaining your own-self care. As a result of this, you have made healthy changes in your personal and professional life, which include simple physical aspects of self-care such as eating a good breakfast on a daily basis, getting enough sleep, and doing regular exercise. For the past five 82 years, you and a friend have been walking together every morning before work, for 60 or 70 minutes, rain or shine. You practice in your own life the skills you teach to clients, including: mindful self-observation and self-management, affect regulation, relaxation and containment of anxiety, stopping negative thoughts, and making conscious cognitive shifts in perspective through self-talk (e.g., "Stop it. Worrying doesn't help.") When distressed or frustrated, you self- soothe by reminding yourself that in the "greater scheme of things," the source of your upset is not such a big thing. This perspective helps you to "let go." Letting Go You consciously choose enjoyable distractions over worry (e.g., bicycling or walking outdoors, listening to music). When on vacation, you are good at letting go of the weight of your professional responsibilities. You are able to think about clients ("carry them in my heart") in a way that is not burdensome. Part of this requires taking time to organize for effective coverage then trusting that people are in good hands. You keep up to date on your paperwork so that it is not a source of worry or stress when you leave the office at night. Mindful Self-Awareness and Active Self-Care You integrate a moment-to-moment embodied awareness of your self and your surroundings into your daily living. You take quiet time by yourself on a daily basis. Throughout each day, you pay close attention to your thoughts, emotions, and physical states as they occur. You cue yourself to experience sensorial/motor awareness by reminding yourself where you are in space and observing, "How am I feeling?" Physical and psychological self-observation alerts you to those times when you find yourself irritable, exhausted, or distancing from others, which allows you to do something "corrective" about this. You are an active problem-solver who make conscious, intentional decisions based upon reflective self-awareness, a commitment to personal 83 responsibility, and trust in the potential for positive change. In this way, you practice optimism. This allows you to live in keeping with your spiritual beliefs and values (see below). You clearly delineate areas in which you have the power to make positive changes, and you act on this potential. This involves three kinds of awareness: 1) clarity around what you want or value, 2) recognizing when you are participating in something contrary to this, and 3) knowing what kind of purposeful action to take in order to remedy this (without sacrificing relationships). Communication Skills You have developed interpersonal awareness and honest, direct communication skills that allow you to maintain respectful, caring connections with colleagues, clients, and loved ones, while respecting your limits and personal boundaries in these various realms of relationship. Relational Self-Healing: Supervision, Peer Support, Personal Therapy You are involved in several different peer supervision/support groups, which help mitigate effects of VT. You have built trusting professional relationships where you can share your concerns about VT symptoms. Doing so helps minimize isolation and shame, because you are able to give voice to your awareness of how trauma work is affecting your life. When you "put that out as reality" and it is witnessed by caring others, this reinforces your commitment to taking active responsibility for your wellbeing (which is informed by your enduring conviction that people, including yourself, can heal). You are able to benefit from shared strategies of other group members, and they also help you self-monitor by checking in with you periodically to ask how you are doing. Drawing on this support, you are better able to recognize and deal with your tendency to internally distance yourself from your partner and others, when you are feeling too "filled up" with work. You also use supervision and personal therapy to help manage those times 84 when work begins to intrude upon personal life. All of this helps you maintain enhanced relationships in your personal life, which further sustain you professionally. Maintaining Boundaries Between Personal and Professional Realms of Life You deeply value your personal time and rich relational life outside work. Because you recognize that these need space to thrive, you are protective of them. A number of your self-care practices involve setting temporal and spatial limits between professional and personal realms. You have made conscious decisions to keep your work-related books in the office, rather than at home, and to minimize the amount of work-related reading that you do on your personal time. Similarly, you have learned to limit the amount of time you spend debriefing at home with your partner (who works in a related field), and you are particularly conscious about this when leaving on vacation. You also recognize that you need personal time independent of your partner. You have many friends with varied interests, and this helps you gain some distance from your professional life. The mutual, reciprocal, loving support that you share in your personal relationships helps you to maintain clear boundaries in your relationships with clients (you do not in any way look to your clients to fulfill your relational needs). You take time off work to travel, and have taken more than one self-funded leave from work. Because you used to get sick when you took time off work, you now build in a transitional period at work when you do not see clients for a few days before leaving on vacation, in order to devote time to ensure proper coverage is in place while you are away, which also helps you leave work behind. Maintaining Temporal, Spatial, and Relational Boundaries within the Work Place You now limit your therapy hour to fifty minutes, whereas you used to see clients back to back all day long with no breaks. This affords you time to breathe, center, and ground yourself between clients, whcih allows you to be more patient and present with each client. At times you 85 focus on a concrete task between sessions (such as a learning-to-type exercise on the computer), which serves as a needed temporary distraction from a previous session. Other times you physically ground yourself by standing, walking, getting a drink of cold water, or by focusing mindfully on your breathing. Or you may use the time to document and keep files up to date. All of these strategies help you remain present, in touch with yourself and your surroundings, and thus relationally available, rather than caught up in a previous client's story. You make a point of eating lunch outside the office (although periodically you intentionally join those colleagues who eat in), and twice a week you go to the gym with co-workers. You consciously strive to remain neutral rather than getting caught up in office gossip or politics (doodling in meetings helps). Informed Acceptance In sessions you allow room for intuition by giving yourself permission to not know how to respond to a client or what to do next. You trust in your ability and allow yourself to be good enough. You practice a non-judgmental acceptance towards yourself as well as towards your clients. "It's being non-judgmental but it's certainly being aware" of your own limits. This parallels your attitude towards pain and sadness in life. You accept sadness without ever giving up hope for its amelioration. Your belief that nothing ever stays the same helps you sustain hope while accepting sadness. You accept the way things are so that they can change. Spiritual Care of the Self: Engaging Your Belief Systems You hold beliefs that are sustaining of you in your work. These include: change is inevitable, "things will work out OK," and people, including yourself, can get back up if blindsided or bowled over by traumatic events. In fact, your work has given you "another gift of really the belief of how resilient people are." You purposefully dwell in gratitude, by reflecting on how you feel fortunate to have loved ones, work that you truly enjoy, decent pay, opportunity 86 to live in a beautiful city and to travel. You make conscious choices to honor this gratitude by "really noticing" the things you enjoy, beginning first thing each morning (when you play with your cats, wake your partner, and meet your friend to walk), and by attending to " corrective kinds of things that you can do to aid yourself even during the day." You make a conscious effort to live in the present, while honoring the past and anticipating the future. You believe the present is real, and you recognize that embracing personal responsibility is actually liberating. You do not have a structured meditation practice; however, you use body awareness, breathing, cognitive shifts, and self-talk to release tension and stay calmly focused in the present. This strategy of sitting with the present moment was first suggested to you by a former therapist. Nature, Present-Focused Joyful Awareness, and the "Work" of Spirituality Although you do not adhere to an organized religion, you think there is some kind of "reason" or larger meaning to life, even though you don't know what that reason is. You feel most in touch with this during quiet, meditative moments of awareness, most frequently experienced in nature (as a child you sometimes experienced these during rituals of the Catholic church). You think a lot of the major religions share spiritual commonalities, which are about embracing life in the present with joy and awareness, and doing the best things you can do. You believe that "it takes work to actually be so-called 'good' in the world," but that everybody shares this potential. You told me "I want to spend most of my energy trying to bring good things into the world." You value this kind of generative living as its own reward (rather than as a means to some reward after death), and you believe that living in the moment allows "the goodness" to unfold as it will. So mindful awareness of your body and thoughts in the present moment helps you to live and choose well, in accord with a universal greater good that you believe everyone is part of, but which escapes or defies words. Being a good therapist also 87 involves this kind of mindful awareness of each moment. In this way, your work habits and practice of therapy are congruent with your spiritual values of contributing to a better world while accepting things as they are. Potentially Protective Practices at the Organizational/Systemic Level You are concerned because organizations ask people to spread themselves too thinly. You witness people around you feeling overburdened due to lack of ample staff to cover caseloads, when workers go away. This results in unrealistic and unmanageably high caseloads, which adversely affects morale in many of the work settings in which you interface. This could be prevented if more people were recruited into the community mental health field, because therapists would not be under such pressure to absorb extra responsibilities, such as coverage and data entry, which cut into the time required to do a good job with clients. Organizations need to make it more appealing to people to work in community (rather than hospital) settings. This could be accomplished by giving employees better pay and greater autonomy in how they practice (rather than pressuring people to always use empirically validated "best practice" such as CBT). Employing organizations and management need to afford therapists time to form meaningful connections with clients, rather than pushing for discharge planning during intake. Similarly, organizations need to value the important skills that therapists have developed through training and practice, and management needs to convey that these skills are valued. If I Had to Sum it Up My understanding is that awareness is key to your professional and personal wellbeing. Mindful living helps you to recognize signs of physical exhaustion and emotional distancing that indicate when your work is intruding upon your personal life. You have many strategies for dealing with this risk, including physical and emotional self-care practices, and accessing 88 supervision, peer support, and personal therapy. You love your work and the people you work with, and your varied professional responsibilities allow you to practice what you teach. You draw upon your spiritual/belief systems, which help you in your challenging work. Finally, you have developed strong interpersonal communication skills, clear boundaries, and the ability to maintain psychological and physical distance between work and your personal life, all of which help you enjoy a rich relational life, which in turn helps sustain you in your professional endeavors. Thank you so much for your time and your interest in my research. Warm Regards, Richard 89 Dear Abigail, I am writing you this letter to share my initial understanding of our research conversation about how you manage to maintain your personal and professional wellbeing given the challenges of your work with clients who have experienced serious trauma. Below, I describe the rich, interrelated, and often overlapping themes that emerged from my review of our conversation. Acknowledging and Accepting the Inevitability of VT You understand VT to be an inevitable hazard of work with traumatized clients, so it is not a question of VT prevention but rather, mitigation of risks. Accepting (rather than denying) the ways that trauma work affects you is a necessary precondition to mitigating the risks of VT. Owning this and remaining self-aware are important aspects of self-care (self-preservation) for people who do the kind of work you do. Recognizing how the work changes you allows you to heal by identifying personal costs and strategies to remedy the deleterious effects of your profession. You accept that some days are better than others and this helps you remain aware. Caring Supportive Community Helps Mitigate Risks After you had been doing this work for a number of years, you suffered a difficult period of VT. Your worldview had shifted and with the help of a caring and supportive community of family and friends you came to recognize how you had been affected by your cumulative exposure to clients' trauma stories, and you made a commitment to address this by identifying strategies and implementing a personalized program to restore balance to your life. In addition to regular self-care practices (healthy eating, sleeping, regular exercise, etc.), which were insufficient, you now have developed a program for yourself, which also includes challenging negative beliefs and creating a sense of meaning and purpose. 90 Giving Experience a Name It was helpful to you to read literature (by Pearlman & Saskvitne; Figley) that named what you were experiencing in a non-pathologizing way. The ability to name VT and read about others' perspective on the problem helped you to recognize what you could do about it. Self-Awareness + Pro/Active Problem Solving You engage in active (and proactive) problem solving, coupled with awareness, and informed by the belief that you can do something about VT. This helps you mitigate its effects. You also actively challenge negative beliefs. Embracing Paradox: Enduring Optimism and Cynical Perspective You are simultaneously optimistic and cynical. Your realistic appraisal of the risks of your work and the malevolence of which people are capable does not diminish your enduring optimism and belief in the potential for change and people's ability to heal. You accept and embrace the complexity (and tension) of these paradoxical, seemingly incompatible attitudes (cynicism and enduring optimism). In this sense you have a capacity for tolerating complexity (rather than seeking to reduce complex experience to simpler, less ambiguous terms). You consciously embrace a cognitive perspective of "both/and" rather than "either/or", and you create opportunities to experience cues that remind you to engage in this kind of thinking. Beauty In: Expanding and Refreshing Your Perspective Despite having developed strategies to process work through creative expression (e.g., "painting your way out of work" at the end of the day or journaling about it) and a variety of rituals (private grounding rituals to prepare and end-of-day practices "to leave work at work") to create a boundary between personal and professional life, these were not adequate to protect you from VT. Although you had done a lot about getting stuff "out" you hadn't done enough about 91 taking "beauty in". Consequently, you now seek out ways to experience more positive and beautiful aspects of life and the human condition Because you recognize that your work has given you a skewed perspective, you now make conscious efforts to remind yourself of other ways of looking at the world, and to experience beauty, levity and joy. You create opportunities for laughter, which you find reparative. Upon realizing that you had become overly serious through your work, you took a proactive approach to the problem in order to reclaim your sense of humor. You joined an improv group with a co-worker/friend, and you gave improvisational "performances" at social occasions. You consciously incorporate humor into your teaching. These things help to remind you of a "both/and" perspective. Countering Isolation: Connection With Ordinary Folk You belong to a book club group, which affords opportunities to interact with "ordinary people" who are not in helping professions. You find their way of thinking about people and the world refreshing. This contact helps you to challenge negative beliefs and counter isolation. You also buy subscription tickets to theatre in order to be exposed to an art form that you enjoy. Diversity of Professional Activities You have observed that organizations where therapists have little variety experience greater turnover. You have always done a variety of professional activities, and this helped you to survive even during the period that was most vicariously traumatizing. These include: individual work, teaching, program and curriculum development, supervision, and writing. This variety helps counter isolation, because it puts you in contact with other practitioners, whose vibrancy and dedication are refreshing and renewing for you. These professional interactions reinforce your trust that you are not in it alone. 92 Community, Interconnection, and Sense of Greater Meaning This awareness that you are in community with like-minded people contributes to your sense of greater meaning (which some people name in terms of spirituality) through interconnection within "the big web of life." (more below) Positive Feedback It also helps to know that you are good at your work. You get a lot of accolades and good feedback, through the teaching and training that you do. Love of the Work/ Vicarious Posttraumatic Growth You love what you do. It enriches you and you feel privileged to have experienced "the depth... beauty... or wisdom of things in this healing process," which most people never get to sense, touch, or experience. This depth of experience is born out of the intimate focus of your work with clients who are survivors of trauma. Making a Difference: Realistic Appraisal of Your Sphere of Influence You simultaneously recognize that you are effective in your work and that there are limits to how much you can help. You take satisfaction in contributing to change (at both the individual and social level), and you remain optimistic that people can heal, and that you can contribute to their healing, yet you recognize that change is incremental. It is a process that unfolds slowly, over time and that you are not in it alone. Knowledge that others are also working towards making change is comforting to you. Otherwise, the challenges of trauma work and the scope of the problems could become overwhelming and the prospect of change would appear bleak. You also have good boundaries and clarity about personal responsibility. You recognize that there are limits to the ways and arenas in which you can help — you listen to and trust yourself and are able to say "no." 93 Sense of Purpose & Acceptance of Work Role You embrace your niche and purpose as a therapist who works with traumatized clients. You trust and accept your professional role, without fully understanding or being able to articulate it in words, nor even needing to understand it. You told me: "I can only trust that there is some purpose, some meaning, some path -- I don't know what the words are --that I am doing this work. So I do it. It's sort of why I accept that trauma is my niche. I don't know the answers about that. I don't need to know the answers about that. Maybe it will get clear, maybe it won't. It doesn't really matter. I'm just gonna to do this... I will help people. Not to the extent that I hurt myself in the process, because [if that happens] I'm not going to [be of] help to anybody in any way at all, but I will do it. " Even when you tried to diversify your clientele by training in couples work, you ended up working exclusively with client systems in which there were survivors of childhood trauma, so at that point you thought: "'OK this is my niche. I might as well embrace the trauma, because I can't get around it.' And that helped too in someway, to be able to just say, 'Hey, that's what I do.' Clarity About Expectations for Change and Bounds of Personal Responsibility You have clarity that your part is to be good enough at what you do, and that you cannot do it all. Reminding yourself of this sustains you, despite the immense need for change. You said: "And if I don't remember that my job is to do good enough about my job, then it becomes too big and too overwhelming. But when I remember, 'generations to get here, generations to fix, I do my part, somebody came before me, somebody will come after me... my purpose then is to just do my part well. Do my part good enough... right here right now in this moment... That's 94 not to say that I do it in an isolated kind of way or that I don't have political or philosophical discussions." Imagery of Interconnection: A Thread in the Web of Life Activities and images help remind you of human resiliency, the incremental nature of change, and that you are not alone in your efforts to heal trauma and create change. The image of a can-can line reminds you of interconnection, that you are linked together with others over time and across generations, and you create opportunities to reinforce this image (you share it with others and have asked groups of women to dance the can-can). This can-can image reminds you that you are part of the web of life, that you are one of the threads. Imagery to Reinforce Compassionate Presence Sometimes when working with a very challenging client, you engage imagery of a compassionate shield, which helps both you and the client by allowing you to be less reactive and therefore stay "more present in a compassionate way". Nature Affirms Resiliency Time spent in nature reminds you of the human will to survive and "that people persist and are resilient" They persevere and maintain, despite tremendous obstacles. You are reminded of this when gardening (plants are resilient), or walking at the seashore (the ocean persists). These are ways in which you create meaning. You also like gardening because you don't need to treat plants with the same care and sensitivity that you practice in your work with clients — you can be forceful and less cautious when deadheading in the garden. 95 Mindfulness You have developed mindfulness based practices (although you have never been able to meditate and do not engage in an organized religious or faith-based community of practice): You have learned to consciously slow down and attend to details of the world around your as well as your own inner state, at different moments throughout the day. Community Building You greatly value community building, and the idea of making a difference by contributing your part is sustaining of you (this is a way in which you create meaning and counter isolation, thereby addressing two key components of your personalized program to heal from VT). You like to be involved in "upstream helping", prevention, early response, education, curriculum development and training, advocacy, and raising awareness beyond the four walls of the therapy office of the devastating effects of violence and the need for healing at individual, organizational, and societal levels. You experience a sense of satisfaction through contributing your part, in these ways, and making a difference. Even parenting your own children is a form of community building. You have made efforts to ensure that your daughter, in particular, can assert herself and her feelings. As a parent, you want your children to be "on the good side of that generational equation" in terms of redressing injustice and malevolence versus contributing to ills in the world. Continuity In Relationships You maintain relationships with others over time (family, partner, friends, colleagues, book club members, board of directors of volunteer organization), and this has been helpful to you in mitigating the effects of VT in a variety of ways. These personal and professional relationships help you counter isolation in two important ways: 1) by reminding you of your 96 connection to something larger that transcends personal experience (some call this the "spiritual" realm); and 2) by allowing you to restore balance to your life and expand your skewed perspective by spending time with non-helpers who can help remind you "of the way that most people think." Time spent with children can be particularly helpful in this way, because their view of the world is renewing, inasmuch as they always expect the good in people. Supportive Partner You have a supportive partner who can always make you laugh. He recognizes that there are some days when you suffer more because the nature of your work, and together you have developed strategies to connect ethically around this without harming him or betraying client confidentiality. This is a true gift for you. Your partner also facilitates your social connection to others in non-professional realms (e.g., he invites and encourages you to go out and enjoy yourself at times when you are reluctant to do so because of your work, which involves being so intimately focused with clients). He also helps create or foster opportunities for you to connect with friends for balance and levity. Practices That Mitigate Risks of VT for Others To mitigate risks of VT you recommend implementation of the following protective practices: Educate and encourage people to be self-aware and develop their own unique proactive program to create meaning, challenge negative beliefs, and be in community; Provide opportunities to discuss VT in supervision in a way that does not cast blame or raise questions about practitioner competence; Create variety in caseloads and work tasks; Offer secondments or leaves of absence to helpers so that they can experience new and different professional responsibilities and opportunities. Organizations could encourage self-care and nourishment in the workplace, and create a structure for graduated return from holidays in which employees 97 resume their full caseload over the course of several days. Employers need to acknowledge VT in the work environment without shaming staff: normalize validate, educate, and commit financial resources and time to minimize the impact of VT. In addition to these strategies, you recommend that individuals practice good basic self-care (e.g., eating and sleeping well, regular exercise). Summary You benefit from continuity in relationship in multiple domains of life, and these connections help you restore balance and enrich your life, as well as remind you that you are not alone in your work, and that there are other ways of seeing the world that differ from the skewed perspective that you have developed after 25 years in this profession. Awareness and commitment are key practices that are central to your wellbeing. You recognize your limits and honor these, and you accept your role and purpose, even though you don't fully understand how or why this path is your purpose (in fact you don't even have words to describe it, nor do you need to understand it) This acceptance and clarity around your role contributes to your sense of meaning, which is an important aspect of your individualized program to counter the effects of VT. Connection to others (both helpers, and non-helpers) in the present, over time and across generations, reminds you that you are a thread in the big web of life, which is your version of spiritual meaning. You counter isolation at multiple levels, from the big transcendent realm to smaller interpersonal arenas. You have learned to be mindful, to slow down and be aware of the world around you, as well as your own inner state, at different times throughout the day. You are an active problem solver, who seeks out humor, levity, and beauty to counterbalance the depth and darkness of your work. You embrace complexity, which allows you to be simultaneously cynical and optimistic (hopeful and realistic). The dark does not eclipse 98 the light — you can hold both. You can witness pain and the aftermath of cruelty and violence (malevolence) yet maintain faith in people's ability to heal and your ability to help. You consciously challenge negative beliefs and remind yourself to expand your perspective and shift frame of mind — to a both/and perspective, which encompasses your skewed worldview and the beauty of life and humanity's will to persist. You take great satisfaction in making a difference, and contributing your part to community building, as well as individual healing. You benefit from having variety in your professional responsibilities, you love your work, and you know that you are good at it, but that your role is only to do your part good enough. This work enriches you, and you feel privileged to have experienced extraordinary depth, beauty, and wisdom as part of your clients' healing process. Thank you again for your valuable contributions to this research, Richard 99 Dear Frank, I am writing this letter to share with you my initial understandings based upon our research conversation about how you sustain yourself personally and professionally, given the challenges of your work with traumatized clients in residential treatment for substance abuse. Below I describe the themes that emerged from our conversation. Balance: The Medicine Wheel You embrace a model of personal wellness based on the medicine wheel, in which you strive to balance emotional, physical, mental, and spiritual realms of life. You engage in protective practices in each of these domains, which you understand to be interrelated and intertwined, rather than discrete categories or distinct aspects of self. Emotional Health: Family The stability of your relationship with your wife and your shared history of emotional connection is sustaining of your professional efforts. This relationship contributes to your emotional wellbeing. You feel both a responsibility to contribute financially to your family and satisfaction in your ability to do so, which is tied to your work. In this sense, work is about something more than just the pain of the clients. Similarly, the importance of your family helps mark the separation between work and personal life. Time spent with your grandchild helps take your mind away from work and affords you great pleasure and a lot of laughter. Separation between Personal and Professional The ability to "compartmentalize" and "leave work behind" is essential to your wellbeing, and you feel fortunate to have always been able to do this. However, you do not know how you do it. The geographic distance between your current workplace and your home allows you to literally, physically leave work behind each weekend when you drive over two hours 100 between these communities. Yet even when you lived walking distance from work, you were able to leave work behind by the time you arrived home on foot. Knowing when to delegate responsibility to others, in your role as an administrator, also helps you maintain this separation. Physical Health Your overall health contributes to your professional wellbeing, and you consciously take care of yourself physically, because you recognize that the type of work you do takes a toll. You do not do drugs or alcohol, and you eat healthily and get ample sleep, in order to keep your energy up and remain as effective, present, and resilient as possible. You walk, play golf, stretch, and currently attend pilates class 4 mornings a week, as well as one weekly Bosu class. You also go to the chiropractor, and get massages. Exercise helps provide stamina to deal with the "rigor of the work and the emotional intensity, which is exhausting." This has become particularly apparent as you approach age 60, and you want to exercise more. Creating Time and Space for Personal Pleasure Although you live at your current workplace (in the treatment center) Monday-Thursday and also devote considerable personal time to your studies, you make certain that you create conscious, structured opportunities to engage in activities that give you personal pleasure. Time spent on the golf course allows you to completely clear your mind of work-related thoughts. You also go to movies and read novels voraciously. Solving Soduku puzzles similarly helps take your mind off work and relax and unwind at the end of the day or first thing in the morning. Intensity of Engagement in the Present This ability to shift focus and leave work behind is related to full engagement with whatever you are doing in the present. At work, you engage your attention fully: "It's there. You're focused on that. It's over. Next!" You are not sure if the ability to shift focus thoroughly 101 when moving between professional and personal contexts is a skill that you developed over time or an aptitude. Enjoy Work: Intimate Honest Connections with Clients You enjoy working in residential treatment for substance abuse and could not imagine yourself doing something else. You appreciate that in your work as a therapist you deal with "real issues" and people who are honest rather than "having masks up", which allows for intimate connections in the professional realm. You get very close to clients, who "share things with you that sometimes they have never shared in their lives. There is a sense of intimacy, connectedness that is real," and which contributes to your professional satisfaction and overall wellbeing. While you experience intimate connections with clients whom you accompany in their painful journeys, when your perspectives on their situation differ, you maintain clear boundaries between these. Goodness of Fit: Mental and Spiritual Wellbeing Because you find your current work meaningful, important, and fascinating, you don't mind going to your job, which you experience as an extension of self and a congruent part of your life. You think of this in terms of goodness of fit, and possibly temperament. In the past, when other work did not capture your interest, you were not comfortable and did not enjoy it. You find your current work richly rewarding, even though it offers less financial compensation than work you did in other fields (which you never found personally rewarding). You particularly appreciate that your current work provides enhanced "understanding of human experience," including self-discovery. You learn a tremendous amount about yourself from clients. 102 Walking Your Talk: Self Awareness, Personal Growth, and Enlightenment Through ongoing training and relationships with colleagues, you have developed a code of ethics and sense of expectations about what it means to be a healthy person. You strive to practice in your own life the kind of integrated and balanced approach to health that you teach to clients. This has required you to take an honest look at yourself and deal with personal issues, which has benefited you. You think being a therapist is a good way to find enlightenment. Although there are a lot of paths, this work is a good one for you because it helps you understand yourself better, which involves recognizing your limits and trying to live fully and work well within them. This kind of learning and personal growth keeps you going. Letting Go and Active Problem Solving You used to get very agitated and reactive when upset, but at one point in your life, after having inadvertently hurt yourself when ranting at the television set, you made a conscious decision not to let things bother you. After making that decision, you learned to face problems differently, by calmly taking stock of the problem situation, accepting that something needs to be done, and determining what you are gong to do to fix it. In this sense, you learned to draw on a peaceful attitude from within and let go of your excited reactivity and agitation, which allows you to become a calm and active problem-solver. This helps you deal with work related challenges. You recognize the importance of choosing your behavior and have learned to choose the way you wish to react to something. Self-awareness is crucial to this choice, because you recognize that things can run away from you. You understand this in terms of the limbic brain moving faster than the cortex, so in order to train yourself to recognize when you've been triggered in to that limbic area, "you've got to be aware of it all the time." You also practice a form of letting go when you terminate with clients. At the end of a group, you attain a sense of 103 closure, without thinking about it rationally, and do not carry client concerns along with you. This helps protect you from "being consumed by the issues that come up during the day" in your work. Use of ritual and ceremony in termination contribute to this sense of closure. Professional Effectiveness, Satisfaction & Sense of Accomplishment You are good at what you do, and the fact that you are "accomplishing things" is sustaining of your professional efforts. You feel proud of your work, and regard it as a position of honor. You also value the personal prestige, and respect that your professional role affords you. Although you don't place a lot of emphasis on this kind of status, you acknowledge it as something that you are getting out of your work and another thing that keeps you going. You want to be successful and you want to be recognized for your success. Meaning and Purpose: Social Responsibility and Making a Contribution On a larger scale, you feel that we have a responsibility as a society to help out people who are suffering, and it is meaningful and important to you to be able to contribute at this level through your work. You have a responsibility to take care of yourself and to contribute financially to your family, but have always felt "if I don't put something back into my community what kind of a person am I?" Sustaining Hope Through Expanded Perspective: Part of a Larger Movement Despite the fact that at work you encounter horrible suffering and a "steady, endless flow of people who need help," you know that the good work done at your centre is part of a movement creating change on a larger scale, and this awareness helps protect you from despair, You recognize that many other people and organizations are making similar contributions, and as a society we are making progress. Your conviction that we will get better at helping and "are only at the beginning of this healing process." is exciting to you. Within the aboriginal 104 community, where you focus your professional efforts to help facilitate change, you see positive change occurring. Seeing this progress helps counter doubts and thoughts of hopelessness. Although within your workplace you only see the people who are having problems, you know that increasing numbers of aboriginal people are doing better than ever before "out there". For example, more aboriginal kids are graduating from high school, and fewer are living in poverty. So when you remind yourself of the larger movement towards change, you are encouraged. Entering Discourse: Increased Public Discussion of Abuse However, you do not hold a utopian view of the future. Rather, you accept that there will always be cruelty and abuse (and a need to help people who are struggling the hardest). You find it heartening, however, that issues of abuse are now commonly part of public discourse. You told me that virtually every client who enters your treatment centre has been sexually abused, and when you consider that 20 years ago, many people and institutions did not acknowledge this problem, you find the progress AMAZING and "almost revolutionary." Looking at abuse and trauma from this perspective is sustaining of you and leads to hope and trust in a better future. Enduring Hope You have "belief in the future," for both yourself and others. Through experience, you have come to believe that "opportunities for success keep coming around." They present themselves again later, if initially missed. There were times when you thought the future was bleak; however, you no longer feel that way. In this sense, you are open to the unknown. Embracing Paradox Around Progress You paradoxically accept that there will always be suffering and that things are getting better and will eventually work out. Progress is not an all or nothing concept for you. The 105 awareness that we will never be able to eliminate suffering, cruelty, and abuse does not eclipse your enduring sense of hope and belief in a movement of continued positive change. You have faith that things will improve; however, you accept that the changes will not occur in your lifetime. Finding a way to contribute to progress while accepting that human suffering is inevitable helps you to deal with the challenges of your work. For you, this is a question of perspective (accepting that change is subtle) and being able to see beyond the moment. Change as Incremental / Recognizing and Accepting Limits of Personal Influence You recognize that change happens slowly, over time and across generations. Coming to the understanding that change does not unfold on your chronology, that you are not solely responsible for change, and that there are limits to what you can accomplish has been helpful to you. You used to worry about moving clients further along in their change process, however you have gained clarity that it is not your responsibility to change people and that client are responsible for their own change. You have learned to accept that you can't do anything about how ready clients are to engage in change. Having developed realistic expectations in terms of the range and limits of your own sphere of personal influence and how much change you can expect to facilitate helps sustain you in professional efforts. Accepting and Appreciating Small Successes as Adequate Similarly, you have learned to measure change in smaller increments and "accept success in smaller movements." You embrace Ralph Waldo Emerson's definition of success, which is about changing the world one person at a time. To change the world even in very small increments, to have affected one person's life, is for you a measure of success on your own terms. I have included the quote you sent me from Emerson: 106 SUCCESS To laugh often and much; to win the respect of intelligent people and the affection of children; to earn the appreciation of honest critics and endure the betrayal of false friends; to appreciate beauty, to find the best in others; to leave the word a bit better, whether by a healthy child, a garden patch or a redeemed social condition, to know even one life has breathed easier because you have lived. This is to have succeeded. Positive Feedback Sometimes you have run into former clients years after having worked with them, and hearing about the profound influence you had in their lives reinforces your awareness that you have affected many people's lives in a positive way. This acknowledgement from self and others affirms the success of your contributions and sustains your professional efforts. Integrated Spirituality Your spirituality is well integrated into your daily life and affects your approach to work. Although you were raised in a Christian family with the belief that living well would be rewarded by life eternal in heaven, you no longer believe this. Your spirituality is well integrated into your daily life and affects your approach to work. Instead, you now primarily embrace a personalized pan-Indian spirituality; however, you have come to believe that this life is heaven (although not eternal), and that there is no afterlife. Rather, "this is all there is." Having come to terms with your mortality gives you peace of mind that helps you stay stable and deal with the challenges of your work. For you spiritual living is about understanding, enriching, and maximizing your experience through profound awareness and acceptance of the moment. Integrated spirituality is about applying the same standards to yourself that you hold for others, being who you are, and accepting what is (including the limits of personal knowledge). Your 107 professional context provides many invitations to "walk the talk," to be honest and live in accord with your values (e.g., to face problems with equanimity and calm). You are grateful for these invitations to be your best. Ritual and the Practice of Spirituality Previously you participated frequently in formalized ceremonies and rituals (e.g., sweat lodges), which you believe have a valuable purpose, which is symbolic cleansing; however, you are more interested in practicing spirituality than getting caught up in the dogma of ceremony and ritual. You understand and live in accord with the spirit of the ceremonial ritual, which is more potent than the performance or choreographed aspects of it. Integrating your spirituality into life is another version of "walking your talk". At the same time, while content with your integrated spiritual practice, you think it would benefit you to participate in ritualized ceremony, and you are considering reengaging with this more formal practice. Vision: Seeing Beauty and Making the Extraordinary Ordinary After a vision quest, you came back with the insight that you already have what you were seeking, because phenomenological experience is itself a vision. You realized that you are "constantly having this remarkable experience of being able to witness creation, and when you think about it, well that's pretty magical!" For you, spirituality is about making the extraordinary ordinary, and the ordinary extraordinary, and you find that life is full of opportunities to do so. Hearing other people's stories of trauma and misery provides this kind of opportunity. You see beauty in nature but also in the resiliency of the young people who come as clients to your treatment centre. 108 Embracing Complexity/Seeing Both Sides of the Story You perceive clients' moment-to-moment survival of their pain to be heroic. Their stories of immense suffering are also tales of great courage and strength. You can hold a multiply storied perspective and simultaneously embrace both the pain and the beauty of your clients' lives. You believe this perspective on clients' experiences protects you against VT. The Drift: Adjusting to the Bad Days You are aware of the risks of your work, and you recognize and accept that you have bad days when you feel discouraged and sad. You like the metaphor of "slips" for VT because people can get up after a slip. You do not regard times when you are down as personal failures but rather, as part of the experience of your work. Realizing that "we are always moving" (that change is constant), that life does not unfold in a straight line (i.e., reaching goals is not a linear process) helps you to deal with the bad days. You accept the need to adjust to "the drift" in order to get back "on track." Here again, you draw upon an expanded perspective: "What is important is to get where we are going." Your spirituality allows you to get back on the path by helping you to see beyond the suffering to the extraordinary beauty in clients' ability to persevere. Practice Optimism Through Awareness and Conscious Shifts in Perspective When the despair of working with such copious amounts of suffering wears you down, you actively practice optimism by reminding yourself that there is more to life than the dark place that you stand in when working with clients. You recognize that focusing on only the darkness (and not the larger picture) is part of the trap of VT and that the way out is through awareness and expanded perspective. In order to shift perspective "you have to be aware" of being caught up in an attitude of hopelessness and consciously "move beyond it" by repeatedly "reminding yourself that beyond the clouds there is sun" and that you know that something more 109 and something better lies ahead. You have done this so long that it seems to have become second nature for you to not let the doom and gloom of clients' stories get you down. Personal Therapy Doing your own personal therapeutic work is the single most powerful thing for you in terms of keeping yourself from being overwhelmed by the work with traumatized clients. You do this in a group-based context (Therapeutic Enactment). You think people could get away without doing some of the other strategies we discussed, but "you can never get away with not doing the therapeutic work." Recommendations In your opinion, workplaces need to get better at caring for employees in order to protect them from being emotionally damaged as a result of devoting their lives to helping people. You recommend that organizations fully support, fund, and implement regular supervision and consistent, structured therapeutic work in the workplace. Workloads need to be held to a reasonable level and therapists must receive proper, fundamental training and ongoing professional development. In addition, you recommend that people in this work engage in self- care practices, including personal therapy, and consciously counter negative cognitions (e.g., thoughts of hopelessness) in order to avoid becoming angry and embittered. I hope this letter finds you well, and I look forward to when our paths next cross, Richard 110 Dear Ernest, I am writing this letter to share with you my initial understandings based upon our research conversation (and preceding correspondence) about how you sustain yourself personally and professionally, given the challenges of your work with traumatized clients. Below I describe the themes that emerged from our conversation. However, this letter cannot begin to convey what I understood, experientially about your protective practices, by virtue of sharing space and time with you. That experience was rich beyond words, which will have to serve as a pale substitute. Exquisite Listening and Empathic Attunement You find sustenance and nourishment in the work itself. Paradoxically, the close intimate connection you form with clients helps you to endure the horrific details of any traumatic experience they may tell you. Through exquisite listening, empathic communication, and personal presence you co-establish a strong therapeutic relationship that is protective. Rather than distancing yourself because of fear of what a person is about to tell you, you "move in," and this way of working helps mitigate risks of secondary traumatization. The connection between you and the client is itself protective of you and simultaneously beneficial for the client. Co-Presence This kind of therapeutic alliance involves heartfelt connection and transparency on your part: you express compassion and show clients when you are touched or affected by their story. You use "co-presence" (established through tone of voice, physical posture, eye contact, and other non-verbal expression, as well as accurate empathic communication), in order to create and share a space with clients, in which they can have an experience of being heard and understood (as opposed to isolated) in their traumatic experience. Moreover, you allow your own emotional 111 experience to enter the room and into the therapeutic relationship as a means of providing clients an intimate healing experience. Allowing yourself to be so present in your work is sustaining of you in a way that is palpable but difficult to describe. You are nourished by your felt sense of connection and your knowledge that it is reciprocal, that clients also feel the connection and benefit from your loving presence. When doing your best work, you are boldly present and, when appropriate, transparent about your vulnerability. You acknowledge your inner life in your approach to the work yet remain focused on the client's experience. This kind of presence is extremely important to doing your work effectively and to your wellbeing in your personal and professional life. Being Effective and Good at What You Do In this sense, being an effective therapist is protective. Both your awareness that you are good at what you do and the interpersonal therapeutic practices that make your work effective are sustaining of your efforts. You recognize that your ability to offer clients an experience of co-presence, exquisite attunement, and shared felt sense of connection is helpful to them, and you benefit from both the felt sense of this experience and knowing it is helpful to others. These two protective aspects may well be inseparable. Personal Experience of Traumatization/ Post-traumatic Growth You have undergone a frightening experience of traumatization that gave you a deeper connection with clients' traumatic experiences. Having lived with your experience of traumatization and the understandings that went along with it, you no longer fear much that clients might tell you. This allows you to stay closer with clients' traumatic material. Moreover, having experienced and managed significant personal traumatization and subsequently gone on to thrive, you now have an increased sense of what is possible, and you can offer ways of dealing 112 with very bad life experiences. Your experience of traumatization also increased your compassion and the ability to open your heart in your work. It increased your sense of inter- connection with all people. You do not see yourself as different from the person in the client chair, and this makes the work you do easier, "as horrendous as the stories are", because you feel connected and as though "we're in this together". This image of inter-connectedness is very powerful for you. Clarity of Boundaries Between Self and Other Although a felt sense of connection and the idea and image of inter-connectedness are helpful to you, you do not confuse clients' experience with your own. You don't suffer the pain of clients' stories as they are suffering. You told me, "It's still their story. It's not my story. I don't lose myself in it." Instead, you are interconnected but differentiated. You simultaneously maintain intimate interpersonal connection and distinct clarity with regard to your separate perspective, experience, and identity. Imagery: Wind through a Screen Door Nonetheless some of what you hear in sessions is too much for you. At those times, you visualize treating the client's story like wind blowing through a screen door, and you are the screen door. The idea that wind blows through but doesn't attach to the screen door is particularly helpful to you. This image assists you in remaining present while allowing horrific details of clients' painful traumatic experiences to "pass through" you. At those times, you may engage self-talk (e.g., "let it pass through me") to invoke or accompany the visualization. Peer Supervision Sometimes, rather than passing like wind through a screen door, client stories evoke themes in your personal life that arouse emotion in you. You are aware when this takes place, 113 and at those rare times, you draw upon peer support from one of three supervision groups in which you participate. These groups are a place where you can go talk with people about what gets stirred up for you, without compromising client confidentiality. Physical Exercise Swimming and hiking also allow you to "unload distress in appropriate ways." You enjoy both of these activities, which help you let go of work-related thoughts and feelings. In this way, physical exercise helps you to separate personal and profession realms of life. When you hike, you enjoy the time spent in nature, as well as the aerobic benefits of brisk walking. Holding and Being Held You share a good home life with a loving companion, and this contributes to your resilience. You are very physically affectionate together, and you find it very reassuring to hold and be held. This non-sexual physical contact is about your relationship, but there is also a deeper unspoken aspect that has to do with the difficult situations faced by each of you in your work. Holding and being held allows you to connect at home "without going into the details of whatever it was that caused the desire for a hug" in a way that would betray client confidentiality or burden your partner. Oftentimes, you will fall asleep on the couch while lying in your companion's lap, holding and being held. This physical touch, which is an expression of love, is tremendously comforting and regenerating. It helps you to deal with the wear and tear of work and life. Community You also have good friendships that are important to your wellbeing. Additionally, you are part of an inclusive, "off beat" community of worship; however, you do not attend all that often. 114 Religion, Tradition, and Belonging There is something about religious traditions that you find familiar and comforting. Although you were raised within an organized religion that your family embraced, as an adult you found this approach to religion to be judgmental and not sufficiently inclusive of diverse lifestyles. Consequently, you stopped practicing your religion in a community setting. You have since found a more progressive community of worship within your broader religion in which you feel a sense of belonging. Spirituality You experience a sense of spirituality in nature and when you see devotion in others. You are drawn to devout people, in whose purity, innocence, sincerity, faith, discipline, love of others, and devotion to their god you glean something transcendent. Being in the presence of people who consistently practice this kind of devotion makes you more aware of your own spirituality and your "hunger" for a connection to the divine. This reinforces your awareness of what you need to do in order to live the more spiritual life to which you aspire. Additionally, you value the sense of connection that you experience when devout people reach out to you; however, you recognize and accept the differences between their beliefs and yours. Here again, you maintain a connection to others without losing your own perspective. You are able to "stay with but not be part of exactly" members of faith-based communities to whose devotion you are drawn or with whom you have close relationships (e.g., family or friends involved with fundamentalist religious groups of which you are critical). Because you experience faith in something that you do not define, it is difficult to put into words what this connection to the divine means to you. It eludes language. You do not need (nor have you thus far been able) to define your spirituality. Instead, you sense it at those times 115 when you slow down and have the opportunity to observe the fullness of your own experience in relation to nature, or when you see others who are focused in their devotion. This practice of focus is important to your experience of spirituality, and you aspire to enhanced, moment-by- moment consciousness in which you attend to every second, so that each of your actions, interactions, and expressions may be filled with awareness and respect. Living in accord with this code of conduct, for you, is synonymous with God. To embrace and revere every moment is to be in connection with the divine, the spirit of love and beauty that imbues all life. Presently, you strive to integrate a practice of this kind of mindful and compassionate awareness throughout your day; however, you recognize that you are not there yet Recently you began practicing mindfulness meditation based on the work of Jon Kabat-Zinn, as well. You are accepting and forgiving of the fact that you repeatedly lapse and fall short of the state of presence and loving consciousness, to which you aspire. In this sense, you acknowledge and accept your limits, while still yearning and intending to transcend them. Contemplating Nature You have developed a morning ritual in which you sit in quiet solitude, over a cup of coffee and observe the cycles of nature as they manifest in your patio garden. Doing so, you feel inspired in a way that has to do with belief, faith, and spirituality, and which is sustaining of your professional efforts and your personal wellbeing. Particularly when plants bloom in spring, you see physical reminders within nature of the potential for rebirth and transformation that reinforce your sense of hope and your conviction that "that there can be transformation, and that though somebody has been traumatized, it doesn't mean that it's the end ... they can create themselves in a different way, be born into some new form of experience." In this way, your morning ritual observing nature reinforces an expanded perspective on post-traumatic experience. 116 Witnessing Client Change: Vicarious Post-traumatic Growth Similarly, experiences of witnessing significant client change inspire an enduring sense of hope and faith that things can move, shift, and get better. You find it very moving to help people get back into the world in meaningful ways, back into relationships and purposeful, generative activities after having had their lives disrupted and shattered by trauma. You used the metaphor of witnessing people "pull from the ashes some form of life that is meaningful. " Witnessing this kind of profound transformation in the wake of trauma, this healing and rebirth, enriches your life. Invigoration: Love for Work and Clients Finally, you enjoy your work and find it meaningful. You also care deeply for your clients. When you are moved by their experience, which is usually the case, you are drawn into the therapeutic alliance and paradoxically feel invigorated (by the experience of co-presence) rather than depleted by "the toxicity of the content being presented." Recommendations In order to mitigate risks of secondary traumatization of therapists, you recommend that organizations implement inclusive, non-hierarchical administrative styles, in which clinicians are asked for input in decisions and feel respected and listened to. Otherwise, the administration risks losing the allegiance of employees, who do not feel supported. You think administrations need to balance concerns about efficiency with respect for employees and their expertise. In addition, institutions that refer traumatized clients as third parties could help prevent therapist vicarious traumatization by being more transparent and candid about the reasons they are making a referral. You have worked with a referring organization whose agenda has frequently been for you to break the bad news to clients who are no longer considered employable, and whose 117 income will be reduced when disability claims are cut off and replaced with a lesser pension. However, the organization does not explicitly tell you this when phoning to offer you the work. As a consequence, you now decline this kind of work, in order to protect yourself. You also recommend peer supervision, paid consultation on difficult cases, ongoing professional development, and personal therapy, possibly in group format, to help protect therapists from the risks of VT. In Closing Ernest, as you mentioned during our research conversation, I was aware of the rich fullness of the experiential process of being in co-presence with you. This experience contained a lot, and I could sense and feel how your way of working would be protective for you given the challenges of your work with traumatized clients and the risks of VT. I am grateful for your generosity of spirit and open heart. I wish I could better convey in written language what I understood from our time together. All the same, I trust that these words do some justice to what you offered my research. Warm regards, Richard 118 Cross Narrative Themes In the following pages I describe themes that emerged across participant narratives and synthesize my understanding of practices that protect and sustain exemplary trauma therapists in their work with traumatized clients, thereby mitigating the risks of VT. The themes articulated below are integrally interrelated. Many of them overlap, and they constellate in myriad ways. Indeed, I have come to view the phenomenon I am researching as a fractal, whose intricacy is such that the overall pattern occurs in each part. The act of parsing them into discrete categories may come at the cost of diminishing their intricacy. Yet, paradoxically, fragmentation (i.e., thematic analysis) better allows one to consider and grasp the intricate whole. The following configuration of cross narrative themes is not intended to be a fixed truth claim nor a totalizing statement about the phenomenon under study. Instead, I suggest that Yvette's metaphor of a kaleidoscope (see pp. 72, 74-5) applies to consideration of these research findings. The constellation of themes that I have generated below is but one of many possible perspectives; its component elements could be "shifted," reconfigured to yield different vantage points on the same phenomenon. Moreover, I recognize that others may construe different meanings even within the proffered constellation. Commensurate with the constructivist epistemology that informs this research method, I have chosen at times to represent the research findings as excerpts of transcribed dialogue between co-participants and myself as researcher (R). Rather than remove all traces of my voice from these conversations, I am deliberately including my speech in the representation of the findings, in order to highlight the co-constructed nature of this research. Because I believe that meaning is co-constructed, it follows that I must, to the best of my ability, show you, the reader, 119 how I arrived at my interpretation. My intention here is to both illuminate and make transparent the process of meaning making, which unfolded in living dialogical moments shared (Shotter & Katz, 1999) and co-created by the research participants and myself, throughout the research interviews. With these thoughts in mind, I invite readers to consider the following analysis of themes that I found to be salient within and across the research narratives of individual participants. Counter Isolation The research participants draw upon and benefit from continuity in relationships in multiple realms, in order to counter isolation and restore balance in professional, personal, and spiritual domains of life, all of which risk being affected by the nature of their work. Professional Community Supervision: Relational self-healing. All participants spoke of the important role supervision plays in mitigating risks of VT. Regardless whether it takes place within an informal peer group, an organizational setting, or as paid consultation, supervision helps decrease trauma therapists' isolation, and when conducted in a sensitive, non-blaming fashion, helps diminish feelings of shame by normalizing VT symptoms. Most participants attend at least one peer supervision group. This practice enhances their self-awareness and ability to self-monitor, and reinforces their commitment to implement self-care practices, as needed. Moreover, peer supervision groups provide a forum in which these therapists benefit from learning about each other's strategies to address VT symptoms. This form of support within the professional realm also helps therapists maintain healthy relationships and balance in their personal lives, which in turn, further sustains them in their professional efforts. Joy described how she uses supervision to mitigate the risks of VT: 120 I have supervision, and that is really helpful to me, and we have a vicarious [trauma peer supervision] group that I go to once a month where we talk about ourselves and some of the things that we notice might be going on for us, and different things that we are doing in order to help with some of those symptoms that might be coming up. It's almost kind of like going on Weight Watchers, too because when you tell somebody and you open up and it is no longer a secret and you are no longer ashamed about the fact that you are more irritable and you are snapping at somebody, and you know that, and you actually put that out as a reality, then other people know that and then they are interested, they care, and they inquire about that (laughs). It helps you keep on track about those things and keep more mindful. It takes away some of the shame when you say these things. You know, because it is a hard thing to admit that one of the ways that I know when I'm overloaded with my work or carrying too much is that because my partner works in a shelter for battered women and has a great need to debrief, [and] I don't want to hear it! (laughs) There's distance between me and her because I don't want any more of her stuff, of her stories, and I don't like that distance, and so that's one of the things that I keep revisiting in the group: Checking in, OK, how am I doing here? Am I distancing or not? Because I have a great ability to manage that and appear as though I'm not distancing and it's an internal distancing. Training, professional development, and organizational support. Participants also underscored the importance of good training, ongoing professional development, mentorship, and organizational support. These practices anchor clinicians within a professional community, 121 which decreases isolation, anxiety, and despair that can arise when a therapist feels solely responsible for redress of daunting and highly distressing problems. All participants asserted that organizations that employ therapists have a responsibility to value and foster clinician self- awareness by dedicating time and space for self-reflection at work and creating forums in which therapists can discuss VT in an open and non-judgmental environment. Similarly, they recommend employers remain aware of how the work is affecting clinicians and institute policy to hold caseloads to reasonable levels. Additionally, non-authoritative, inclusive administrative styles that convey appreciation for clinicians' expertise can enhance a sense of belonging, and professional satisfaction. Clare described the need for early training in self-awareness and self- management strategies: I really want people to get training before they go out and start working. I really want them to learn how to take care of themselves first, instead of having to learn on the job! Because sometimes the damage is already done and people have to leave early in their career because nobody taught them how to take care of themselves! So I'd really like people to start to learn how to take care of themself and for that to be promoted as a part of professional practice. Just as you have to be really good at your communication with your clients, you have to be really good at self-care or all is lost. And people are too important to lose. People shouldn't go to work and be hurt to the point that they have to go on disability. So I think that, just like we do communication classes, we should do self-awareness classes. Multiple professional roles. All participants were involved in a variety of professional responsibilities (i.e., some combination of direct practice, teaching, supervising, and/or 122 administration). Several explicitly stated that they found this to be protective and sustaining of their professional efforts, because this diversity expanded their professional role and put them into contact with a larger community, thus allowing them to feel a sense of interconnection and renewed hope. Abigail described how the variety in her work helped her to get through a particularly challenging period: So one of the things that I think has allowed me to survive was that I have always done lots of different things. So I have always done individual work, I have always taught. I have written different manuals, different articles, stuff like that, so I have a lot of variety in my work whereas the [program for women who have experienced violence] counsellors don't, and I think that is part of why there is such high turn over there is that they just have an endless, endless stream of [abused women clients] and they don't have any variety. In that way I'm luckier than lots of other practitioners because I get to go out and meet lots of practitioners all the time, and have a good sense of the different kinds of work, and the vibrancy, and the dedication, and all that amazing stuff that is out there. That helps a lot: I'm not just in the four walls. I think if there was more variety for most people's work, they would be in better shape. Therapetic connections. Interconnection with clients is also sustaining of the professional efforts and personal wellbeing of these trauma therapists, some of whom discussed the depth of their relationships with clients in terms of love. In the following exchange excerpted from our research conversation, Joy conveys the strong, interpersonally affective (loving) quality of her interactions with clients by contrasting her approach to clients' stories with that of the medical system in which she works. In doing so, she elaborates on how her connection with clients is sustaining of her professional efforts. This excerpt also serves to illustrate the co- constructive nature of the interview process. Joy: There is certain things that I chart only because I think that it might be important in terms of legality or continuity of care, but their stories are so personal that it doesn't belong on a chart. It's their story to tell and not my story to tell and put on a paper record. R:^And that's what I started talking about here [in terms of ethics of narrative research]. I think I get what you are talking about, because as soon as you take it and tell it, it becomes something other than what// J:^Yes, exactly. So, what I am very much aware of is that over time, what happens is, I think, in terms of my work with people, is that I say that I love them because I develop a relationship with them, and so a lot of what they have been through, it is almost like being with a friend or someone who tells you something that is so important to them that you don't forget it, right? I mean because it means something to you. So in my charting, I don't have to put down the details, because everybody's life is so real to me. It takes time, but [we] develop relationships where what they say becomes so important so I know their story. I don't have to record their story, or the details of the story. I know their lives, and I think that's because of the nature of the relationship. So there's a difference there. There is a difference there. R:^I'm hearing you say you see them as people, and their stories are so meaningful and dear to you that they don't become these clinical objects, or something, does that fit? 123 124 J:^Exactly. Exactly. Exactly. Exactly. Exactly. R:^And so is that also part of what is sustaining of you in this work? J:^Yes. It's the relationship. It's the relationship I have with people. It's definitely the connection that I have with people. R:^Is there more you want me to know about that before we move on to your self- care strategies? J:^I would just once again say, that is the heart of my work {laughs}. I can't imagine myself ever doing anything else. The educational part is part of it that I think is a self-care strategy because it allows me to have some variety, and get out into the world, out of the office and into something a little bit bigger, which I think is important, but I would never give it [clinical practice] up. R:^And I think you called it the heart of your work, and I think you also said, you say about these people that you love them? J:^Yes, and there's moments in therapy where you are just so aware of that connection and that love. It's that absolute, and the other really rewarding part, it's that moment of true connection and understanding, which doesn't happen every session, but it happens at times and it's what, I'm sure it's what carries us both through [her and client] (laughs). Personal Community All participants value the role played by their personal community of family and/or friends in helping them to maintain balance and separate work from the rest of their life. Most described belonging to a rich network of mutually caring relationships, upon which they can rely when in personal need. The reciprocity in these non-professional relationships stands in sharp 125 contrast to the asymmetry of their professional role and helps them to maintain clear, consistent boundaries with clients from whom they expect nothing in return (and whom they actively discourage from taking on a care-giving role in the therapy relationship). Because these trauma therapists are nourished and sustained by relationships in the personal realm, they find their care- giving role less depleting. Some have developed strategies to connect physically with loved ones and seek solace when distraught, in a way that neither betrays client confidentiality nor burdens relational partners with potentially harmful details. This kind of physical contact with trusted close others acknowledges and helps trauma therapists contain the challenging knowledge and experiences that they acquire, embody, and carry forward as a consequence of their work. Below, Clare described how this kind of connection helps her: My partner of many years, although he works in a completely different area, and some of what I do kind of freaks him out, he's really good at being able to just say, "What is this that's going on for you in your day?" or "Is there anything you need?" If I come home and say, "Ohhh, I've just had a horrible day" and I'll often say to him-- he has a chair that rocks in the front room—"I just need to sit with you and rock." And so I will sit in his lap. We will rock in the chair. We won't really say anything, but it will just be a chance for me to get connected with another human being. It's a way for me to separate from all the emotionality. Sometimes I sit and cry, sometimes I don't, and he'll often ask is there anything you need, and I'm like, "No, just this. Just this is a way of processing." And it is about being connected, because some of the things that are hard about doing this kind of work is that it's very isolating and that you can't really share everything that you experience with other people, nor is it in their best interest for you to do 126 that, so you do have to carry some of it yourself.. Those moments I think are very helpful for me, because it is about the non-language stuff. It is about just being held, and so you're not alone, even though the content, he doesn't know. I think all of us need to be held. And it's very hard in work environments, people are so busy, and they'll say: "I don't have a minute to even talk to you." Not to mention to sit with you quietly and... hold. Sometimes you have to create your own environments and ways of doing that, which I think is part of my own self-care management stuff. And so that that's very important. In addition, participants look to their relationships outside the professional domain for opportunities to experience levity and joy, in order to counter-balance or expand the restricted and skewed perspective on life that they otherwise risk developing based upon the frequent and repeated stories of suffering and cruelty to which they are exposed at work. Moreover, the participants rely on personal community to help them gain awareness at those times when professional concerns are intruding upon personal life. Again, Clare described how her personal community helps her maintain balance and counter isolation: I am not just my work. I am a person in the world who has work and family and relationships and friendships and things that I do for fun, and so it's not only about my professional identity. And I think the thing that kids and partners do is to remind you about the non-work life: about playing and movies and books and outdoors, because that's how they join you in life. They engage with you in those places. And so as soon as I leave my work and engage in those places, then I have people that I can connect with in that other realm. And again, I think being alone is a risky thing. Either in your personal life or in your professional life it can be 127 risky. And so I think [the] more connectedness there is, the easier it is not to be at risk. And I think we are all at risk at one level, but I think that connectedness, both in the personal level but also then in the spiritual level, is a way of keeping ourselves balanced and... safer, if that's the right way of putting it. It keeps us safer in ourselves, that we have those kinds of things as touchstones. For example if I get too crazy in work, or if I get too crazy in play, somebody in one of those realms is going to say, "Hey, Clare! Hey Clare, pay attention, you've fallen off into one of those realms." If I don't do it myself That's part of the risk reduction factor when you have those connections you don't have to always be so vigilant for yourself. Other people will also monitor and assist you with that [self] monitoring. Countering Isolation Through Spiritual Connection Participants further described experiencing a sense of connection to a spiritual realm or a sense of larger meaning that transcends individual boundaries and reason. This sense of interconnectedness with the mysterious transcendent, which is tacitly known and cannot be clearly articulated through words or otherwise apprehended, is sustaining of therapists' professional efforts and personal wellbeing because it helps counter isolation and despair. These trauma therapists are comforted by the belief that they are part of something larger, meaningful and good, that they are not alone in their efforts, and that these are not futile. This felt sense of spiritual interconnection reinforces their positive disposition and renews their conviction that: 1) people are resilient and can heal; 2) growth can occur in the wake of trauma; 3) life is about more than suffering; 4) their professional efforts are meaningful; and 5) they are not solely responsible in their efforts to heal trauma. In these ways, spiritual connection inspires these 128 trauma therapists and helps them to keep going despite the difficult challenges of their work. For most of these professional mentors, time spent in nature is an important aspect of this sense of spiritual connection. Abigail described how her personal, highly cognitive version of interconnection with humanity, nature, and the transcendent helps her persevere: When I go walking by the ocean, which I do very frequently, I always think about and pay attention to how the ocean persists, and that's how humanity persists, people persist, you know, that kind of idea. Persevering and persisting and maintaining, right? It is important for all of us who do this work, I think, to have a sense of being connected, to being part of the web of life somehow, however we define that in whatever kind of way that is. Because trauma is so isolating, and we get isolated. So however you create meaning helps to break that down. I think you have to do it in the "big web of life", I will call it --some people call it "spiritual", or whatever you are going to call it -- and I think you have to do it in terms of being with some other folks who are not helpers. So from the big to the small. It just reminds me that I am part of this web of life, I am one of the threads and my job is to do my part good enough. Develop Mindful Awareness: Integrated Practice of Spirituality The practice of mindfulness (present-focused attending to minute, ongoing shifts in mind, body, and the surrounding world), integrated into daily life from initial waking to final moments before sleep, helps most of these therapists to develop enhanced patience, presence and compassion. Mindulness, as described by participants, involves curiosity and holistic awareness of one's experience in relation to both external and internal environment. Breathing consciously and redirecting attention to their embodied experience of the here-and-now helps trauma 129 therapists to stay calmly focused and grounded, which allows them to be less reactive and engage with greater equanimity. This contributes to increased ability to embrace complexity and tolerate ambiguity, as well as enhanced capacity to hold multiple perspectives, engage in both/and thinking, and remain hopeful in the face of suffering. Profound awareness and acceptance of "what is" also helps participants accept limits (including those of personal vulnerability, range of personal influence, responsibility for change, and limits of the known and knowable) and maintain clarity about self in relation to others, both in terms of interconnections and boundaries. Mindful awareness helps participants recognize if and when their interpersonal boundaries are at risk of becoming overly permeable, as well as other times when they need to take action to restore balance in their lives (e.g., employ imagery or ritual, engage in self-care practices, seek consultation, and reach out to personal community). In addition, moment-by-moment embodied awareness of self and surroundings helps therapists develop the kind of interpersonal presence and clarity crucial to the practice of exquisite empathy (described below). Moreover, I propose that because it is impossible to be truly present in two places at once, the practice of mindful self-awareness helps these therapists keep personal and professional realms separate. Their ability to fully engage in the present moment, while in the personal realm, protects them against intrusions from the professional realm. Most participants related mindful awareness to their practice of integrated spirituality and sense of purpose. Clare described how this works for her: Being able to connect with your spirit as a mindful practice then means that you can do that anywhere at anytime and its completely yours, in the sense that you create and honour what the essentials that have meaning for you are. And so they look to me more like the natural world, so the sun, the moon, the stars, the earth, 130 you know, the rain, the water, all of those things are for me, really the elements of spirituality because they are the things of life. Through mindfulness practice participants seek to make connections between mind, body, and spirit, in order to maximize and enrich every moment and interaction with heightened attention and loving acceptance. This in turn facilitates professional satisfaction and related sense of making a meaningful contribution to life through work. While some currently or previously engaged in a structured meditation practice to develop mindfulness, others had never done so. In the following excerpt from our research conversation Joy and I explore how her version of mindfulness contributes to her professional satisfaction (ultimately by helping her integrate spirituality into her professional life): Joy: I have incorporated into my own life things that I do in order to be able to sit quiet with people and to be patient. Some of that is just mindfulness practice, It's interesting because lot's of people whom I know are going into more structured kinds of practices and do meditation and go to do yoga and stuff like that, which I think is really great. I am much more an introvert than an extrovert, in terms of those things, so I do those kind of practices [by] myself on a very regular basis... [which] have really been helpful for me to get back to myself just to be calm, just to clear out, just to centre myself, just to breathe, just to do those kind of things. So that's part of my patience, my ability to be patient and also to--You know, I'm pretty good also at accepting the fact that I don't always know everything, which really helps me. There are times where I don't have to be thinking about what I need to say to that person or do for that person. Sometimes I just need to be there. R:^I just wrote -- when you said "patience," I wrote "patience and presence". 131 J:^Yes, so that makes things much easier again for me, and I think at times, much more helpful. R:^Is the patience and presence that you are able to...(searching for the word "embody")... "BE" (both laugh) Is that part of what's sustaining to you, do you think? J:^Oh absolutely. Absolutely. R:^I would really like to know what do you mean when you say mindfulness? J:^I think the whole thing for me is just trying to be really centered (laughs) and aware of things now as they are and really holding on to that. What is now for me is now and it is REAL. I don't wanna get stuck in my past. There is certain times where bringing my past forward is really helpful to REMIND me about where I can stay in the present with that, but dwelling on things that happened in the past again, it's not useful for me to go back there anymore. The same thing about the future, up to a certain point, having plans for the future is really important but worrying about things and spending time agonizing about "well, what if this happens or this happens?" It's not REAL! R:^So it is a perspective? The mindfulness for you is a lot of perspective? J:^Yes, a lot of perspective. And a lot of just checking back in and staying... aware of things, staying... connected. Staying grounded. R:^So how do you do those things? J:^Like literally sometimes staying grounded {moves feet on floor}. Reminding myself where I am in space, knowing if I am starting to kind of drift off into something. Bring myself back to things. 132 R:^OK so these are body things also. It's not just the thoughts. J:^No. It's bringing back -- I'm not religious, and I don't know how to define what it is I believe in SPIRITUALLY. I do, and I think it has to do with -- the closest I can get to is that I think we have a life that -- my belief is that I want to with my life do the best I can with it, I want to be a good person, I want to spend most of my energy trying to bring good things into this world whatever it is, and when I die and if there is no heaven, if there is no reincarnation, it's not going to matter. I want to do it HERE and now. This is where I want to be able to -- and that's the mindfulness part is really knowing on a daily basis that what you're doing is trying to ... it's too much to say "have an impact" but just to BE and try and be whatever that IS. I don't know what words to put around it. It's not light or anything, but it is kind of the light. I want to try and do the best things. You know, I want to not fill myself full of anger. I want to try and be polite to people, do all these LITTLE kind of things. That's why I think I'm in a really good job, because I really like working with people and trying to walk by their side and accompany them and help them through some of the stuff that they've been through. And I think those things are so overlooked. For Joy and others, mindfulness practice begins first thing in them morning: Literally checking in with myself, observing how I am feeling even when I get out of bed, that kind of awareness of sensation, knowing what it is like out in the day, feeling that against my skin, or if it is dark outside. [Observing] What am I starting to think about? Being happy when I see my friend for a walk. So it's really noticing... (long pause) Yeah, I guess, noticing and trying to pay attention 133 to myself and how I'm doing, how I'm feeling physically, emotionally, and I think there's always when you are doing that there's always corrective kind of things that you can do, you know? To aid yourself (chuckles) even during the day. Consciously Expand Perspective to Embrace Complexity The above-described self-awareness helps participants recognize when they are caught up in despair, at which times, they consciously challenge negative cognitions in order to expand their perspective. All of these trauma therapists purposefully cue themselves, at times through self-talk, use of imagery or metaphor, time in nature, or interactions with non-helpers in order to encompass wider horizons of possibility and counter-balance their skewed perspective on the world. When discouraged or caught up in negative thoughts, they purposefully remind themselves of other ways of viewing life. Yvette described this metaphorically in terms of shifting her internal kaleidoscope: Metaphors help a lot for me, personally. I think about my work metaphorically. Let's say about ourselves we use a metaphor that is the kaleidoscope. Everything is in but sometimes you have to move and then you see different configurations of what is in. For example, something is disturbing me. Then I shift my kaleidoscope. It helps me because I don't see the people I work with as TRAUMA!! (booming voice) You know, I see them as people (softer) who in some way are very stuck in some holes and they believe that it is dark and fearful and they cannot get out of the hole. And for me, you know, life has holes. Big holes, little holes, but there is no life with no holes. And if I can almost like tell people, have a peek in the road, you know, get off the hole. But the awareness is not just where you ARE if you are in a hole. The awareness is there are holes and I accept 134 it. And I also feel very... faithful [trusting] that I can get out of the hole. That life is not a hole. And that's how I protect myself. I accept my holes and I don't feel I get dragged in people's holes. I feel very sad, very sorry, but I feel very... empowered, I feel very honored that I am asked to assist people. And that for me is something that I grab like you know, a real light switch. Because participants are able to embrace cognitive complexity, tolerate ambiguity, and simultaneously hold multiple perspectives (including those of client and self), they can accept the inevitability of pain and suffering as well as life's potential for beauty, joy and growth. Therefore, even the cumulative knowledge of clients' horrific experiences of trauma does not eclipse their positive worldview or sense of hope and purpose (more below). Moreover, they are able to see the gift side of loss, which is to say that devastating experiences can also be generative, and that these are not mutually exclusive. They recognize that positive growth does not diminish or efface agonizing pain; rather, pain and positive transformation coexist in a Taoist unity. This awareness is sustaining of trauma therapists because it allows for the possibility that clients, too, can achieve an expanded perspective that embraces life's pain and beauty in the wake of devastating trauma. The research participants have been inspired by their experiences of witnessing and accompanying clients who have done so. They described their lives as having been enriched, deepened, and empowered by their vicarious experiences of client post-traumatic growth (and by their own personal experiences of trauma and PTG). Clare talked about how one family's ability to face seemingly "insurmountable" loss helps remind her of both the ethical importance of therapist self-care and an expanded perspective on life: One of the gifts of one of the families that I worked with was to realize that... I mean I watched them do something that was like a parent's worst, worst nightmare. I thought this was insurvivable. How can families survive? And I watched them do it. It was like amazing. And I thought, well jeez, if they can do that, then as the witness, I have to figure out a way to be present with them, but not be overwhelmed to the point of being unhelpful or potentially harmful. I mean they are having way more than anybody should have to deal with. So I have a responsibility as a professional to make sure I'm doing my stuff so that I don't add to theirs. And that someone else's horror is an inspiration to you is one of those things that I don't know how you explain that to yourself, but there you are. Because they were remarkable in their ability to survive that. I know that was one of those ones and will be one of those ones that will remind me of not only the resilience of that family, but of the general resilience of human kind, and then the exposures to other people's suffering and watching what people are capable of is in itself a reason to do the work, because you then... that's part of the gift. RH: You just said the word that was in my mind. Because, I guess this isn't about what I believe, but I'm here too, [and] I hear [you talking about]... I mean I was going to call that "the gift side of loss" C:^Mmm hmmm. Exactly. And there is one! There is one. I think the gift side of the loss is that you realize how precious life is, and then you figure out that life includes these horrendous things, and life is still precious. So it's not an exclusionary clause, it's an inclusionary clause. And so for the joys to be what they are, the losses to be what they are, that is what life is all about, and so when you engage in those things, that's ultimately living. And so it's a reminder that it's not just about surviving, it's also about both being inspired and inspiring. And so 135 136 those people inspire me, and that helps me to inspire my self, when I'm in these situations of "what's the purpose of this and this is horrible and all I want it to do is to end, and there's nothing good that going to come out of this", and then I think, "No that's not true. You have to figure out what's.... There's something else in it besides just the sad part or the difficult part or the hard part. There's something else in it. What is it? It's your job to figure that out. " Because then, it's like for me it's possible for me to see myself growing beyond the bounds that I thought I had. R:^Yeah, so... what I'm thinking is that your experiences have expanded... C:^And enriched me in ways that I never imagined I would get that. And I feel incredible gratitude for the opportunity to get that. I know it's at someone else's pain. You know, I know it comes at the expense of someone else's pain or my own pain if it's a personal experience, but I also feel incredible gratitude that I got the [realization that] "It's possible to have the experience of being through something like that, and therefore getting the hit that it's not all there is, there's more there." Furthermore, conscious shifts in perspective also help these therapists counter isolation and tolerate ambiguity. They remind themselves that they are not in it alone, that others are doing similar work to redress abuse, and that change is incremental and happens slowly over time. Frank further described how such shifts in cognitive perspective are protective: In this work, I think it is very easy to despair when you see the suffering, the endless suffering, the litany of suffering that people have. I mean it doesn't stop coming. You get rid of one group and the next group just comes in. And horrendous amounts of suffering. You begin to wonder is it hopeless? And yet we are moving forward, and you do see change. It is beginning to happen and I see it happening, and it is working, and I also know that our centre is not the only centre out there that is working. There is a movement of people moving. There's lots of people in it, and we'll always be dealing with the people who are struggling the hardest. There is always going to be cruelty. There is always going to be abuse. For example, it is not going to be done in my life time, but if I can contribute to the moving forward and accepting that perspective, that it's pretty subtle stuff, the thing is, that makes it deal-able. I mean that's what makes it [bearable]: knowing, ACCEPTING that "well, no it's never going to change, it's always been with us and it always will be with us, and so how do we make things well? If you despair and take the attitude that there's no hope, you're doomed as a person. You've got the wrong perception, and you become on of those disillusioned, unhappy miserable people. And THAT is why working in this field you have to be careful, because you see nothing but doom and gloom. If that's all you are exposed to eventually it will happen to you, but you have to be AWARE of the fact that that's what's going on, and that's part of the trap, and that you have to move beyond it. Because these people [clients] in many ways they've lost the vision. If you say it's a dark world for them, they can't see the sun anymore. And you have to keep reminding yourself that behind the clouds there is sun. I'm standing in a dark place too, but I know beyond it there is something more. I'm standing in a dark place too, with you, but I know beyond it there is something better. And the thing is it depends on your perspective. I mean, even in the... there is beauty in the 137 SUFFERING of these youth as they come in there [to residential treatment]. Their resiliency. If you have any idea of the human suffering, the human misery that some people have experienced, and yet there they are. Like, what a heroic story. It's a great tale of heroism. It's remarkable. You can either see the darkness of it or a very heroic story. It's both. Remain Open to the Unknown Ultimately, this expanded perspective encompasses openness to the unknown, and a belief or tacit sense that meaning and purpose transcend the limits of individual identity, language, and quantifiable knowledge. Participants accept their inability to articulate or apprehend this mysterious, transcendent unknown, and they do not feel a need to name or otherwise define it (although several assoicate it with light). Many equated this elusive realm with their sense of spirituality, which they primarily practice outside the context of organized religion (most of the participants were raised in a religious tradition, which they subsequently left or moved beyond). Remaining open to the idea that some aspect of life transcends personal boundaries and interconnects all people makes trauma work less distressing for these therapists, because it counters isolation on a larger scale (as described above), and helps them to feel that life is meaningful, even when difficult. Many participants equated their calling to trauma work with some transcendent purpose. Moreover, some took solace in mystery, itself, and find it comforting to accept that some things are beyond the ken of human understanding. Clare described one of her many positive experiences of mysterious interconnection in the professional realm that "go beyond" rational explanation: C:^One of the little kids that I worked with who died, right before she died her grandpa was in the room, her mom, a nurse and myself. And she had a spell, 138 where she really started to die but she didn't die in that moment, and all the lights changed in the room. There was a light that went across the room like a rainbow, it got very dark, then it got very bright, and then we saw this light. There were five of us in the room! It was either a very good group hallucination, or it was a visit from another realm. And my belief is that it was a visit from another realm. And her parents and her grandpa were getting prepared for her death. And the light is again for me a symbol of that this can be a good place, that there is something positive there. After they said, "Did you see the light?" I said, "Oh yeah." Several of us said, "Yeah. Yeah. Yeah." And I said, "How are you? Do you feel OK?" "Oh yeah." "Did it make you nervous?" "No actually I found it quite comforting." So it was a way of us getting a communication. I can't explain it! RH: Right. This is what I'm hearing you saying: It's not about naming it, it's about the fact that it's something beyond our ability to name or even comprehend (Yeah) and that somehow that in itself is comforting. C:^Yeah, because you know that you are not alone! You're there. These people are there. but you are also not alone in the bigger mystery of it all. What's going on? There was other stuff going on there that we don't really appreciate in the here and now way. But I certainly appreciated that it was there, And when this little girl actually died, her mom said it was all about the light change. It was all about the light. The day that she died, the light in her room was all about... goodness. She said you walked into the room, it was all very good, even though her daughter of four years old was dying. And she said, "So I know that when she actually 139 140 died, it was the goodness coming to get her." That's how she described it, and that was beautiful. And so for me it is very important to make room for mystery, to welcome it, not to be frightened by it, and if I am frightened by it to sort of figure out what about it is frightening for me. On a more reflexive note, personally, I am not a religious person and although others have often perceived me as deeply spiritual, I do not identify as such. Yet, in conducting the research, I was at times palpably aware of seemingly portentous interconnections and movement throughout the research conversations, which coalesced around participants' discussions of their tacit sense of faith and openness to the unknown. For example, during the first interview that I conducted, Clare had spoken eloquently about her ability to connect through light to a transcendent realm of spirit, in which she took solace and sought guidance. The following day, while conducting an interview with Yvette on a grey afternoon, at the very moment when, seemingly out of the blue, Yvette departed from her initially rational and cognitive approach to the research questions and unexpectedly began to talk about faith (which she named in terms of "the light") the sun suddenly broke through the clouds and shone through the window directly into my eyes. This sudden shift in light was so apparent that Yvette offered to get up and adjust the blinds. I was powerfully aware of the synchronicity of this experience (having the sun shine directly into my eyes just as Yvette shifted from a rational cognitive style to a tacit explanatory system that involved her faith), which seemed uncanny, given Clare's description the previous day of connection through light to spirit, and the mysterious benevolent transcendent. In the following exchange, which was similarly evocative for me, Ernest struggled to convey his elusive relationship to spirituality and the divine, which nevertheless sustains him as a trauma therapist: 141 E:^I've taken to sitting in the mornings before I go to work. There's a patio garden and I like the seasons around the garden. I sit quietly and I look outside and it's not very long, it's just a cup of coffee, ten minutes maybe fifteen minutes, but it's something about the seasons and it's something about cycles I find reassuring and I'm drawn to something. I don't know exactly what. I'm certainly drawn very often to devout people. I've a relative who's very religious and I'm drawn to his world. I feel drawn to what I sense is a purity. Maybe when I'm around somebody like that I sense the divine because they're so focused on defining their connection with the divine and I hunger I guess for it and when I see that, even though it's in a form that isn't exactly mine, I can still see that sort of divine and that draws me in. So those things, nature, in a nutshell, nature can help me feel a certain sense of spirituality and seeing it in others can draw me into it as well. RH: Can you tell me what you mean by the divine? E:^In words, I don't know if I can exactly, but it's a nice question. I live with somebody who is a devout atheist so that's a point of difference for us that's hard on me. Not because I know. I don't know what exactly it is. It's... it's just an appreciation that I have of persons with faith but I'm critical you know of certain aspects of certain groups, I make an exception with my relative for whatever reason but generally speaking I'm very critical of fundamentalist forms of religion. Yeah, I mean, I'm not sure where I am with it all, but when I have those moments of taking time, slowing things down and having the opportunity to observe perhaps nature... urn you know urn or others who are very urn obviously to me urn devout I think I absorb, you know, you can see as I'm processing and my non-verbal, when it's more complex the question and I'm more uncertain, I'm on less firm ground. My eyes will go in a bit because I'm trying to, I'm grappling, it's still, it's a difficult, I haven't got it all figured out. RH: Yeah, what I hear you saying is that you experience faith in something that you don't necessarily define, is that accurate? E:^YEAH! That's probably got it, that's probably accurate, yeah, yeah, yeah. I just have a sense of it, but I don't define it or put words necessarily to it. Like I have a forsythia in the back, in the patio, and it's starting to bud and it's only February 13th and I know it's going to get into a luscious beautiful bloom, and isn't it amazing that here it is, another year, and that's the first one to come out and I just love it you know. And every year, isn't that interesting how that happens, the seasons. Or sometimes when I walk by trees that are very old and think that, my god what it's seen, what it's weathered, and it's just... So, I can't exactly put words on what faith is but I feel somehow inspired in certain situations and it feels that it has something to do with faith and belief, a spirituality... Doesn't mean I don't fear death (chuckles) but faith is, it's good to have a little bit of anyway. Is this emotional for you, Richard? RH: Well the part that's emotional for me, what you were just saying, well can I ask how come you asked? E:^Oh, I'm seeing something in your eyes. RH: Yeah. A lot just came together. There's been kind of a funny connection between the different interviews that I've done that's moving for me, and so some of that just happened. A little bit of it was my making, but not very much of it. It's the two-year anniversary of the death of my father today. 142 143 E:^Oh, God! RH^So when you named February 13 th , and the story you told earlier [about having worked with a man who was grieving the loss of his father, who had been an exceptionally critical man but still the only father the client had ever had], and now in the context of faith, but this faith that isn't articulated a lot? E:^Right. RH: The movement through all of my research interviews is [emotionally] moving and constellates... stuff that isn't easy to talk about or be rational about... E: Mmmmm. RH:^...Or verbal about, in a way, which is kind of what I think you've been just dealing with. E:^Mmm-hmm. RH: So yeah, I mean, that's something I would have scribbled in my little research journal [had you not asked me about it just now]. But the sense I'm making out of what you're saying is that seeing a tree that's quite old or seeing nature, getting a sense of the cyclical seasons is inspiring to you. E:^Something in it. Yeah. RH: And can you tell me anything more about something in it or how so, and how that helps you in the work and in your personal [life]. E:^Well there's rebirth, for example. Spring is one of my favorite seasons and it's the notion of rebirth. So these physical reminders of the potential for rebirth in the work you know that people can (laughs) be born again but not in the fundamental sense you know that's not what I mean. 144 RH: What do you mean? (both laugh) E:^What I mean is that there can be transformation and that though somebody has been traumatized it doesn't mean that it's the end and that they can create themselves in a different way, be born into some new form of experience and of self. So, when I think of different people I've worked with and when I've seen really significant change... Yeah. They're almost different. They're not the same person that they once were. The trauma has deeply affected them but their new form of self, now that they've been shattered by this trauma but they're recreating and pulling from the ashes some form of life that is meaningful, inspires faith-- connected to faith you know that, Wow there's hope. Faith. RH:^It inspires faith? Faith in? E:^Faith that things can move, things can shift, things can get better. Sustain Hope and Trust in People's Capacity to Heal This belief that people can heal is central to a positive disposition, which envelops and underlies the phenomenon of therapists who manage well in their work with clients who have experienced serious traumatic events. Research participants shared an over-arching positive orientation, conveyed in terms of an ability to maintain faith and trust in: a) self as good enough; b) the therapeutic change process; and c) the world. In retrospect, I realized these three attributes parallel the core assumptions that Janoff-Bulman (1992) identified as being shattered by experience of trauma. The professional elders in my study viewed the world as ultimately benevolent, the therapeutic enterprise as meaningful, and self as good and capable in their professional endeavors. 145 Moreover, they shared a belief that increased awareness and expanded perspective ultimately equate with goodness unfolding. Several participants explicitly equated optimism with awareness. There is a circular quality to this positive orientation, inasmuch as the ability to sustain hope and maintain faith that things get better informs many of the protective practices these exemplary trauma therapists engage in, which in turn serve to renew their enduring hope and trust. In the following exchange, Joy described how her positive orientation and expanded worldview are protective: J:^I just think that I have belief systems (laughing) things are going to work out the way they are going to work out, and I can manage them. That's the other trust I have in myself now, and this is true when I tell clients: I don't think there is much that they can tell me that would really, at this point, not that it won't evoke feeling in me but there is nothing that will SHOCK me (laughs). So there is something in me that also has belief that -- well it's for them [clients] as well as me-- that things will work out the way they should be and things will be OK. So nothing really is beyond my ability to... I think TOLERATE things. Like when it all comes down to it, Yeah, I know about trauma so I know that traumatic events at any time things can blind side you (laughs) and you can go over, but I also believe that you can get back up, you know. And so on a day to day basis, for the most part, that's about being able to go through it with people or go through my own stuff or manage what people are telling me, and ... carry on! (laughs) RH: So exposure to the bad stuff that happens in the world doesn't diminish your belief that people can get back up? 146 Joy: Absolutely. Absolutely. As a matter of fact, if anything that's where this work is (laughs). Work has given me another gift of really the belief of how resilient people are. People go through incredible things. (silence) Active Optimism and Problem Solving These trauma therapists put their optimism into action, through proactive problem solving. They approach problems as solvable. When the scope of a problem is too large, they look at what small part they can address, which may take the form of advocacy or self-talk in order to let go of anger and dwell in acceptance. This active approach to problem solving also informs how they respond to the unique challenges of their work with traumatized clients. For instance, they use their heightened self-awareness to recognize how work is affecting them, then determine what to do about this. Most have consciously developed a plan or personalized set of strategies to counter VT and recommend that other therapists do so, as well. Their practice of active optimism involves creating time and space for self-care practices to restore balance in their lives (described below). They have purposefully developed strategies to separate work and personal life, as well as effective communication skills to deal with problems in either of these realms. Moreover, participants create and enact optimism by purposefully planning pleasurable activities in order to have something to look forward to, including travel or time in nature. Clare described this as a conscious self-management strategy: "I always plan for something good to come next. I mean, as soon as I finish one thing, there is the seed for something more. I never go without, even if the seed is a teeny tiny little kernel." Participants consciously seek out opportunities for laughter or to take in beauty, and some have deliberately joined book clubs populated by members in different lines of work, in order to be reminded of other perspectives on life. Sometimes active problem solving involves using imagery or ritual to maintain clarity 147 around boundaries or provide closure (more below). Many of the other protective practices described herein are versions of active problem solving (e.g., countering isolation or consciously challenging negative cognitions to expand perspective when caught up in despair). Below, Abigail recounts how she problem-solved after loved ones expressed concern that work was adversely affecting her life: I had to acknowledge that yes some of these things were true about me and what was I going to do to fix it? I certainly acknowledged that I had gotten very serious. That I saw things very bleakly. So a colleague and I went and took an improv class. We were terrible at it but we laughed and laughed and laughed. And we would go to diinner parties and put on these improv things that made the other people laugh. That helped a whole lot. It really helped to bring the humor back in. The other thing that I realized in retrospect, is that I was very good at getting stuff out, like I would paint my way out of work at the end of the day. I would go to my thing [easle] there and paint it, or I will journal about it, I have all kinds of rituals before I start work and end work, and I did all those things around self-care around work and getting stuff OUT but I hadn't done enough about bringing beauty in. And that's when I realized I have to do some stuff about that. I am a voracious reader, but I had stopped reading the breadth of books that i used to read, and I was just down to murder mysteries. And only murder mysteries where there was a body on page one and then the body exited stage left. Sexual abuse was the theme in a lot of those murder mysteries, too, and I would get quite cocky by page 40 saying "I know who the perpetrator is going to be" and you know, I was right a lot of the time, and I thought, "I have a really skewed view of the world." I need to read something else. So I joined a book club. The book club only allows one person of each profession to be represented so I'm the only helper in the book club. That has been extraordinarily helpful to be in contact -- I've been with these folks maybe 8 years -- and they don't think like me. I don't think like them. They are sort of regular people, sort of ordinary people, and they don't know what I know and they don't carry what I know, and it's very useful for me to be around people like that. Partly it's about being reminded that not everybody thinks the way I think. Holistic Self Care These professional mentors take a holistic approach to self-care, which they consider crucial to their ability to maintain personal and professional wellbeing. They attend to physical (e.g., healthy diet, ample sleep, regular exercise, holding and being held), mental (e.g., training, continuing education, mindful awareness), emotional (e.g., personal therapy, trusting relationships, laughter and joy, emotional expression, release or redirection of anger), spiritual (e.g., meditation, time spent in nature, creating meaning and purpose), and aesthetic (taking beauty in) aspects of self-care. Some participants think of self-care in terms of practicing what they teach, or "walking my talk." They practice self-care within both the personal and professional realm, and their ability to separate these two realms of life is itself a form of self- care. Self-care provides balance, and at times closure. Moreover, it is renewing and consequently allows them to be more present when engaging in both personal and professional relationships. Participants recommend that all trauma therapists engage in self-care practices, including some form of personal therapy. Many have found group-based therapy to be particularly helpful. Moreover, these trauma therapists recognize that there is an ethical 148 149 component to self-care. If they do not take care of themselves, they are at risk of harming others. Consequently, they strongly believe that taking care of caregivers needs to become a higher priority in health care and related fields. They think that there is a need to incorporate self- awareness and self-care into professional training, at an early stage. Below, Joy talked about the importance of daily self-care in her life: I decided that I needed to build in some exercise for myself on a regular basis. I am fairly active but I was a week-end active kind of person, so since 2000, I get up every morning at five o'clock, and I have a friend, and we walk for about an hour and ten minutes and we do it Monday to Friday. We don't miss, doesn't matter if it's raining. It doesn't matter. Sometimes we walk in silence, sometimes we talk, but if I miss that, my day is totally different. That gets me grounded, that gets me connected, I see the seasons change, I am aware of things, I have a friend that I really love and care about that is with me every morning, and it's something I just / it's REALLY IMPORTANT TO ME. So walking becomes really, it is a walking meditation {laughs} to some extent. Clare described how her personal, holistic approach to self-care practice provides her time to attend to and "process" work related concerns that otherwise risk interfering with her ability to be fully present in both personal and professional life: What I learned to do initially, was to... I said, "Oh, I've got this all stuff in my body and my supervisor's, "Whoa, you know, what are you going to do?" And he said, "Have you ever thought about doing anything physical?" And I was like, "Ohhh, Who has time for that?! I'm in graduate school I have children." You know, I have a husband, a life, I'm working part time, so I was going: "How is that ever gonna work! ?" And I thought this is just a ridiculous notion [laughs]. This will never work! And I thought, "Well, but I do need to do something with it. And although I processed a lot with him [supervisor] and spoke, I also knew that wasn't enough, because I still left thinking or wondering or worrying about some of the things, and they translated into a kind of tension that I felt in my body. So, it was like, "OK, What am I going to do with that?" Because I had to come home to little kids, who needed their mother to be... attentive and not disengaged to whatever was going on. So it was not only for me but for them, I have to figure out a way to make sure that it gets processed in a way that makes me present with the next layer of my life. So what I started to do was, I would either run into work or run home from work as a way of... doing my... processing stuff. And I always put on my agenda, psychologically in my head, this is what the purpose of this activity is. This is for me to process all that stuff that I don't have time to talk to people about. Some people can't listen to it; I haven't other places that I can do it besides my supervisor, and so that's where I did all of my processing, and usually by the time I finished my run, and sometimes I needed the time to be longer, so I would run home and run past my house and not realize that I'd run past my house because I still was in the processing, and then I'd catch myself near, you know (laughs) some street and I'd say to myself: "Oh, I probably should turn around and go home!" (laughs). And then it moved to doing body stuff but then also doing mind-body stuff, and then combining my body stuff with meditation, and so I have a meditative practice that is a part of my self-care, so that on the days that I couldn't run, I didn't have enough time for that, and I still was carrying stuff, 150 besides using other people in my life and other mechanisms, I became a meditator. R:^There's a lot I want to hear about there. Can I just ask you first about, when you are running and processing, how do you process? If I were experiencing that, what might I be doing? C:^Well, it's like watching for me. What I start out doing is I sort of run a little movie of the people, if I had people that I was... fussing about, worrying about or concerned about, or not finished with, I would often run a little movie in my head about what was left over. And then I had to make up an ending, so that by the end of it I knew or had some feeling that the ending of that little clip had come around, cause often I wouldn't be able to finish with people. If you work in an acute care setting you can start something and it never finishes because the patient gets moved to another facility or they die, and so, often there was a lot of lack of closure. So I had to actually for those people... finish. I had to finish the story, in relation to them, and so I had to be able to come to some kind of resolution for myself, even though I may never have been able to do it in the real world, in the real time with them, I couldn't keep carrying them in that unfinished kind of way, so I had to sort of put them to rest, if that's the right way of saying it. And so that's sort of what the movie would look like as I ran along, and usually what would happen by the end I would come to some kind of resolution, which often was more like a thought that: "You were meant to... see them for that long, they were meant to get what they got from you and you were meant to get what you got from them. It isn't about having it all nicely tidied up. This was just what, the 151 most that that experience was supposed to give you... Okay." (sighs). And so then that would be about accepting that piece. That even though it was unresolved, or it never got finished in a way that you might have liked it to, that was really the extent of that experience, that it was complete, even thought it was incomplete. It was meant to be incomplete. Even though I would have might have preferred another thing... So it was coming to terms with the reality of what that was. Maintaining Clear Boundaries and Honoring Limits These professional mentors maintain clear and consistent boundaries in multiple realms of interaction. They accept, honor and maximize limits, including those of their professional role in relationship to clients. All participants acknowledge their own limits, including personal vulnerability to VT, and they believe that it is imperative for others in this work to do so, as well. In addition, they maintain clarity about the limits of their sphere of influence. They avoid dual relationships, and recognize that as therapists, they are not responsible for making change in clients' lives. Joy said: I really do have to hold onto the fact that it's their lives, they're responsible for it, they exercise choice around it, and that I can't save them. Like, I can't take over their lives, even though they pull. You know, trauma survivors pull that. There's times I just want to take some of them because they are the two or three year old, and just kinda put my arms around them and say, "There there, it's going to be OK". Now I may say, "It's OK. You know, things are going to be Ok." But I know I can't make it OK for them. I know I can't...make them want to survive. That ultimately it's them that do that. 152 153 Furthermore, participants hold realistic expectations of self, other, and the world, and do not confuse the ideal with the actual or the likely. They recognize that change unfolds slowly, in small increments, and that larger scale change is a community rather than an individual responsibility. However, some participants do engage in advocacy. Abigail said, "I do advocacy work, but only when I feel passionate about it. I'm really also very able to say 'NO. I give at the office,' so to speak." She recognizes that taking on too much volunteer work can interfere with the balance in life that she requires in order to sustain her professional efforts as a trauma therapist. Moreover, these exemplary trauma therapists have developed a range of strategies to help maintain boundaries (both psychological and physical) between work and personal life. These include use of supervision, peer consultation, personal therapy, physical self-care and/or mindful attending to "process" unresolved material in order to achieve closure; personal rituals before and after work; meditation practice; taking time off work to travel; and consciously setting temporal and spatial limits between professional and personal realms (e.g. keeping work- related books at the office, limiting time spent debriefing with partners, not working on one's birthday), among others. Perhaps most importantly, they maintain clear boundaries with regard to the distinction between empathy and sympathy. While remaining highly attuned to clients, they do not engage in emotional fusion or otherwise confuse clients' feelings or experiences with their own. Instead, they maintain firm interpersonal boundaries that are sufficiently permeable to allow them to experience intimate connection within the context of a present-oriented professional relationship, without losing personal perspective. Ernest explained that although he is often deeply touched by clients' stories of prior traumatic events, he remain clear that "I'm not in, I didn't have that thing happen to me. [It] doesn't get painted on my wall, you know. It passes through." Moreover, 154 participants are attentive to those times when clients' stories resonate more powerfully with the therapist's personal history, in which case they may seek supervision or personal therapy to help maintain clarity and manage what gets stirred up for them. In these ways, exemplary trauma therapists differentiate between their own worldview and those of the clients with whom they empathize. This clarity around boundaries is helpful to clients and protective of therapists. Yvette described how important it is to her to maintain what she termed "rigid" boundaries: Every time I meet a client who wants to work with me, I pose the question to the person, "Do you want to work with me, because if we work together we [n]ever will be social friends together. We never will. This is very rigid in that way. That's what I'm saying "rigidity". I don't go for coffee with people. I don't look after their dog. I don't go and help them and give money for the bus. And I work with people with a variety of different needs and difficulties and I'm very sensitve to those difficulties, but I'm not a social worker, a mo [tiler]. I don't do that. Even though in my life I cook for everybody You know, I do that. But no. Not for my clients. And that's...I say rigid, because I don't bend that and that's where the rigidity is. I don't bend. The life of some of the people I deal with are very precarious. How can I assist? That's my point. So minimal, so limited. I only can assist in respecting and providing an experience that this person take and say, "What a good hour I spent there." Whatever it takes in an hour, that's the only thing that I can do. Invoke Imagery Moreover, these exemplary trauma therapists employ visualizations, metaphor, and personal ritual as a self-management strategy to simultaneously stay fully present and maintain 155 consistent boundaries when client material risks encroaching upon their personal life or perspective. This allows them to remain present and connected but protected and distinct in their role as attuned, caring witness to client stories of traumatic experience. Abigail described how the image of a can-can line is helpful to her: On the bad days I say to myself, "What is important is that I be good enough today, that I do what I need to do, to the best that I can, and trust that everybody else who is doing their bits and pieces and trying to turn around all this generational trauma stuff is doing their bit. I sort of start to think about it as a can- can in my mind, you know, a can-can line. So we are all sort of linked together, and every one is doing their little bit. SO ON BAD DAYS I think OK, that's what I can do. Further examples of imagery and metaphor include: Abigail's compassionate shield, Yvette's kaleidoscope metaphor for helping shift perspective, Clare's "going up in to the light to check bounds, " or running mental movies to achieve closure, and Ernest's wind through the screen door, which is described below: I try to think of myself as a screen door, where the wind blows through the screen and doesn't attach to the screen. It's just an image that I find particularly helpful, to allow to pass through and still be present, as they tell me the story of whatever it is just happened to them. I see their story as the wind and it's not coming up against the solid surface, it's not beating at that solid surface, it doesn't have to weather a solid surface, it just moves through it as it would through a screen, and that's kind of how I think of their story as the wind and I'm the screen. They will have stories that could, if forceful like a gale wind, be dangerous and something 156 to be contended with but if my door is solid and my screen allows for air to move through it, then even a gale force wind can pass through my screen door. Exquisite Empathy Most of the participants described how intimate empathic engagement with clients sustains them in their work. This finding surprised me, because I went into the research thinking that empathic engagement was a risk factor rather than a protective practice. However, when therapists maintain clarity about interpersonal boundaries, when they are able to get very close without fusing or confusing the client's story, experiences, and perspective with their own, this exquisite kind of empathic attunement is nourishing for therapist and client alike, in part because the therapists recognize it is beneficial to the clients. Thus the ability to establish a deep, intimate, therapeutic alliance based upon presence, heartfelt concern, and love is an important aspect of professional satisfaction for many of these trauma therapists. Ernest elaborated on this: I actually can find sustenance and nourishment in the work itself, and I do that by working on maintaining a very good therapeutic alliance with the client, joining with the client, empathizing, hearing, listening exquisitely, being co-present, expressing compassion, showing that I am affected and touched by their story, and being as present and connected with them as possible rather than leaving because of fear or upset at an abreaction or something like that. I move in as opposed to move away and I feel that is a way that I protect myself against secondary traumatization. The connection is the part that helps and that is an antidote to the horror of what I might be hearing. It's about working with the heart from a place of warmth and care and even love. People see my heart, you know. 157 People see when they feel cared for. I know you see. So you're seeing how I am, and that's what I do in a session. Professional Satisfaction All participants take satisfaction in being effective in their work, making a meaningful contribution through their professional efforts, and being highly skilled at what they do. In these ways, they find the work deeply rewarding. They are honored by their professional role, which expands and enriches their life in non-monetary (as well as fiscal) ways. They consider it to be an extraordinary privilege to assist people who have experienced trauma, and this sustains them in their professional efforts. Management styles that value therapist expertise and afford practitioners greater professional autonomy can further contribute to professional satisfaction. Frank described how he finds his job personally enriching: I like working in the field. I can't imagine myself doing anything else. There were times when I've had jobs [in another field], which were in many ways very good jobs and if I had stayed I would be retired now with a big pension, I mean, financially I would be better off, but personally? I never enjoyed going to work. I got into this work almost by accident. When I got into it, I just found that it was fascinating, and I don't mind going to work everyday. It's not that I'm not looking forward to retirement and having my own free time and all the rest. But I do enjoy this work, and I do find it rich and rewarding. I like what I'm doing, I'm interested in what I'm doing, I'm good at what I do. It feels different. It's a nice fit. I really think it's important [work]. Another thing is I'm seeking an understanding of the human experience, too. It's almost like this work is a good way to find enlightenment. There's lots of paths, but for me, it also helps me understand myself more. I'm a bit selfish about this, but as I go through this experience, I find myself having personal growth. I'm beginning to understand this puzzle better. I think that is part of the reward for me. It's real, its honest, and I have learned a lot, just working in that area. That kind of stuff is what's rewarding for me. That's what keeps me going, I am not bored with it. Joy described how she takes inspiration from her work as a trauma therapist: Part of what sustains me is that I really like the work. (chortles/ small laugh). I really really like the work. And I really like the people that I work with. There is something that is very inspiring in me being able to be with people and see them and hear their stories and know their strengths and know their ability to overcome some horrible things. So being able to sit with people I really do, I know it sounds a little bit cliché but it is such a privilege. Like I really feel that is a privilege to be able to go with people on this kind of journey. Abigail echoed these sentiments: If people were to say to me, well why do you do this work? If I won the lottery, I wouldn't quit work! I like my work. But I can only trust that there is some purpose, some meaning, some path, I don't know what the words are, that I am doing this work. So I do it. Creating Meaning Finally, these therapists recognize the importance of their ability to create or perceive meaning, regardless whether through belief in an ultimate universal goodness, an elusive transcendent greater purpose, their commitment to family, work, and/or community building, or 158 159 a sense of interconnection with the efforts of others in continuity over time. Clare described how she takes personal and professional solace in making meaning: Even though I've known people who have gone through difficult things, [and I] have had difficult experiences in my own life, my belief system at this point is such that I have a belief that there is some meaning or purpose in that, even if I'm not aware of it. And it may be that I'm never aware of it. That doesn't mean it was without purpose. That makes it more tolerable. That makes it more endurable, to watch these things happen, and know that they have an impact both for the individuals and for yourself. And even if the meaning doesn't become apparent or the purpose doesn't become apparent, that there is one. That frees me. If I believed that they were meaningless, that they served no purpose, I don't think I could do what I have done for a living. That's part of one of my explanatory systems that has to work for me to do it, I think. I have to believe that somehow, somewhere, at some level, even though I may not get it, it sort of makes sense or has meaning or purpose beyond... and I often think, you know that mystery serves a really good purpose. And one of my explanations is that it may always be a mystery, but that is a purpose in and of itself. I like mysteries. So I have to have some faith or trust that that mystery is attached to meaning and purpose even though I don't get it. And so that interpretation comforts me, which is part of I think why I can do what I do. Reflecting upon the way in which important mentors and guides unexpectedly came into her life and helped facilitate her own healing in relation to personal trauma, which in turn allowed her to 160 be present in her work in a new way, Clare further explained how her way of creating meaning helps sustain her professional efforts: C:^I think that whole piece around being able to realize that what might appear to be unendurable is not only endurable but can provide a growth or positive experience despite the fact that it is also ultimately agonizing, that they are not mutually exclusive, that it isn't one or the other, it can be both [was very helpful for me]. So those people who I think have had a very important role in helping me to understand that concept personally, they have all played a part in that development, which is indescribably useful and a gift. And I think they came into my life... part of the mystery. I mean who would have guessed? If you'd asked me, "Will this happen in you're life time,? I would have said, "Are you kidding? N0000." (whispers) I think that's about the mystery. I see that as being part of my own process of healing and the unexplainable intervening and providing purpose and meaning for all the things that have gone on. They all make sense, if I look at it that way... Otherwise it's like, "Hmmm. I can't really make sense out of that." But if I look at it that way, then it totally makes sense. When I just accept that the universe wanted me to have these experiences, and that they were meant to be helpful, supportive, then it all makes sense. And so then that is the ultimate goodness coming through. The ultimate goodness, which is, you know, we are meant to be here. We are meant to have experiences that challenge us and cause us pain, but ultimately it is about the goodness. R:^How does that awareness about the goodness sustain you? 161 C:^Well, cause then, it feels like, people [clients] will not be left only with pain and suffering, that they too will have the opportunity to process and work through this to a point where they make those connections to the goodness. They can look back and say, "That was really terrible and awful, and ... That's not all that's there." Summary In conclusion, the research findings describe how exemplary trauma therapists engage in protective practices that mitigate the risks of VT. I have articulated these in terms of twelve major themes: countering isolation (in professional, personal and spiritual realms); developing mindful self awareness; consciously expanding perspective to embrace complexity; openness to the unknown; sustaining and renewing hope; active optimism and problem solving; holistic self- care; maintaining clear boundaries; invoking imagery, metaphor, and ritual; exquisite empathy; professional satisfaction; and creating meaning. 162 CHAPTER V Discussion Although previous research has been conducted on VT, there is a great paucity of research investigating protective practices that mitigate the risks for trauma therapists. Consequently, this study makes an important contribution to the existing literature and begins to fill a gap that deserves continued attention. Moreover, this study augments the existing literature, much of which has been based upon quantitative research, by offering thick, rich description of the lived experiences of professional mentors who are managing well despite the risks of this work. While the current findings confirm and extend prior research, they also depart from previous literature in interesting ways. Most notably, the finding that exquisite empathy seems to be a protective practice for some trauma therapists challenges previous ways of conceptualizing VT and points to exciting new applications to practice and avenues for further study. In this chapter I elaborate on this surprising finding and other ways that the current research study contributes to the literature; discuss implications for future research, theory, and practice; and identify limitations of the study. Contributions to the Literature The current study yielded a novel finding that runs counter to previous assumptions in the literature about the relationship between empathic engagement on the part of trauma therapists and the evolution of VT. Participants who engaged in exquisite empathy (highly present, sensitively attuned, well-boundaried, heartfelt empathic engagement) described having been invigorated rather than depleted by their intimate professional connections with traumatized clients. Prior to the current research, therapist empathy for traumatized clients had consistently been depicted as a key risk factor for VT rather than a protective practice. 163 Empathic engagement in the trauma therapy relationship had been named as a causal factor in conceptualizations and definitions of both VT and Compassion Fatigue (CF). Figley (1995, p. 15) called CF "a natural by-product of therapeutic engagement" with traumatized people on a regular basis; he stated: "from research on STS and STSD we know that empathy is a key factor [italics added] in the induction of traumatic material from the primary to the secondary victim." Similarly, Pearlman and Saakvitne (1995a, p. 31) defined VT as "the transformation in the inner experience of the therapist that comes about as a result of empathic engagement [italics added] with clients' trauma material." Pearlman (1999) further described repeated empathic engagement with traumatized clients as potentially draining and enervating. This stands in contrast to current participants' experiences of the therapeutic connection with traumatized clients as invigorating and sustaining of their professional efforts. The difference between these two perspectives highlights an important distinction between the practice of empathy and that of sympathy or identification with client pain. My understanding is that the participants in the current research are able to connect empathically and interpersonally, in the here and now, with their clients, while maintaining clarity around boundaries of experience and influence. I believe this differs in important ways from the practice of "allowing oneself to enter into the emotional state of" the traumatized client, which Pearlman and colleagues found to be "particularly enervating" in their work with adult survivors of childhood sexual abuse (Pearlman, 1999, p.58). Similarly, Pearlman and Saakvitne (1995a) described how as therapists they "experience the survivor's experience of her trauma: past and present" and personally feel the overwhelming "terror, anger, vulnerability, and pain " that the client felt during past traumatic events. The latter descriptions of what these authors call "affective empathy or empathic comprehension" (p.296) sound like a therapist's sympathetic 164 identification with, rather than understanding of, the emotional and perceptual world of the client. This stands in contradistinction to Rogers' (1980) description of empathy as "entering the private perceptual world of the client... [and] being sensitive, moment-to-moment to the changed felt meanings that flow in the other." (p. 142), further characterized by Egan in terms of "being with and understanding the other" (2007, p. 80). The disparity between current research findings, in which exquisite empathy emerged as a protective practice, and previous conceptualizations of empathic engagement as a risk or causal factor in the development of VT raises an important question of semantics and practice: Is there a difference between understanding a client's emotional state and entering into it? The current research findings lead me to believe so. Participants in the current study described having understood the emotional impact of traumatic events upon clients, and having been deeply moved by this; however, none of them spoke about entering into the client's emotional state. To the contrary, several talked about being particularly attentive to those times when clients' stories resonated more closely with the therapist's own personal history. At such times they were inclined to seek out help in the form of supervision, because they did not want their own strong feelings about emotionally charged personal life events to risk interfering with their ability to remain fully present and empathically attuned in their work with clients. These trauma therapists did not confuse clients' experiences with their own, nor did they confuse empathy with sympathy or emotional fusion. Yvette made a pertinent distinction: what she shared as therapist with her clients was a present-oriented experience. Although at times she felt very moved and very sad by what she learned from clients about their traumatic experiences, she clarified for me that the client's trauma story "is part of them, not my relationship with them." Ernest made a similar distinction 165 when he said, "It's not my story. [It] doesn't get painted on my wall." This clarity about who owns the trauma story appears to have allowed these exemplary trauma therapists to feel very connected to clients, without suffering clients' pain or the effects of VT. The current findings suggest that allowing self to be fully present as witness to a client's recounting of a traumatizing event, while feeling interpersonally connected through an exquisitely empathic therapeutic alliance with clear and consistent boundaries is less depleting of therapists than the type of engagement in which the therapist attempts to enter into the emotional state of the client and feel the client's pain. In this way, exquisite empathy differs markedly from identification with the emotional state of the client, sympathy, or emotional fusion, each of which could be deleterious to both therapist and client. Based upon these findings, I hypothesize that the ability to establish and sustain intimately attuned, mutually felt therapeutic contact and connection, while simultaneously maintaining clear, consistent boundaries and the ability to hold multiple perspectives, lies at the heart of this distinction between protective exquisite empathy and deleterious forms of engagement previously identified in the VT literature. Evidence from the current study also challenges Salston and Figley (2003)'s hypothesis that an ability to create "distance between the worker and the work (including the clients with whom they work) - both physically and mentally" (p. 172) is one of the most important variables in predicting VT. This hypothesis appears to follow from Figley's (1995) assumption that trauma workers fall prey to CF "no matter how hard they try to resist" (p. 15) being drawn into the intensity of their work. However, the identified protective practice of exquisite empathy does not involve efforts to resist contact with clients as they convey narratives of their traumatic experiences. Although my research findings support maintaining boundaries between one's work and personal life, this was not described in terms of creating mental distance or otherwise 166 resisting the intensity of trauma therapy work. Instead, this protective practice appeared to have more to do with a worker's ability to maintain balance and clarity, as well as an expanded perspective, rather than distance. By expanding perspective, therapists in the current study were able to envelop that which is troubling in a larger context, which helped assuage distress without creating mental distance, per se. Research findings related to the practice of engaging in conscious shifts in perspective to embrace complexity are compatible with Pearlman's (1999) suggestion: "One approach to remaining connected with the client while protecting oneself emotionally is to purposefully remain aware of the broader context as the client is sharing his or her experience of abuse or victimization" (p. 58-59). Rather than attempting to achieve distance from their clients, many participants in the current study relied upon a well-boundaried closeness to clients in order to sustain their professional efforts (e.g., Yvette's use of self-in-relationship to guide decisions regarding when to facilitate a shift, Joy's ability to carry clients in her heart, even when on vacation, in a way that is not burdensome, Frank's deep valuing of the intimacy and honesty of the work, and Ernest's strategy of moving in rather than distancing). Joy described how she rejects the idea, often expressed as a fear by her clients, that traumatic material is " so-called 'toxic'," and that client stories could "contaminate" or otherwise hurt her: Even though I understand it [clients' traumatic material] and I get it, and it's some terrible things that they say, it's not as though this BLACKNESS or thick oil or something actually comes into my system. That's not how I view my relationship with them or what they tell me. These findings highlight the potential value in expanding upon or revising previous metaphorical conceptualizations of VT that construed trauma as contagious (Harrison, 2007). 167 While I recognize that earlier usage of contagion, infection, toxicity, and other biological transmission metaphors in the VT literature (e.g., Figley 1995, 1999, 2002; McCann & Pearlman, 1990; Pearlman, 1999) was well intentioned and helped give this important problem credibility and attract needed attention and resources, these metaphors fail to sufficiently encompass (and may, for some, inadvertently preclude) the possibility that trauma therapists can indeed repeatedly get and remain close to traumatized clients without taking up clients' traumatized world view or ways of being, as evidenced in the current research. Research findings from the current study also underscore the ethical responsibility, previously identified by Arvay (2001) and Arvay and Uhlemann (1996), shared by employers, educational institutions, professional organizations, and individuals, to create time and space to address VT. Moreover, the current study provides empirical evidence, based upon qualitative research findings, that is verifying of many of the personal, professional, and organizational strategies to redress and mitigate risks of VT, previously proposed by theorists and researchers such as McCann and Pearlman (1990), Pearlman and Mac Ian (1995), Pearlman and Saakvitne (1995b) Pearlman (1999), and Yassen (1995). These include: engaging in restorative self-care practices both within and away from the workplace; countering isolation through participation in regular supervision, case conferences, peer groups, and ongoing training, all of which can help normalize and elucidate trauma therapist reactions to clients' traumatic material; maintaining interpersonal connections with family, friends, and professional colleagues; balancing work, rest, and play; establishing diversity in professional responsibilities (e.g., teaching, supervision); accessing help, including personal therapy, as needed; spending time in nature; fostering spiritual development, engaging in conscious reflection on the value and meaning of trauma work; and recognizing and accepting limits in personal ability to help. 168 Similarly, the findings reinforce McCann and Pearlman's (1990) recommended coping strategies, including maintaining a realistic worldview (i.e. one that encompasses the existence of pain, suffering, and cruelty), a sense of hope and optimism, and belief in humanity's ability to endure and transform pain. Moreover, the study extends the work of these authors in important ways. Firstly, their recommendations were based on personal experience and speculation. While personal experience is a valid basis for knowledge claims, these authors' suggestions for coping with VT did not appear to have emerged from a study that gathered knowledge based on a specified method of inquiry, as is the case with the present research. In this way, my study redresses a shortcoming of earlier contributions to the VT literature by McCann and Pearlman, Pearlman & Saakvitne (1995b), Pearlman (1999), and Yassen (1995) by virtue of its clearly articulated research epistemology, design and method. Furthermore, the research findings from my study extend the aforementioned recommendations by offering specific strategies that therapists can implement to sustain and renew hope, such as consciously engaging cognitive shifts (including use of metaphor and imagery) to expand perspective, or Clare's conscious self- management strategy of "planting seeds' to ensure she always has something enjoyable to anticipate. Although evidence provided by the current research study is confirming of the abovementioned recommendations for ameliorating the effects of VT, my research findings challenge Pearlman and colleagues' (McCann & Pearlman, 1990; Pearlman & Saakvitne, 1995a; Saakvitne & Pearlman, 1996) prior assertions that VT is inevitable. Findings from the current study provide evidence that not all therapists who engage in trauma work inevitably suffer permanent and deleterious effects from their cumulative professional experiences. Only one participant in the current study described having suffered a challenging period of VT before 169 having learned to mitigate its influence over her life. The study suggests that the majority of participants successfully and purposefully changed their perspective and their practices before having suffered VT, which challenges its inevitability for trauma therapists. Moreover, Yvette suggested that the construct of VT is a culturally bound, North American concept, and she was wary of the possibility of a VT industry being fostered within the professional therapeutic community. The current research findings support previous research and theory that established VT as an occupational hazard; however, they lead me to hypothesize that vulnerability to VT may depend upon a therapist's worldview and their capacity to embrace complexity, practice optimism, tolerate ambiguity, and simultaneously hold multiple perspectives, in combination with their ability to maintain meaningful connections in personal, professional, and spiritual realms of life. Many of the exemplary trauma therapists who participated in this research study experienced positive shifts in their sense of meaning or spirituality as a consequence of their work with traumatized clients. In this regard, the research findings support and augment PTG research, theory and literature. However, when the research participants spoke of feeling enriched or having gained an expanded worldview through their work with trauma, they were describing a phenomenon that differs from either VT or PTG. I suggest the term Vicarious Posttraumatic Growth to describe therapist growth experienced as a result of witnessing the sequelae of other people's experiences of trauma. Findings from my study provide initial evidence in support of the otherwise untested hypotheses of Calhoun and Tedeschi (1999), who postulated that therapists could experience PTG vicariously through learning from clients about their own vulnerability and the paradoxical, dialectical nature of being alive (i.e., that humans are more vulnerable and stronger than they had previously imagined possible). My research findings 170 extend the previous work of Calhoun and Tedeschi by offering in-depth descriptions of trauma therapists' experiences of Vicarious PTG. It is worth noting that Vicarious PTG differs from compassion satisfaction, which Stamm (2002) construed in terms of efficacy and the ability to make the world "a reflection of what one thinks it should be" (p. 113). The exemplary trauma therapists in my study provided evidence of compassion satisfaction (i.e., making a meaningful contribution through being good at what they do), as well as Vicarious PTG. Together these contributed to their sense of professional satisfaction. The findings also offer documented evidence in support of Calhoun and Tedeschi's (1999) recommendations for therapists, which include: recognizing one's limits in ability to bring about change, actively noticing small changes in clients' growth or adaptive coping, engaging in practices that reinforce boundaries between personal and professional realms, spending time in nature and enjoying recreational activities (regardless of level of skill or ability in these), seeking out and utilizing humor as self care (as well as other forms of self-care), accessing supervision, and developing and maintaining supportive relationships in and away from the workplace. Another aspect of the research findings that augment the literature is the role that mindful self-awareness plays in the phenomenon of how exemplary trauma therapists practice sustainability of their professional efforts. Mindful self-awareness encompasses more than the self-monitoring for signs of impairment identified by Coster and Schwebel (1997) in their research on psychologist well functioning. Participants in my research provided initial evidence, in the form of rich qualitative description, that appears to confirm Saakvitne and Pearlman's (1996) recommendation that mindfulness practice can help trauma therapists manage the unique challenges of their work. Five out of six participants in my study explicitly described a 171 personalized mindfulness practice as protective in mitigating risks of VT, and the sixth participant (Frank) described something very similar to mindfulness, when he spoke of his intensity of engagement in the present, the crucial role self-awareness played in his ability to draw on a peaceful attitude from within in order to let go of reactivity, and his integrated practice of spirituality through profound awareness and acceptance of the moment. These therapists all linked mindful practice to both enhanced professional satisfaction and a personal sense of spirituality. Clare, for example, valued her mindfulness and meditation practice as a means of connecting mind, body, and spirit that sustained her when confronted with the challenges of her professional efforts in palliative care. Joy further helped me to understand the relationship between mindfulness practices and professional satisfaction as a trauma therapist. While describing how her mindfulness practice was both embodied and cognitive, she unexpectedly began to speak to me about spirituality. She explained how integrated mindfulness practice contributed to increased efficacy and presence in her work with traumatized clients and thereby afforded her opportunities to live in accord with her spiritual value of contributing to part of a greater good. In this way, her work provided opportunities to practice her spirituality, which enhanced professional satisfaction. Frank similarly expressed appreciation that work offered many opportunities to practice his integrated spirituality, which he described in terms of "walking my talk." Likewise, Ernest clearly aspired to increase mindful self-awareness as a way of living in deeper connection to his personal spirituality and sense of the divine for which he hungers. Consequently, he has begun to incorporate mindfulness meditation practice, based on the work of Kabat-Zinn (1994), "to help." It seems plausible to me that Ernest experiences exquisite empathic attunement and co-presence with traumatized clients as protective, nourishing, and sustaining of his professional efforts because within the arena of the therapeutic 172 relationship with traumatized clients he consistently practices the kind of loving, respectful awareness with which he seeks to fill his every moment and interaction in life. In this way, mindful self-awareness both facilitates these therapists' ability to engage in their work as a practice of their personal spirituality and contributes to their professional satisfaction. To me, this is beautiful and profound. Of course mindfulness practice also helps them to become aware of counter transference or salient self schema and ensuing "needs" that might put clinicians at increased risk for VT, as described by McCann and Pearlman (1990); however, it encompasses much more than this or the kind of self-awareness with regard to potential impairment described by Coster and Schwebel (1997). Personally, I appreciate that these exemplary therapists' sense of connection to the transcendent was expressed in terms of an openness to the unknown, rather than through a more simplistic or reductive storying of the spiritual realm that might have come at the expense of cognitive complexity. Indeed, throughout the research conversations, participants' efforts to describe their connection to the transcendent eluded definition and narrativization. Instead, this elusive realm was described as having been tacitly known, in a way that eclipsed language. For me, this was a rich and heartening finding: Encountering the limits of the known and knowable need not be daunting or distressing. Rather, not knowing can be reassuring, in and of itself, when it comes to the meta-theoretical and metaphysical. Yet, these exemplary trauma therapists also highly valued theoretical and practical knowledge (e.g., solid foundation in training, access to ongoing learning through professional development, reading, peer support, consultation, and supervision). The research findings support a Taoist, dialectical and holistic approach to knowledge, in which profound knowing includes awareness of that which is unknown. All participants appeared to share this openness to ambiguity and cognitive complexity, which is 173 commensurate with Skovholt and Jennings' research on master therapists (1999). This suggests potential implications for practice and training, inasmuch as this line of work may be contraindicated for people with concrete cognitive styles and/or a need for certainty. Research findings from the current study closely resemble those of Jennings and Skovholt's (1999) research on master therapists, as described in the literature review above. In addition, findings from the current study provide initial evidence in support of Skovholt, Jennings, and Mullenbach's (2004) supposition that master therapists are often anchored in a profound spiritual dimension, which may have been enhanced by their repeated vicarious experiences of human suffering. The similarity between my findings and those of Skovholt and colleagues (1999, 2004) raises a question as to whether master trauma therapists differ from master therapists? One difference may be that the participants in my sample practiced mindfulness more than those in that of Jennings and Skovholt (1999); however, this is not clear. Although participants in the earlier research were described as self-reflective and aware people who spent quiet time alone on a daily basis, the authors did not specify whether these individuals engaged in mindfulness practice. Nonetheless, the findings from my study suggest that there is great overlap between master therapists and exemplary trauma therapists, and in this way, confirm the findings of Jennings and Skovholt (1999). Finally, the current study explored the experiences of a range of trauma therapists who worked with a variety of different client issues. In this way, the sample in my study differed from those in many of the preceding research studies on VT, which investigated therapists who worked exclusively with clients who had experienced one kind of traumatic stressor (e.g, sexual abuse). The participants in the current study worked primarily with seriously traumatized clients (e.g., people victimized by sexual abuse, war and refugee-related trauma, multiple historical 174 traumas); however, they all had some diversity in professional responsibilities and caseload, regardless whether employed in a community agency, hospital, private practice setting, or some combination of these. By offering an exploration of the experiences of trauma therapists whose professional practice was not limited to clients suffering sequelae of a single kind of traumatic stressor, the current study begins to fill a gap in the research literature previously identified by Sabin-Farrell and Turpin (2003). In summary, the current study contributed to the research literature in multiple ways, most surprisingly by identifying exquisite empathy as a protective practice for trauma therapists. The novel finding that intimately attuned, well-boundaried empathic engagement with traumatized clients can be nurturing and sustaining of trauma therapists' professional efforts challenges previous conceptualizations and definitions of VT. In addition, the current study confirms and expands upon previous research by providing evidence in the form of in-depth qualitative research findings that are verifying of earlier recommendations for ameliorating VT. These findings underscore the ethical imperative shared by employers, educators, professional organizations, and individual practitioners to take proactive steps to protect against this occupational hazard. Moreover, the study provides initial evidence of trauma therapist Vicarious PTG. Finally the current research findings contest prior assumptions that VT is inevitable for those who engage in trauma therapy, thereby highlighting the need for further clarification of this construct. Implications for Research and Theory Implications for research. The findings point to future directions for research. First and foremost, it would be important to expand the scope and design of this study in order to further explore the novel findings related to exquisite empathy, as well as the other protective practices 175 identified above. Furthermore, because much of the initial research on VT involved trauma therapists who worked with survivors of sexual abuse, it would be beneficial to conduct a study to investigate whether findings similar to those in the present study emerge among a population of therapists who work exclusively with clients traumatized by experiences of sexual abuse. Similarly, it would be of value to compare the protective practices between groups of trauma therapists for whom diversity in professional responsibilities and caseloads differ (e.g., to compare frontline workers who always treat clients suffering from the same traumatic stressor with other therapists who have more balance in caseloads and a range of professional responsibilities). There is also a need for future research to explore and elucidate the relationships between trauma therapists' personal trauma history, vulnerability to VT, and experiences of PTG. While some participants in the current study disclosed a personal trauma history and described subsequent experiences of PTG, this was not a focus of the present study. Moreover, prior research investigating whether therapist personal trauma history serves as a buffer or a risk factor in the development of VT/STS has been inconclusive (Arvay, 2001; Buchanan, Anderson, Uhlemann, & Horwitz, 2006). Those research co-participants in the current study who disclosed a personal history of trauma described having come to terms with their own traumatic experiences. They explained how personal experiences of ensuing PTG had allowed them to become more fully present with clients and to better offer the possibility of an expanded perspective that encompassed a sense of hope and trust that there is more to life than the client's traumatic experience. Based upon these findings, I hypothesize that a personal history of both trauma and PTG may mitigate risks of VT for trauma therapists, whereas unresolved experiences of personal trauma may put therapists at increased risk. This interpretation could explain 176 apparent contradictions between previous research findings with regard to therapists' personal trauma history. Further research is needed to explore whether there are differences within the subgroup of trauma therapists who have experienced personal trauma (i.e., between those who experienced PTG and those whose are still struggling with unresolved emotions related to their personal history of trauma). In addition, it would be interesting to design a study using a grounded theory method in order to explore relationships between the various practices that help protect and sustain trauma therapists in their work. The current research findings also highlight the importance of creating, implementing and evaluating a pilot program designed to foster self-care and preventative practices in the workplace. Moreover, it might be helpful to research whether there are indeed differences between master therapists and exemplary trauma therapists. Finally, it could be important to conduct future research to identify any structural barriers to the protective practices described above. Implications for theory. As mentioned above, previous theoretical conceptualizations of VT/STS have construed empathy as a risk factor rather than a protective practice. The current findings suggest the need to expand the ways in which empathic therapeutic engagement is construed within the theoretical context of VT. It may also prove helpful to incorporate additional theoretical frameworks in future consideration of the research questions. Daniel Siegel's (2007) recent work on clinician neural integration and awareness, Allan Schore's (2003) work on affect regulation, as well as an adult attachment theoretical framework (e.g., Bartholomew & Horowitz, 1991) could further illuminate research findings that therapist presence, self-awareness, and well boundaried interpersonal interconnectedness are sustaining of exemplary trauma therapists. Moreover, it could be elucidating and beneficial to metaphorically 177 consider the construct and problem of VT as a form of inadvertent apprenticeship rather than trauma contagion. In a separate manuscript, I have elaborated this alternative conceptualization of VT by drawing upon sociocultural theory and contemporary relational psychoanalytic notions of intersubjective space (Harrison, 2007). Implications for Practice The findings from the current study have important implications for training and practice in trauma therapy, as well as for the treatment of VT. This research suggests that effective, protective empathic engagement with traumatized clients involves neither over-identification with nor avoidance of clients' traumatic material. Rather, exquisite empathy requires a sophisticated balance on the part of the trauma therapist as s/he simultaneously maintains clear and consistent boundaries, expanded perspective, and highly present, intimate interpersonal connection in the therapeutic relationship with clients. Efforts to avoid or resist the intensity of clients' trauma stories may be counter-productive. Instead, trauma therapists may benefit from accepting their relationship to clients' traumatic material and integrating this aspect of their professional life into their identity. This is in keeping with the literature on PTSD treatment, which guides therapists to help traumatized clients integrate traumatic experiences into their identity and self story, rather than splitting these off (Herman, 1992). Additionally, findings about the important role that supervision and therapist self-care play in mitigating the risks of VT may be particularly helpful to counsellor education programs in their training of students. Similarly these findings could help inform the decision making processes of community agencies with regard to how to best support clinical staff, and also be highly beneficial to individuals in private practice. Based upon these qualitative research findings, I recommend that greater time and attention be dedicated to therapist self-reflection and 178 self-care as crucial components of ethical practice. Moreover, all trauma therapists need to access ongoing, regular supervision and be part of either formal clinical teams or informal peer networks, in order to minimize risk of harm to self or clients. It is imperative to the wellbeing of therapists, clients, and our communities that no trauma therapist should work in isolation. Employing organizations, professional bodies, and independent practitioners share the ethical responsibility to ensure that clinicians have access to and take advantage of these supportive resources. In addition, the findings from this study suggest that it may be helpful to therapists and clients alike to incorporate mindfulness training in trauma therapist education, as well as curriculum that invites (and teaches) trainees how to expand perspective to embrace complexity, tolerate ambiguity, and differentiate between empathic engagement and sympathetic over- identification with clients. Furthermore, I recommend that trauma therapists acknowledge the importance of both their professional and non-professional relationships, and actively nurture these. On a personal note, doing this research has changed how I regard professional colleagues in both my clinical and academic communities. I now regard these individuals as an invaluable and cherished resource; whereas, before I may have been more inclined to take these relationships for granted at times. Finally, there is an ethical obligation to warn trainees about the risks of the working with traumatized clients, as well as to teach them about protective practices. In this way, training could also serve a self-screening function that might prevent future VT and professional attrition. Well-informed trainees who are uncomfortable with ambiguity and/or who experience a significant degree of interpersonal isolation could elect not to pursue this kind of work, or alternatively, actively seek to develop more expansive cognitive and social practices. 179 The current research also raises questions about the value of organizational policy and structure in some community agencies, where programs for traumatized clients (e.g., sexual abuse) are staffed separately from other therapy services. This practice typically does not promote balance within caseloads or among professional tasks. All of the peer-nominated exemplary trauma therapists who participated in the current study had some diversity in their professional responsibilities as well in the type of traumatized clients that they treated. Furthermore, most of the participants' caseloads offered some balance between trauma and non- trauma clients. However, it is not clear why therapists who worked exclusively providing direct service to clients traumatized by a similar type of traumatic stressor did not present for inclusion in the study. Limitations of the Study Because I worked with a small number of co-participants in this research study, we will not be able to make generalized, universalizing claims about the representativeness of their experiences and stories (Miller, 2002). However, my goal in undertaking this research was to participate in an in-depth exploration of the practices that have been sustaining of a small group of therapists who work with traumatized clients. It is my hope that the knowledge gained and shared through this research may be subsequently extended through further research, theory building, and application to practice. Although there was some diversity in the sample, with regard to gender, sexual orientation, religion, and ethnicity, there was little racial diversity. Specifically, people of African and Asian heritage were not represented in the research sample (nor were a number of others). The lack of racial (and to a lesser extent, ethnic) diversity is a limitation of the study. This is perhaps in part a function of the small sample size, which is both a strength and a limitation, inasmuch as it allowed for greater depth, possibly at the expense of 180 greater breadth of knowledge. Although these narrative research findings cannot be generalized beyond the population of the research sample, the knowledge generated in the current study may well be helpful to some other practitioners who work with traumatized clients, both in counselling psychology and related fields. However, future research is needed to explore whether these findings are applicable within other (e.g., non-western) cultural contexts, particularly findings with regard to interpersonal boundaries. In addition, I did not ask participants whether they had a personal history of trauma when gathering demographic information. Consequently, this study does not help elucidate whether a therapist's previous trauma history is a risk factor for or serves as a buffer against VT (Buchanan et al., 2006). Moreover, the narrative research design provides no grounds for comparison between groups, as might a study whose design included a different method, for example involving a "control group." Conclusion I believe this research study contributes to an expanding of the story of VT by providing rich, in-depth descriptions of protective practices that help sustain exemplary trauma therapists in their professional efforts with seriously traumatized clients. Most surprisingly, the study yielded the novel finding that exquisite empathy can be a protective practice for trauma therapists, thereby challenging prior assumptions that empathic engagement puts therapist at increased risk for VT. In addition, the current research provides initial evidence confirming of many recommendations for coping with VT that were previously based on informal observation. My research findings further extend the VT story and contribute to the field by introducing evidence of a new concept, Vicarious PTG, into the discourse of trauma therapy. The research also offers an important contribution through its illumination of the beneficial role that mindfulness practice and related presence can play in the cultivation of personal and professional wellbeing among 181 trauma therapists (as well as that of their clients). Finally, the voices, stories, and lives of the participants in this study contribute to existing knowledge by bringing further into discourse the potential for satisfying spiritual growth and expression of one's spirituality through professional endeavors with traumatized clients. 182 References Arvay, M.J. (2001) Secondary traumatic stress among trauma counsellors: What does the research say? International Journal for the Advancement of Counselling, 23, 283-93. Arvay, M.J. (2002). Talk as action: A narrative approach to action theory. Canadian Journal of Counselling/Revue Canadienne de Counselling, 36(2), 113-120. Arvay, M.J. (2003). Doing reflexivity: A collaborative narrative method. In L. Finlay & B. Gough (Eds.) Reflexivity: A practical guide for researchers in health and social sciences (pp. 163-75). London: Blackwell Press. Arvay, M.J., & Uhlemann, M. (1996). Counsellor stress in the field of trauma: A preliminary study. Canadian Journal of Counselling, 30 (3), 193-210. Bartholomew, K., & Horowitz, L.M. (1991) Attachment styles among young adults: A test of a four category model. Journal of personality and Social Psychology, 61 (2), 226-244. Boscarino, J.A., Adams, R.E., & Figley, C.R, (2005). A prospective study of the effectiveness of employer-sponsored crisis interventions after a major disaster. International Journal of Emergency Mental Health, 7 (1), 9-22. Bruner, J. (1986). Actual minds, possible worlds. Cambridge, MA: Harvard University Press. Bruner, J. (1990). Acts of meaning. Cambridge, MA: Harvard University Press. Bruner, J. (1991). The narrative construction of reality. Critical Inquiry, 18 (1), 1-20. Buchanan, M., Anderson, J.0., Uhlemann, M.R., & Horwitz, E. (2006). Secondary traumatic stress: An investigation of Canadian mental health workers. Traumatology, 12 (4), 1-10. Burr, V. (1995). An introduction to social construction ism. New York: Routledge. 183 Calhoun, L. G., & Tedeschi, R. G. (1998). Posttraumatic growth: Future directions. In R. G. Tedeschi, C. L. Park, & L. G. Calhoun, (Eds.), Posttraumatic growth: Positive changes in the aftermath of crisis (pp. 215-238). Mahwah, NJ: Lawrence Erlbaum Associates. Calhoun, L. G., & Tedeschi, R. G. (1999). Posttraumatic growth: Issues for clinicians. In Facilitating posttraumatic growth: A clinician's guide (pp. 125-141). Mahwah, NJ: Lawrence Erlbaum Associates. Clandinin, D. J., & Connelly, F. M. (2000). Why narrative? In Narrative inquiry: Experience and story in qualitative research (1st ed.) (pp. 1-20). San Francisco: Jossey-Bass Publishers. Collins, S., & Long, A. (2003). Working with the psychological effects of trauma: Consequences for mental health-care workers--a literature review. Journal of Psychiatric and Mental Health Nursing, 10 (4), 417-424. Coster, J. S., & Schwebel, M. (1997). Well-functioning in professional psychologists. Professional Psychology: Research and Practice, 28 (1), 5-13. Egan, G. (2007). The skilled helper, 8th Edition. Pacific Grove, CA: Thomson Brooks/Cole Figley, C. R. (1995). Compassion fatigue as secondary traumatic stress disorder: An overview. In C. R. Figley (Ed.), Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized (pp. 1-20). Levittown, PA: Brunner/Mazel. Figley, C. R. (1999). Compassion fatigue: Toward a new understanding of the costs of caring. In B. H. Stamm (Ed.), Secondary traumatic stress: Self-care issues for clinicians, researchers, and educators (pp. 3-28). Baltimore: The Sidran Press. Figley, C.R. (2002a). Compassion fatigue: Psychotherapists' chronic lack of self care. Journal of Clinical Psychology/In Session, 58 (11), 1433-41. Figley, C.R. (Ed.) (2002b). Treating compassion fatigue. New York: Brunner-Routledge. 184 Figley, C.R. (2004). Some new directions in work-related stress: Theory, research, assessment, prevention, mitigation, iatrogenic treatment effects, and the promotion of resiliency. Keynote address at the Vicarious Trauma in the Workplace Exploratory Workshop at the Peter Wall Institute for Advanced Studies, University of British Columbia, Vancouver, June 21, 2004. Fiske, J. (1989). Understanding popular culture. London: Routledge. Freeman, M. (1997). Why narrative? Hermeneutics, historical understanding, and the significance of stories. Journal of Narrative and Life History, 7 (1-4), 169-176. Foucault, M. (1965). Madness and civilization: A history of insanity in the age of reason. New York: Random House. Foucault, M. (1972). The archaeology of knowledge. New York: Harper & Row. Geanellos, R. (2000). Exploring Ricouer's hermeneutic theory of interpretation as a method of analyzing research texts. Nursing Inquiry, 7, 112-119. Hanh, T.N. (1976). The miracle of mindfulness: A manual on meditation. Boston: Beacon. Harrison, R.L. (2005). Vicarious traumatization of counsellors: A sociolcultural perspective. Paper presented at the 37th International Conference of the International Association for Counseling, Buenos Aires, Argentina, April 21, 2005 Harrison, R.L. (2007, submitted). Counsellor vicarious traumatization as ventrilloquation: Apprenticeship gone awry? Hayes, J.A., Gelso, C.J., Van-Wagoner, S.L., Diemer, R.A. (1991). Managing countertransference: What the experts think. Psychological Reports, 69, 139-148. Herman, J. (1992). Trauma and recovery. New York: Basic Books. 185 Hollis, J. (1994). Under Saturn's shadow: The wounding and healing of men. Toronto: Inner City Books. Janoff-Bulman, R. (1992). Shattered assumptions: Towards a new psychology of trauma. Jennings, L., & Skovholt, T. M. (1999). The cognitive, emotional, and relational characteristics of master therapists. Journal of Counseling Psychology, 46 (1), 3-11. Josselson, R. (2003). Introduction. In R. Josselson, A. Lieblich, & D.P. McAdams (Eds.), Up close and personal: The teaching and learning of narrative research (3-11). Washington, DC: American Psychological Association. Josselson, R. & Lieblich, A. (2003). A framework for narrative research proposals in psychology. In R. Josselson, A. Lieblich, & D.P. McAdams (Eds.), Up close and personal: The teaching and learning of narrative research (259-274). Washington, DC: American Psychological Association. Kabat-Zinn, J. (1994) Wherever you go, there you are: Mindfulness meditation in everyday life. New York: Hyperion. Kvale, S. (1996) InterViews: An introduction to qualitative research interviewing. Thousand Oaks, CA: Sage Publications. Lapadat, J.C., & Lindsay, A.C. (1999). Transcription in research and practice: From standardization of technique to interpretive positionings. Qualitative Inquiry, 5(1), 64-86. Latour, B. (1996). On interobjectivity. Mind, Culture, and Activity, 3 (4), 228-245. Lave, J., & Wenger, E. (1991). Situated learning: Legitimate peripheral participation. Cambridge: Cambridge University Press. Lieblich, A., Tuval-Mashiach, R, & Zilber, T. (1998) Narrative research: Reading, analysis and interpretation. Thousand Oaks, CA: Sage Publications. 186 Linehan, M.M., Cochran, B.N, & Kehrer, C.A. (2001) Dialectal behavior therapy for borderline personality disorder. In D.H. Barlow (Ed). Clinical handbook of psychological disorders, 3rd Edition (pp. 470-522). New York: The Guilford Press. Linley, P. A., Joseph, S., & Loumidis, K. (2005). Trauma work, sense of coherence, and positive and negative changes in therapists. Psychotherapy and Psychosomatics, 74 (3), 185-188. McCann, I. L., & Pearlman, L. A. (1990). Vicarious traumatization: A contextual model for understanding the effects of trauma on helpers. Journal of Traumatic Stress, 3 (1), 131- 149. McLeod, J. (2001). Qualitative research in counselling and psychotherapy. London: Sage Publications. Medeiros, M. E., & Prochaska, J. 0. (1988). Coping strategies that psychotherapists use in working with stressful clients. Professional Psychology: Research and Practice, 19(1), 112-114. Meyers, T.W., & Cornille, T.A. (2002). The trauma of working with traumatized children. In C.R. Figley (Ed.), Treating compassion fatigue (pp. 39-55). New York: Brunner- Routledge Miller, V.M. (2002). Mothers' coping with autistic children: The role of life goals. Unpublished doctoral dissertation proposal, University of British Columbia. Mullenbach, M., & Skovholt, T. (2001). Burnout prevention and self-care strategies of expert practitioners. In The resilient practitioner: Burnout prevention and self-care strategies for counselors, therapists, teachers, and health professionals. Boston, MA: Allyn and Bacon. 187 Myers, D., & Wee, D. (2002) Strategies for managing disaster mental health worker stress. In, C.R. Figley (Ed.), Treating compassion fatigue (pp. 181-211). New York: Brunner- Routledge. O'Leary, V., Alday, C. S., & Ickovics, J. R. (1998). Models of life change and posttraumatic growth. In R. G. Tedeschi, C. L. Park, & L. G. Calhoun (Eds.), Posttraumatic growth: Positive changes in the aftermath of crisis (pp. 127-151). Mahwah, NJ: Lawrence Erlbaum. Pearlman, L. A. (1999). Self-care for trauma therapists: Ameliorating vicarious traumatization. In B. H. Stamm (Ed.), Secondary traumatic stress: Self-care issues for clinicians, researchers, and educators. (pp. 51-64). Baltimore: The Sidran Press. Pearlman, L. A. (2004). Understanding and ameliorating vicarious traumatization: Theory, research, and practice. Keynote address at the Vicarious Trauma in the Workplace Exploratory Workshop at the Peter Wall Institute for Advanced Studies, University of British Columbia, Vancouver, June 21, 2004. Pearlman, L. A., & Mac Ian, P. S. (1995). Vicarious traumatization: An empirical study of the effects of trauma work on trauma therapists. Professional Psychology: Research and Practice, 26 (6), 558-565. Pearlman, L.A. & Saakvitne, K.W. (1995a). Trauma and the therapist: Countertransference and vicarious traumatization in psychotherapy with incest survivors. New York: Norton. Pearlman, L. A., & Saakvitne, K.W. (1995b). Treating therapists with vicarious traumatization and secondary traumatic stress disorders. In C. R. Figley (Ed.), Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized (pp. 150-177). Levittown, PA: Brunner/Mazel. 188 Pearson, H.M. (2004). Exploring group-based life review with family physicians: Constructing narratives of experience and meaning. Unpublished doctoral dissertation, University of British Columbia. Polkinghorne, D. (1988). Narrative knowing and the human sciences. Albany: State University of New York Press. Riessman, C.K. (1993). Narrative analysis. Newbury Park, CA: Sage. Rogers, C.R. (1980). A way of being. Boston: Houghton Mifflin. Saakvitne, K.W., & Pearlman, L.A. (1996). Transforming the pain: A workbook on vicarious traumatization. New York: W. W. Norton & Co, Inc. Sabin-Farrell, R., & Turpin, G. (2003). Vicarious traumatization: implications for the mental health of health workers. Clinical Psychology Review, 23, 449-480. Salston, M.D., & Figley, C.R. (2003). STS effects of working with survivors of criminal victimization. Journal of Traumatic Stress, 16 (2), 167-74. Schore, Alan (2003). Affect regulation and the repair of the self. New York: W.W. Norton Sexton, L. (1999) Vicarious traumatisation of counsellor and effects on their workplaces. British Journal of Guidance & Counselling, 27 (3), 393-403. Shotter, J., & Katz, A.M. (1999). Living moments in dialogical exchanges. Human Systems, 9, 81-93. Siegel, D. J (2007). The Mindful Brain: Reflection and Attunement in the Cultivation of Well- Being. New York: Siegel, D.J. (1999). The developing mind: Toward a neurobiology of interpersonal experience. New York: The Guilford Press. 189 Skovholt, T.M., Jennings, L., & Mullenbach, M. (2004). Portrait of the master therapist: Developmental model of the highly functioning self. In T.M. Skovholt & L. Jennings (Eds.) Master therapists: Exploring expertise in therapy and counseling (pp.125-146). Smythe, W.E., & Murray, M.J.(2000). Owning the story: Ethical considerations in narrative research. Ethics & Behavior, 10 (4), 311-336. Stamm, B. H. (2002). Measuring compassion satisfaction as well as fatigue: Developmental history of the compassion satisfaction and fatigue test. In C. R. Figley (Ed.), Treating compassion fatigue (pp. 107-119). New York: Brunner-Routledge. Stamm, B.H. (2003). Professional Quality of Life: Compassion Fatigue and Satisfaction Subscales, R-III (Pro-QOL) .http://www.isu.edu/-bhstamm. Tedeschi, R. G., & Calhoun, L. G. (1995). Personality characteristics and successful coping. In Trauma and transformation: Growing in the aftermath of suffering (pp. 43-57). Thousand Oaks, CA: Sage. Van-Wagoner, S.L., Gelso, C.J., Hayes, J.A., & Diemer, R.A. (1991). Countertransference and the Reputedly Excellent Therapist. Psychotherapy (28) 3,411-421. Wertsch, J.V. (1991). Voices of the mind: A Sociocultural approach to mediated action. Cambridge, MA: Harvard University Press. Westwood, M.J., Keats, P.A., & Wilensky, P. (2003). Therapeutic Enactment: Integrating individual and group counseling models for change. Journal for Specialists in Group Work, 28 (2), 122-138. White, M., & Epston, D. (1990). Narrative means to therapeutic ends. New York: W.W. Norton & Co. 190 Whittemore, R., Chase, S.K., & Mandle, C.L. (2001). Validity in qualitative research. Qualitative Health Research, 11 (4), 522-537. Yassen, J. (1995). Preventing secondary traumatic stress disorder. In C. R. Figley (Ed.), Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized (pp. 178-208). Levittown, PA: Brunner/Mazel. Appendix Consent Form THE UNIVERSITY OF BRITISH COLUMBIA  Department of Educational and Counselling Psychology, and Special Education The University of British Columbia Faculty of Education 2125 Main Mall Vancouver BC Canada V6T 1Z4 Tel 604-822-8229 Fax 604-822-3302 UBCvw ^ Participant Consent Form "Preventing vicarious traumatization of mental health therapists: Identifying protective practices" Principal Investigator: Dr. Marvin J. Westwood, Professor Department of Educational and Counselling Psychology and Special Education University of British Columbia (604) 822-6457 Co-investigator: Richard L. Harrison, PhD Candidate Counselling Psychology Program Department of Educational and Counselling Psychology and Special Education University of British Columbia (604) xxx-xxxx Purpose: The purpose of the study is to identify practices and attributes that are protective of therapists who might otherwise be at risk for vicarious traumatization or burnout due to the demands of their work with traumatized clients. Richard Harrison is conducting this research as a doctoral dissertation under the supervision of Dr. Marvin Westwood. You have been invited to participate in this study because: a) you have a minimum of ten years' experience working as a therapist or as a supervisor of therapy with traumatized clients; b) you have been nominated as a potential participant by a colleague or peer; c) you self-identify as managing well in your work with traumatized clients; and d) based on your score on the Burn Out and Compassion Fatigue subscales of the Professional Quality of Life: Compassion Fatigue and Satisfaction Subscales, R-III (Pro-QOL) (Stamm, 2003). 191 Study Procedures: This research study consists of two individual interviews, which are described below: 1. The Research Conversation You will participate in an open-ended research interview of approximately 2 hours' duration. The purpose of this research conversation is to explore your understanding of what protects and sustains you in your work with traumatized clients and your ideas about how protective practices might best be engaged in order to mitigate the risks of vicarious traumatization of mental health therapists who work with traumatized clients. The research conversation will be audio tape-recorded and transcribed. You can stop the interview any time you want to. Subsequent to the research conversation, further questions may arise, and with your permission, may require additional telephone contact with the co-investigator. 2. The Follow-up Interview A one-hour follow-up interview will be arranged, at which time the co-investigator will share with you his initial narrative account of your research conversation. At this time, he will ask if there is anything you would like to add or remove from his interpretive account, and he will incorporate any requested revisions. Time Commitment: In total, participation in this research will involve 2-4 hours of your time within a six months time frame. Risks: Although there are no known risks to this study, anytime someone talks about a challenging situation, there may be some risk of stirring up unwanted or unanticipated emotions. The co-investigator will provide all participants in the study with referral information to appropriate professional resources who are qualified to provide additional support as needed. Confidentiality: Your name will not be used in any report of this study and the researchers will be very careful to protect the confidentiality of all participants. Furthermore, if you discuss any of your clients in the research interviews, their confidentiality will also be protected, and no clients will be identified by their real name. Access to all of the research materials, including audiotapes will be restricted to the co-investigator and his supervisor, and will be identified only by codes in place of real names. All of the documents and tapes will be kept in a locked filing cabinet. Computer data records will be password protected. Contact for information about the study: If you have any questions or would like more information about this study, you can contact Dr. Marvin Westwood 604 - 822-6457 or Richard Harrison (604) xxx-xxxx. 192 Contact for concerns about the rights of research subjects: If you have any concerns about your treatment or rights as a research subject, you may contact the Research Subject Information Line in the UBC Office of Research Services at 604- 822-8598. Consent: Your participation in this study is entirely voluntary and you may refuse to participate or withdraw from the study at any time without jeopardy. Your signature below indicates that you have received a copy of this consent form for your own records. Your signature indicates that you consent to participate in this study. I consent to participate in the research project described above. Name:^ Signature: Date:^/2005 I agree to be contacted in the future for research participation in similar studies by the same researcher. initials:^Date:^/2005 193 The University of British Columbia Office of Research Services and Administration Behavioural Research Ethics Board Certificate of Approval PRINCIPAL INVESTIGATOR Westwood, M.J. DEPARTMENT Educ & Couns Psych & Spec Educ NUMBER B05-0876 INSTITUTION(S) WHERE RESEARCH WILL BE CARRIED OUT UBC Campus , CO-INVESTIGATORS: Harrison, Richard, Educ & Couns Psych & Spec Educ SPONSORING AGENCIES TITLE : Preventing Vicarious Traumatization of Mental Health Therapists: Identifying Protective Practices APPROVAL DATE ^, TERM (YEARS)1 DOCUMENTS INCLUDED IN THIS APPROVAL:DCT 2 7 2005 Oct. 2005, Consent form / Sept. 2005, Advertisement /Questionnaires CERTIFICATION: The protocol describing the above-named project has been reviewed by the Committee and the experimental procedures were found to be acceptable on ethical grounds for research involving human subjects. ---....___. C( C21 .— Approval of the Beha ioural Research Ethics Board by one of the following: Dr. Peter Suedfeld, Chair, Dr. Susan Rowley, Associate Chair This Certificate of Approval is valid for the above term provided there is no change in the experimental procedures


Citation Scheme:


Citations by CSL (citeproc-js)

Usage Statistics



Customize your widget with the following options, then copy and paste the code below into the HTML of your page to embed this item in your website.
                            <div id="ubcOpenCollectionsWidgetDisplay">
                            <script id="ubcOpenCollectionsWidget"
                            async >
IIIF logo Our image viewer uses the IIIF 2.0 standard. To load this item in other compatible viewers, use this url:


Related Items