Open Collections

UBC Theses and Dissertations

UBC Theses Logo

UBC Theses and Dissertations

What helps and what hinders in recovery from cumulative trauma Holland, Elizabeth Robin 2011

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

Item Metadata


24-ubc_2011_fall_holland_elizabeth.pdf [ 1.15MB ]
JSON: 24-1.0072294.json
JSON-LD: 24-1.0072294-ld.json
RDF/XML (Pretty): 24-1.0072294-rdf.xml
RDF/JSON: 24-1.0072294-rdf.json
Turtle: 24-1.0072294-turtle.txt
N-Triples: 24-1.0072294-rdf-ntriples.txt
Original Record: 24-1.0072294-source.json
Full Text

Full Text

WHAT HELPS AND WHAT HINDERS IN RECOVERY FROM CUMULATIVE TRAUMA  by Elizabeth Robin Holland Hon. B.A., The University of British Columbia, 2006  A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF  MASTER OF ARTS in The Faculty of Graduate Studies (Counselling Psychology)  THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver) October 2011 © Elizabeth Robin Holland, 2011  Abstract This qualitative research used a Critical Incident Technique to explore the resources women have used in their recovery from cumulative trauma, how they used these resources, and what meaning these resources had for the women who used them. Interviews were conducted with seven women who had experienced traumatic events in both childhood and adulthood, and who had reached a level of recovery from this cumulative trauma. Several findings emerged which have the potential to inform counselling approaches when working with women who have experienced cumulative trauma. One finding was that of new resource categories which may be useful for counsellors to explore in their work with women recovering from cumulative trauma. Another finding in regard to the importance of the meaning of these resources was highlighted, leading to the suggestion that counsellors work on a ‗meaning‘ level when exploring helpful resources with their female clients who are recovering from cumulative trauma.  ii  Preface This research project was granted Full Board approval by the University of British Columbia Behavioural Research Ethics Board on March 11, 2011. (UBC BREB Number H10-01549)  iii  Table of Contents  Abstract..…………………………………………………………………………………………..ii Preface……………………………………………………………………………………………iii Table of Contents….……………………………………….…...…………………………….......iv List of Tables…………………………………………………………………………………… Acknowledgments……………………………………………………………………………….vii Dedication………………………………………………………………………………………..ix 1  Introduction…………………………………………………………………………………...1 1.1 Rationale for the Study……………………………………………………………..4  2  3.  Literature Review……………………………………………………………………………..6 2.1  Resilience and Recovery…………………………………………………………….6  2.2  Resources in Recovery……………………………………………………………..13  Methodology………………………………………………………………………………..17 3.1  Researcher Subjectivity……………………………………………………………17  3.2  Introduction to CIT…………………………………………….…………………..18  3.3  Definition of Terms…………………………………………….…………………..20  3.4  CIT Method…………………………………………………….……………….....23  3.5  Participant Recruitment……………………………………………………………25  3.6  Participants…………………………………………………….…………………...30  3.7  Ethical Considerations……………………………………………………………..31  3.8  Data Collection…………………………………………………………………….32  3.9  Data Analysis………………………………………………………………………34 3.9.1  Credibility/Trustworthiness……………………………………………...34 iv  4. Results………………………………………………………………………………………...41 5. Discussion…………………………………………………………………………………….72 5.1 Similarities to the Reviewed Literature………………………………….………...72 5.1.1  Helping resources……………………………………………….……….72  5.1.2  Hindering resources…………………………………………….………..78  5.2 Differences from the Reviewed Literature…………………………………………80 5.2.1  Helping resources………………………………………………………..80  5.2.2  Hindering resources……………………………………………………...81  5.3 New Findings……………………………………………………………………….83 5.4 Meaning…………………………………………………………………………….87 5.5 Implications for Counselling Psychology………………………………………….89 5.6 Future Research……………………………………………………………………93 References……………………………………………………………………………….............95 Appendices……………………………………………………………………………………...101 Appendix A……………………………………………………………………………..102 Appendix B…………………………………………………………………………..…103 Appendix C…………………………………………………………………………..…104 Appendix D……………………………………………………………………………..107 Appendix E……………………………………………………………………………..109 Appendix F……………………………………………………………………………..111 Appendix G…………………………………………………………………………….114  v  LIST OF TABLES Table 1  Helping and Hindering Category Descriptions…………………………………..44  Table 2  Resource Categories, Number and % of Participants, Resources………………....49  Table 3  Participant Helping and Hindering Resources and Resource Meanings………...53  vi  Acknowledgments I would like to take this opportunity to express my gratitude to the many people who contributed to this research and to my thesis. My research supervisor Dr. Marla Buchanan has been a vital source of support and guidance for me, and this research would never have begun, taken shape, or been completed without her help and encouragement. Just as important was her unwavering belief in me and my abilities, and I cannot thank her enough for all she has given me over the course of this process. Thank you Marla, you are the kind of mentor every graduate student only hopes for, and I consider myself blessed to know you. I would also like to thank my thesis committee: Dr. Marv Westwood, Dr. Norm Amundson, and Dr. Marion Porath. I very much appreciate your time and support, and your feedback has been invaluable to the quality of this research project. I would particularly like to thank Dr. Marv Westwood for his insightful questions, helpful feedback, and guidance throughout this research, and for his encouragement during my application to the Counselling Psychology program. Within the Counselling Psychology program are so many talented and wonderful professors, and I could not begin to thank them properly for all they have taught me during my time in the program. I would like to thank Dr. Colleen Haney and Dr. Chris Shelley in particular, for teaching me so much of what I know about how to be a counsellor. Thank you, as well, to Stephanie Capyk and Jude Marleau of the Victoria Women‘s Sexual Assault Centre, who were kind enough to lend their expertise and support to this project. Special thanks must be given to two UBC students and friends who have contributed more than they know to this study. David Chiu was instrumental in my choice of methodology and research supervisor and, for the latter especially, I will be eternally grateful. Adrienne  vii  Johnson cleared the thesis trail by going first, then graciously came back and helped me find my way along it when she probably never wanted to hear the word ‗thesis‘ again. Thank you both so much. For all the times they made me laugh, reminded me that there is life outside of ampersands and et als, and showed unending patience for conversations about immediacy and cognitive dissonance, thank you to my friends. You all mean more to me than I can say. A big thank you to my colleagues and supervisor in the Sabil lab. Your patience and support while I researched cumulative psychological trauma instead of traumatic brain injury was a big part of my academic success and will not be forgotten. Finally, thank you to my wonderful husband Scott. You encouraged me to take this journey, believed in me every step of the way, and sacrificed and supported me in so many ways that your name should be beside mine on my degree. Your love and encouragement has been the biggest inspiration in my life, and I can‘t thank you enough for always being my biggest cheerleader.  viii  Dedication This research is dedicated to the seven brave and amazing women who shared their stories with me and made this research possible. You have all inspired me with your courage and your determination to reclaim your lives in the wake of your traumatic experiences. Helen Keller said, ―Although the world is full of suffering, it is also full of the overcoming of it.‖ You are all proof of the truth of this, and I am honoured to have been entrusted with the job of telling your stories.  ix  1. Introduction To say that trauma is common in our post-modern world would perhaps be an understatement. Certainly, for most North Americans, our view of the world as a safe place all but ended with World War II. In fact, the first Diagnostic and Statistical Manual of Mental Disorders (DSM) classification detailing the psychological outcome of trauma was created following World War II (Ozer, Best, Lipsey, & Weiss, 2003). For those too young to remember that era (and even for those who are not), the spread of the Internet and other forms of media in the past twenty-five years has resulted in nearly unlimited, uninterrupted access to online videos of everything from bar brawls and car accidents to up-to-date coverage of wars in countries many of us will never visit. The end result of which is that virtually anyone with a computer or a TV can witness others‘ trauma 24 hours a day, seven days a week if they choose to and, thanks to others‘ public consumption of these forms of media, often even if they do not. ‗Trauma‘ is a broad term, and is used in everyday conversation to describe everything from relatively insignificant life events to horrific experiences. However, the DSM-IV TR gives the following definition of psychological trauma: ―the person has been exposed to a traumatic event in which both of the following were present: a) the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury or a threat to the physical integrity of self or others, (and) b) the person‘s response involved intense fear, helplessness or horror‖ (APA, 2004). This is the definition for trauma that is used throughout this study. This research has as its focus trauma, and it began with a concept and a theory. The concept is that of ‗cumulative‘ or repeated trauma, and the theory (Van der Kolk, 1  2002) is the idea that trauma can accumulate within the person who has experienced a traumatic event, and that later trauma can re-trigger earlier trauma in such a way that the person experiences markedly increased difficulty in their daily functioning. What is more, this cumulative trauma may result in more severe psychological symptoms and may be more difficult to overcome than an earlier trauma because the later trauma has ‗piggy-backed‘ on earlier trauma, so to speak. The earlier trauma has, in effect, made it more difficult to recover or heal from the later trauma than it would be if the earlier trauma had not been experienced. The other aspect of this theory is that people, being the adaptive creatures we are, find ways to recover from trauma; we use resources to navigate our way through cumulative trauma and to regain a certain level of functioning in our lives (Murthy, 2007; Roth & Newman, 1992; Schumm, Briggs-Phillips, & Hobfoll, 2006). This post-trauma functioning will likely vary from person to person and may not be at the same level as it was before the most recent trauma, but it exists at a higher level of functioning than was experienced in the midst of trying to come to terms with the most recent trauma. Not everyone does recover well though, if current rates of Posttraumatic Stress Disorder (PTSD) are any indication. In commenting on the effects of trauma, Van der Kolk (2002) stated, ―Previously well-functioning traumatized adults often have a significant decline in their overall functioning‖ (p. 134), and researchers estimate that 5 to 10% of those who experience trauma will go on to develop PTSD (Ozer et al., 2003). Survivors of natural disasters and accidents, including motor vehicle accidents (Blanchard & Hickling, 2004), and sexual or physical abuse trauma (Briere, Kaltman, & Green, 2008; Durand & Barlow, 2003) for instance, may be susceptible to developing PTSD. 2  The psychological trauma literature suggests that trauma is indeed a widespread phenomenon, and that cumulative trauma is a reality. Approximately 50% of American adults have experienced at least one traumatic event in their lives, with roughly 30% having experienced two or more traumas (Breslau, Chilcoat, Kessler, Peterson, & Lucia, 1999; Kessler, Sonnega, Bromet, Hughes & Nelson, 1995). In areas such as South Africa where there are high levels of interpersonal and violent crime, 75% of respondents report having experienced one trauma, and nearly 56% report having experienced multiple traumas (Williams, Williams, Stein, Seedat, Jackson & Moomal, 2007). Further, repeated trauma has been shown to be related to decreased health and lower overall quality of life, as well as high rates of PTSD (Cloitre, Cohen, Edelman & Han, 2001; Cloitre, Scarvalone, & Difede, 1997). Researchers (Briere et al., 2008; Williams et al., 2007) currently suggest that trauma symptomatology reflects an additive or cumulative effect, in that those participants who reported the most traumas were five times as likely to experience psychological distress as those who reported fewer traumas. Increasingly, researchers are finding that the number of traumas a person experiences over their lifetime predicts the severity of post trauma psychological symptoms such as anxiety, depression, and anger, as well issues of substance abuse and a variety of physical conditions (Brewin, Andrews, & Valentine, 2000; Follette, Polusny, Bechtle, & Naugle, 1996; Markoff, Reed, Fallot, Elliott, & Bjelajac, 2005; Ozer, et al., 2003). Also, in a recent study (Ullman, Filipas, Townsend, & Starzynski, 2007), a history of traumatic events and sexual abuse in childhood were both found to contribute to increased severity of PTSD symptoms for women who had been sexually assaulted in adulthood.  3  As well, certain types of trauma have a higher incidence of psychological outcomes. Those who have experienced sexual or physical assault, for instance, have higher rates of PTSD, as do those who have experienced childhood trauma (Lisak & Miller, 2003). In addition, it has been found that, although men are twice as likely to experience trauma as women, women are twice as likely as men to develop PTSD as a result of their traumatic experiences (e.g. Breslau et al., 1999; Brewin et al., 2000). 1.1  Rationale for the Study Given the results of the studies mentioned, in particular the higher likelihood of  psychological outcomes of trauma for women, the goal of this research was to explore how women use resources in an attempt to recover from cumulative trauma, and how these resources help or hinder this recovery. The rationale for this research was to address some of the gaps in the current psychological trauma literature with regard to the lack of knowledge about the resources women use in their recovery. Specifically, the goal for this study was to learn more about the actual resources women access to aid in their recovery, how they use these resources, and what these resources mean to them and their recovery. The mostly quantitative approaches used thus far in studying recovery from psychological trauma seem to have left these questions largely unanswered, and this may be to the detriment of the counselling field. The purpose of this research, therefore, was to explore these questions more deeply, hoping to come away with a greater understanding of how women use resources to aid in their own recovery from trauma, an understanding which has the potential to inform counselling approaches when working with women who have experienced trauma or cumulative trauma, and in that way hopefully contribute to the counselling field. 4  The research questions for this study were: (a) How have women who have experienced cumulative trauma used resources to aid them in recovery from their traumatic experiences? (b) Which of these resources were helpful? (c) Which of these resources were not helpful or even hindered their recovery? (d) What meaning did these resources have for the women who used them? To learn about the specific resources used by these women, a Critical Incident Technique (CIT) approach was used. Because CIT examines discrete experiences, or ‗incidents‘, it was deemed an appropriate methodology to use in discovering the particular incidents—in this case, resources—that led to the desired outcome of recovery from cumulative trauma. CIT‘s focus on behaviour that is ‖outstandingly effective or ineffective‖ (Flanagan, as cited in Bedi, Davis, & Arvay, 2005, p. 73) in reaching goals seemed nearly ideal for the purpose of this research.  5  2 Literature Review In this review the psychological trauma literature as it pertains to the concept of recovery from trauma is discussed. The first focus is a discussion of the concept of ‗recovery‘ itself, and the second is what researchers have learned about various resources and their use in recovery from psychological trauma. 2.1  Resilience and Recovery An important point in discussing recovery from trauma is the distinction between  recovery and resilience. Bonanno (2004) sees these two terms as qualitatively very different, defining resilience as the ability to ―maintain a stable equilibrium‖, which in the case of trauma is reflected in the ability to ―maintain relatively stable, healthy levels of psychological and physical functioning‖ (p. 20). He contrasts this with recovery, which he defines as ―a trajectory in which normal functioning temporarily gives way to threshold or subthreshold psychopathology…usually for a period of at least several months, and then gradually returns to pre-event levels‖ (p. 20). These descriptions characterize resilient people as those with the inner resources or personality characteristics to help them mostly avoid troublesome outcomes from traumatic events, whereas people recovering from trauma have had sudden and jarring changes in their normal functioning—even to the level of psychopathology—before returning to pretrauma levels of functioning. Harvey (1996) puts forth an even more detailed description of recovery, one that takes into account seven different dimensions of the person‘s life. The first is that the person has developed control over their memories of the event, that is, memories are not intruding randomly and uncontrollably, but are recalled at will. Second, feelings and memories of the trauma that had become fragmented become re-joined, so that the person 6  can remember the past with affect or feeling. Third, these feelings no longer overwhelm the person; affect is less intense and can be managed. Fourth, though symptoms may still come up, the person now manages them by predicting their arousal and finding effective ways for coping with them. Fifth, damage to self-esteem and self-cohesion created by the trauma is repaired, so that the person has a more cohesive sense of self. Sixth, trust and attachment issues that arose as a result of the trauma are resolved, in the sense that the person has repaired their ability to be in relationship with others. In the seventh and final aspect of Harvey‘s model of recovery, the person ―assigns new meaning to the trauma, to the self as a trauma survivor, and to the world in which traumatic events occur and recur‖ (p. 13). Though Harvey uses the terms ‗recovery‘ and ‗resilience‘ nearly interchangeably, her emphasis on regaining functioning lost in the aftermath of the trauma more closely fits with that put forth by Bonnano, and fits well with the concept of recovery put forth in this study. Much research has already been done in the area of cumulative trauma, however little seems to be known about how women recover from these traumas. Recently, researchers Schumm, Briggs-Phillips and Hobfoll (2006) conducted a study using a retrospective self-report method, in which 777 inner-city women who had experienced both childhood abuse and rape as adults completed the Childhood Trauma Questionnaire. In this study, the researchers found that high levels of social support predicted lower levels of PTSD severity. However, a survey format with limited response options constrained the participants‘ replies and, therefore, the amount and type of information researchers gained about these women‘s experiences. Resilience and recovery have been studied in populations as diverse as female survivors of war from El Salvador and Guatemala (Radan, 2007), survivors of rape in 7  Pakistan (Haeri, 2007), and American women enrolled in a co-occurring disorders treatment program for abuse and addiction recovery (Stenius, Veysey, Hamilton, & Andersen 2005). However, in these studies either the authors, respectively, did not discuss the resources accessed in the women‘s process of recovery, the women seemed not to have reached a point of recovery (as defined by Bonanno or by Harvey, who is cited by the author of the study), or the women‘s recovery was not well defined or measured. A similar problem is seen in a detailed case study of two women recovering from incest trauma, both of whom were working with a therapist in trauma-focused group psychotherapy (Roth & Newman, 1992). Roth and Newman used transcripts from a structured interview process, conducted multiple times over the course of the therapy to evaluate schema and affect change, and found that for these women, coming to accept their helplessness in the abuse was an important point in their recovery from trauma. Recovery in this study is not well defined, however, and it is unclear in what ways the women had reached recovery. In fact, it could be said that the argument is somewhat tautological in that it assumes recovery is reached when helplessness is acknowledged, then takes that acknowledgement as a sign of recovery. In a recent review (Murthy, 2007) of 28 studies on the effects of mass violence, the research reviewed consistently reflected the valuable role played by psychological support, as well as cultural and religious practices, in decreasing the effects of these traumatic events. Accessing resources such as faith, culture, and psychological support seems to have played an important role in helping those affected by trauma, but it is unclear from this review what specific resources were accessed or, indeed, how they were  8  accessed. The meaning these resources had for the people who accessed them remains equally undefined. In a recent study of resilience and recovery with a population of 164 incarcerated women, Bradley and Davino (2007) found that—in spite of having been the victims of frequent and severe interpersonal violence—many of the women had high levels of resilience, as measured by Harvey‘s (1996) multidimensional model of trauma recovery (discussed previously). Although, similar to Harvey, Bradley and Davino use the terms ‗recovery‘ and ‗resilience‘ in a way that perhaps confuses their meanings, these findings are fascinating and somewhat counterintuitive. Again, though, how the women came to their respective states of recovery remains somewhat unclear. There is no discussion of what the experience of recovery meant for these women, or even what it entailed. In a survey of 276 women in Utah who had been sexually abused as children, Feinauer and Stewart (1996) used the Trauma Symptom Checklist (TSC) to establish respondents‘ current level of functioning, and found that attribution of blame played a large role in trauma symptomatology. Specifically, those women who blamed their attackers for their abuse had lower scores on the TSC. The authors concluded that this attribution style contributed to these women‘s resilience. Because of the large scale and quantitative nature of this study, however, these women‘s recovery experience was not explored beyond the level of symptomatology they experienced. As well, resilience is not recovery and, beyond the attribution of blame, the study does not answer the question of what else these women may have done to facilitate these lower symptom scores, or what meaning their attributions had for them. In a series of complex structural equation modeling studies of the factors contributing to PTSD among 1200 male and 432 female Vietnam veterans, King and 9  colleagues (1999) found that constructs such as ‗hardiness‘ and social support were related to better recovery outcomes. Again, what constituted social support and how it was accessed were not explored. As well, hardiness seems to be related to the construct of resilience discussed above, so while hardiness or resilience may be instrumental in recovery for many, if one is resilient (according to Bonanno‘s definition), there is little recovery to be gained. Also, if resilience is an innate construct, or even the result of having certain social and economic advantages, it is not something that can be taught to clients in a counselling setting. Some researchers (Schnurr et al., 2007) have also found that the cognitive behavioural therapy (CBT) technique of prolonged exposure has been effective in treating PTSD, while other researchers (Bisson, Ehlers, Matthews, Pilling, Richards, & Turner, 2007; Seidler & Wagner, 2006) have found similar efficacy for both traumafocused CBT and Eye Movement Desensitization and Reprocessing (EMDR), and similar results for Prolonged Exposure Therapy and Cognitive-Processing Therapy (Nishith, Resick & Griffin, 2002). With structured interviews and checklists, though, these studies—while contributing valuable information to our understanding of PTSD treatment—have not been able to fully explore what meaning these treatment resources had for the participants. Why do the meanings the resources had for the clients matter? From a personcentred perspective, a fuller understanding of a client‘s experience cannot help but aid us as therapists in gaining a better understanding of the best way to help our clients (Rogers, 1961). Regardless of our approach to counselling, what counsellor would reject the opportunity to understand their client‘s perspective better? Finally, knowing what meaning a resource had for a client could be instrumental in helping another client use 10  the resource effectively. For example, it would be more useful to know that the experience of attending a place of worship was helpful for one client if we know that the meaning she attached to it was that she felt she belonged to a supportive community. If we just assume that ‗going to church/temple/mosque‘ will help all our clients with traumatic experiences, regardless of whether they feel that same sense of belonging in their place of worship, we may not be able to help them as effectively. If we know that the sense of belonging is what was felt to be helpful, we can help other clients find ways to have that experience. A fair amount of research has been done with women in integrated drug, alcohol and trauma recovery groups as well. In studying women with a history of childhood abuse who attended an abuse recovery program, Parker and colleagues (Parker, Fourt, Langmuir, Dalton & Classen, 2007) used a phenomenological approach and a semistructured interview to explore seven group members‘ experience of the abuse recovery group. The authors reported that women in this group setting had found the connection they formed with other women who had experienced similar traumas to be particularly helpful. These women found that sharing their stories with other women, and being accepted rather than judged because of their experiences, was liberating and allowed them to move forward in their journey toward recovery. Similarly, VanDeMark and colleagues (VanDeMark, Brown, Borneman & Williams, 2004) studied 57 women with backgrounds of abuse as well as current addictions. A comprehensive program including cognitive behavioural treatment, a solution-focused approach, employment skills, and addiction treatment was studied, and focus groups and exit interviews with program members allowed the researchers to obtain data on the effectiveness of the program. This seems like an excellent program and it 11  appears to have helped these women move on from addiction, but the study seemed to focus more on addiction recovery than trauma recovery. Findings from studies such as Parker and colleagues‘ and VanDeMark and colleagues‘ are certainly valuable and add to our understanding of the process of recovery from trauma, but may have limited applicability outside of group settings or with those who are not dealing with addiction. For those people seen in a private practice counselling setting, for instance, other routes to recovery may need to be mapped out. As well, these studies have had as their focus populations of women with formal PTSD diagnoses. Many women, however, may never be formally assessed for PTSD even if they once had the associated symptomatology or, if assessed, may present with slightly sub-clinical levels of posttraumatic symptomatology. In exploring post-traumatic growth in a group of 100 women with PTSD who were accessing treatment after physical and sexual assault, Grubaugh and Resick (2007) used the Beck Depression Inventory-II, the Clinician-Administered PTSD Scale, the Structured Clinical Interview for DSM-IV-Patient Version, and the Post Traumatic Growth Inventory. The authors concluded that, although women in their study did report post-trauma psychological growth, similar to other studies in this area, the severity of PTSD symptoms and the amount of post-trauma psychological growth reported by women were largely unrelated. We could conclude from Grubaugh and Resick‘s findings that post-trauma growth could be less, as much, or more for women with lower levels of post-trauma symptomatology as for those with higher levels of post-trauma symptomatology. This is worth mentioning because these might be the very women who walk through the doors of the average counselling practice, and so it would be important for counsellors to have an 12  understanding of what women with lower levels of post-trauma symptomatology may find helpful in their recovery process. 2.2  Resources in Recovery Researchers have already reported some resources as helpful in recovery from  trauma, and although the settings or situations do not all necessarily translate to a counselling setting, these resources do give some insight into what can be helpful in trauma recovery. Researchers using regression analysis in a study of over 600 female sexual abuse survivors (Ullman et al., 2007) found that talking about the trauma with others may be a helpful resource for these women, and better earlier rather than later. In another recent study (Hassouneh-Philips, 2003), using an interpretive phenomenological approach and the participant‘s choice of either an individual or group interview process, the researcher found spirituality was an important coping mechanism for 17 American Muslim women, but that it was also found to create barriers to their safety, by reinforcing values such as remaining with the abusive partner and not seeking any type of assistance to end the abuse. Recovery was not part of this study, as the women were still regularly experiencing the trauma of abuse, but the findings nevertheless point to spirituality as one possible route to coping and recovery. Duma and colleagues (2007) used a grounded theory method to conduct a longitudinal qualitative study, interviewing 10 South African women who had been sexually assaulted, and asking them about their experience of recovery. Many of these women, even in this research design, were able to discuss specific ‗turning points‘ in their journeys toward recovery. Resources such as the support of the community were part of one woman‘s journey toward recovery. She described how their fundraising for her transportation to court gave her the strength and resolve to continue to pursue justice 13  against her attacker, and move toward healing. Another woman used both financial and professional resources to help her in her recovery. She used the financial resources given her to bolster her confidence by buying a new pair of shoes and having her hair done for an appointment with a social worker, and then utilized the resource of the social worker herself, explaining, ―I wanted to look good because I have decided that I am moving on with my life and the social worker was going to help me do that‖ (p. 15). Clearly, even though the format of this research was not geared toward eliciting specific critical incidents in these women‘s recovery from trauma, the women nevertheless told their story in such a way that the researcher felt it was important to highlight these incidents as distinct and identifiable parts of that journey. In a phenomenological study of women‘s recovery from rape, Smith and Kelly (2001) conducted interviews with seven women, and found that reaching out to others for support, reframing the rape to make sense of it, and redefining one‘s sense of self in the aftermath of the rape—including elements of the self that may have been lost and those, such as personal growth, that may have been gained—were all part of the journey to recovery for these women. Both Duma‘s and Smith and Kelly‘s studies contribute greatly to our understanding of what women may go through after sexual assault. However, rape is only one type of trauma, and because these were phenomenological studies, they work from the perspective that, to some extent, the experience these women had captures the essence of what it means to recover from this type of trauma. In fact, it is possible that there are many different routes to recovery, routes that may fall under many more than three broad headings, and this is exactly what the critical incident technique was used to capture in  14  this research – the many and varied ways in which women have used resources in their paths to recovery. One very moving study (Botwin, 2001) was the autobiographical account of a therapist‘s own experience of recovery from trauma. The author discussed how internalizing the love and acceptance she felt from her own therapist allowed her to deal with her abuse, and that she used these qualities to replace the beliefs she had internalized as a result of her abuse. It is perhaps not surprising that therapy can have such a restorative effect, and this is exactly what counsellors hope for. The ‗internalizing‘ process the author describes may be one way in which clients can do this. While it is important to know which evidence-based techniques are most effective in working with traumatized clients, the fact that social support seems to be an important part of at least some women‘s recovery (Schumm et al., 2006) highlights the possibility that, for many women, what happens outside of therapy sessions may be just as important (if not more important) to their healing process. These resources can still be discussed within the counselling setting, however, as options for the client to pursue outside of the sessions. Some resources may not appeal to or work for every client, though, so the more resources a counsellor can offer a client, the better. Some clues to a fuller recovery for those people who do not recover well may be found in knowing how people who have recovered have accomplished this. The literature does not seem to have addressed this problem adequately. As discussed, studies have either been large-scale and quantitative in nature, therefore missing many of the details of these women‘s recovery process, or they have been qualitative but missing important elements around either recovery or meaning, or both. We need to understand what resources these women used, what meaning the resources they accessed had for them, 15  and whether the populations in these studies were representative of many of the women who access private counselling services. As well, these traumas were mostly single experiences, as opposed to multiple traumas. Therein lies the purpose of this research, to understand what has helped women recover from their cumulative trauma; it is hoped that this understanding can help to inform work with traumatized clients in a counselling setting.  16  3 Methodology This was a qualitative study in which the Critical Incident Technique was used to explore the following research questions: (a) How have women who have experienced cumulative trauma used resources to aid them in recovery from their traumatic experiences?; (b) Which of these resources were helpful?; (c) Which were not helpful, or even hindered their recovery?; and (d) What meaning did these resources have for the women who used them? For this type of research question, the most fitting approach was deemed to be a qualitative methodology. Because the intention was to explore these women‘s experiences of moving through and past their trauma via their use of resources, a quantitative methodology did not seem appropriate. Instead, a one-to-one, open-ended Critical Incident Technique interview process (Butterfield, Borgen, Amundson & Maglio, 2005a) was used to access these women‘s experiences, exploring how the women used the resources, and what these resources meant to them. 3.1  Researcher Subjectivity In any qualitative study, the researcher is the medium through which the  participants‘ experience is filtered and then reported. Given that, it may be helpful for readers to be aware of the point of view the researcher brings to this study. As a counsellor, I believe in people‘s innate potential for growth and for the recovery of whatever may have been lost through having experienced traumatic events. I also believe that people are resourceful in facilitating that growth and recovery for themselves, given a little help or encouragement. And I believe that people have the ability to reflect on their own mental, emotional and behavioural processes enough to articulate these insights and processes.  17  With regard to cumulative trauma, I have seen its effects in the clients I have worked with, and in friends and loved ones. I have been witness to those times when the person felt overwhelmed by the mental and emotional fallout of their accumulated experiences of trauma, and when they felt that they were searching in vain for a way to recover their former sense of self and safety. But I have also seen that with encouragement and help these people were often able to recover parts of themselves they had thought lost, to heal aspects of themselves they thought were damaged beyond repair, and to emerge from these experiences changed but not diminished. It is these beliefs and experiences that I bring to my role as researcher in this study. 3.2  Introduction to CIT Authors Butterfield, Borgen, Amundson and Maglio (2005a) provide an excellent  review of the history of John C. Flanagan‘s Critical Incident Technique, detailing the history and current status of CIT in post-modern qualitative research. As both they and Flanagan (1954) explain, CIT was first developed for the selection of American aircrews during World War II, through Flanagan‘s work with the Air Force. Flanagan indicated that he focused on gathering ―factual reports on performance made by competent observers‖ (1954, p. 328) and emphasized that CIT ―obtains a record of specific behaviors from those in the best position to make the necessary observations and evaluations‖ (1954, p. 355). Given this focus on the importance of the observer, it is perhaps not surprising that CIT has since been adapted and applied to counselling psychology research (Butterfield et al., 2005a) where the client is often the observer, and the client‘s perspective is highly valued. Because using CIT in this way is an adaptation of the methodology, Butterfield and colleagues (2005a) also discussed several ways in which 18  we can be faithful to Flanagan‘s original intent in using CIT, while adapting it for less post-positivist research approaches. (These steps are discussed in detail below, under ‗CIT Method‘.) Flanagan (as cited in Bedi, Davis, & Arvay, 2005, p. 73), used the term ‗critical incident‘ to refer to ―extreme behaviour, either outstandingly effective or ineffective with respect to attaining the general aims of the activity‖. His critical incident technique (CIT), with its goal of isolating outstanding or exceptional events, therefore seems a good choice to explore particularly helpful and unhelpful resources that women have used in moving through trauma. The activity in this case is recovery from trauma, and the behaviour refers to how the women have used the resources in their recovery. Because the research method one uses depends on the type of research question one wants to ask, it is important to examine this question closely before deciding on a method. At first blush, a narrative method may seem the most logical choice for exploring women‘s recovery from trauma. If the research questions for this study were focused mainly on the quality of women‘s experience in working through cumulative trauma, a narrative method likely would have been the best choice. If, however, the goal was to specifically ask women who have experienced cumulative trauma what they believe were the most important incidents, or resources, that helped or hindered them in working through their trauma experiences, the Critical Incident Technique seems the better choice of methodology. As much as the narrative of these women‘s experience matters, the literature discussed previously (Duma et al., 2007; Smith & Kelly, 2001) suggests that there do, in fact, exist distinct, discrete experiences that people can point to as having had an impact on their lives. Our lives may be storied, but the plots of these life stories often center on 19  specific events, and we cite these events when we explain the stories of our lives. The above-mentioned phenomenological studies asked women to tell the story of their experience, and the researchers then extracted what they determined were the main themes. In CIT, the researcher asks the participants to talk about what they consider the most important aspects in their recovery, and then the researcher checks the validity of the many emergent themes with these participants during the data analysis phase of the research. One study (Bedi, Davis & Arvay, 2005) of clients‘ perspectives on the aspects of counselling that were important in the formation of a counselling alliance between themselves and their counsellors used CIT to highlight these aspects. If ever there were a study where a narrative approach might be seen as the natural method to use, the ebb and flow of individual counselling would be it, and yet the use of CIT in this study was quite successful. In fact, CIT has been used widely in counselling psychology in the last 57 years (Butterfield, Borgen, Amundson & Maglio, 2005a) including in studying trauma, life transitions, engagement in the workplace, and processes in counselling relationships (Bedi et al.., 2005; Butterfield et al. 2005a; Morley, 2003). 3.3  Definition of Terms In terms of ‗recovery,‘ the intention for this research was that each woman who  participated in this research would define for herself what recovery meant to her. Based on Bonnano (2004) and Harvey‘s (1996) definitions of recovery, however, there was a requirement that she needed to be at a place in her life where she felt that her functioning was for the most part no longer impaired by the trauma, that she was largely ‗symptomfree‘ from the effects of the trauma.  20  To protect potential participants from negative psychological outcomes as a result of participating in this research, in the event that they were not as far along in their recovery process as they felt they were, a telephone screening interview with potential participants was conducted. During this interview, participants were asked about the status of their mental health, and the remaining impact of the traumatic events was assessed using the Impact of Events Scale-Revised (IES-R), a widely-used screening tool for PTSD and trauma related symptomology with good psychometric properties, including reliability and validity (Eid, Larsson, Johnsen, Laberg, Bartone & Carlstedt, 2009; Feinstein, Owen, & Blair, 2002) (see Appendix A). This also helped establish an operationalization of the term ‗recovery‘ and what that looks like in terms of functioning. It is perhaps worth mentioning the reasons for the choice of the term ‗recovery‘ over the more subjective term ‗healing.‘ First, although the researcher was very interested in participants‘ subjective experiences, there was an ethical need to use a screening tool for the protection of potential participants, as mentioned, to establish an objective minimum level of psychological wellness for safe and appropriate participation. This, by necessity, created a less subjective definition for the participants‘ experience of having overcome the effects of their traumatic experiences. Second, the term ‗recovery‘ is widely used in the psychological literature to refer to overcoming the effects of psychological trauma, and its use seemed logical in this study as well. ‗Cumulative trauma‘ itself was also important to define operationally. This research focused on exploring historical psychological trauma—trauma that has its roots in early life—which has been re-triggered, brought to the forefront, or exacerbated by a more recent trauma. The DSM IV-TR definition mentioned previously was used to determine what constituted trauma, with each participant making the decision as to 21  whether or not the definition fit what she had experienced, hence reintroducing more of the participants‘ subjective experience. As discussed previously, childhood trauma often contributes to increased PTSD symptomology that is experienced once further trauma takes place in adolescence or adulthood, so it seemed fitting to include childhood trauma as an inclusionary criterion. The participants were not necessarily aware that the more recent trauma had this triggering function, of course, but as long as participants had at least one childhood trauma and at least one trauma in adulthood, a cumulative effect was thought to be likely. No upper limits were set as to how many traumatic incidents each participant had experienced, but all participants had at least two traumatic incidents in childhood, and most had two or more traumatic incidents in adulthood. ‗Resources‘ was also an important concept to define. The definition given to participants for ‗resources‘ was ―actions, experiences or events you participated in that helped/hindered you in your recovery from cumulative trauma.‖ As much as possible, the interviewer tried not to convey any preconception of what a resource needed to be. The expectation was that participants would likely bring a wealth of experience in their own recovery that could not be categorized or imagined ahead of time. A resource that has ‗helped‘ was loosely defined as any action, experience or event that a participant participated in, which moved her toward recovery, and one that ‗hindered‘ was defined as any action, experience or event that a participant participated in, which moved her away from recovery or caused distress. Resources were also explored for detail and clarification. If a participant reported using a resource such as ‗inner strength‘ or ‗resilience,‘ for example, further questions were asked to determine what exactly that resource was and how the participant used the resource. For example, ―What does inner  22  strength look like?‖ or ―How did you participate in your own resilience?‖ (M. Buchanan, personal communication, November 17, 2009.) Finally, the term ‗critical incidents‘ was defined using Flanagan‘s (1954) definition – ―extreme behaviour, either outstandingly effective or ineffective with respect to attaining the general aims of the activity‖ (as cited in Bedi, Davis, & Arvay, 2005, p. 73) – and a critical incident was operationalized as any resource that, when accessed, moved a participant either toward or away from recovery from trauma. The terms ‗critical incident‘ and ‗resource,‘ within the context of this research, have the same meaning and are used somewhat interchangeably. 3.4  CIT Method Including Flanagan‘s (1954) five procedural steps in CIT is one way we can aim  for fidelity to his method. His five steps are: ―(1) ascertaining the general aims of the activity being studied; (2) making plans and setting specifications; (3) collecting the data; (4) analyzing the data; and (5) interpreting the data and reporting the results‖ (as cited in Butterfield et al.., 2005a, p. 477). (For a detailed description of these steps, see Butterfield et al.., 2009b, pp. 268-278.) In this study, the general aim of the activity being studied was recovery from cumulative trauma, and this recovery was defined first by the participant, and then second by a telephone screening interview in which questions about mental health and functioning were asked, to determine the remaining impact of the traumatic events the participant had experienced. Making plans and setting specifications refers to determining what is being observed, who is doing the observing, how to conduct the interview with the observer, and understanding how the incident affected the activity of interest, in this case the 23  participant‘s recovery from cumulative trauma (Butterfield et al., 2009b). In this study, the participant who has both experienced and recovered from trauma was the observer, and what she was observing were the resources she had accessed in her journey toward recovery. The guidelines for how to conduct both the telephone screening interviews and the in-person research interviews were created by the researcher and her research supervisor. The in-person interview guideline consisted of a series of open-ended questions about the traumatic events the participant had experienced, which resources had helped or hindered her in her recovery from cumulative trauma, how she had used these resources, and what they had meant to her. It is worth mentioning at this point that incorporating questions around ‗meaning‘ is becoming more common in using CIT in counselling psychology (Bradbury-Jones, Sambrook & Irvine 2007; M. Buchanan, personal communication, November 17, 2009; Morley, 2003). In this way, it is possible to access a deeper level of understanding about not just what the incident was, but in what way the incident was critical for the participant. Flanagan (1954) emphasized the importance of gaining a full and precise level of detail about each incident in order to ensure the accuracy and credibility of findings. Because critical incidents in the context of this study are resources that either helped or hindered in recovery from trauma, knowing what meaning they had for the participant becomes an integral part of understanding what it was about the resource that was most helpful or most hindering. For example, in determining the most appropriate category for each resource, the researcher often found it helpful to refer to the meaning of the incident, rather than to just its description. Data collection, analysis and reporting are covered in the respective sections below. 24  3.5  Participant Recruitment In terms of recruitment, permission was obtained where applicable and posters  (see Appendix B) were placed within college and university buildings in both Victoria and Vancouver. The researcher, while still a UBC student, currently lives in Victoria so recruitment began in Victoria and the surrounding areas. Recruitment was later expanded to Vancouver to access a larger population of potential participants. To access as diverse a population as possible, posters were also placed in coffee shops, community centres, community counselling agencies, and on local general posting boards, in both urban and suburban areas of Victoria and Vancouver. Diversity is perhaps less of a concern with qualitative research than with quantitative research, as qualitative research does not have the same issue of generalizability, but the intention with this research was to be able to learn about the experience of women from as many backgrounds as possible. Electronic recruitment was also undertaken, via ‗Craigslist‘, an online classified ad service (see ‗Craigslist advertisement, Appendix B). It was via this online service that the majority of participants were recruited. Potential participants were asked to contact the study‘s researcher by e-mail at a Gmail account ( specifically set up for this study. Although this necessarily limited the possible participants to those who had at least a rudimentary understanding of and access to computers and e-mail, due to safety and privacy concerns the researcher deemed this as the most appropriate communication method to offer for potential participants‘ use in volunteering for the study. Potential participants were asked to reply to the advertisement if they matched the inclusion criteria mentioned, and to include in their e-mail just their name, a telephone number and  25  the best times to be reached. (Once enrolled, participants were given a phone number at which they could reach the researcher.) The first inclusion criterion was the potential participant‘s age. In order to meet the requirement of having experienced trauma both in childhood and adulthood, only adult women were recruited for this study. As well, because the interviewer‘s primary language of communication is English, only women who were reasonably fluent in spoken and written English were recruited. The initial screening interview process was deemed adequate to establish potential participants‘ fluency in English, and any woman able to complete the interview process without the need for translation of the terms used was considered fluent enough in English to participate in the study. Because the poster and advertisement were both in English, this criterion was not explicitly stated, and neither there were any women excluded for reasons of language or communication barriers. The poster and online advertisement also asked women only to contact the researcher if they had recovered from the psychological impact of their traumatic experiences. As mentioned, because women were asked to define recovery for themselves, and recovery is a highly subjective concept, there was the concern that some women would consider themselves recovered while still very much in the midst of a posttraumatic reaction. In fact, part way through the recruitment process, a phrase needed to be added to the poster and advertisement to indicate that the study was not appropriate for women experiencing the symptoms of PTSD. This was necessary because of the number of e-mails received from women with a current PTSD diagnosis. To establish a minimum level of recovery as a criterion for safe and appropriate participation, the Impact of Events Scale-Revised was used to assess potential 26  participants‘ current functioning and trauma-related symptomology (Eid, Larsson, Johnsen, Laberg, Bartone & Carlstedt, 2009; Sterling, 2008), and only those women with a score of 26 or lower on this scale were considered eligible to participate. An error in the IES-R cut-off score application was discovered by the researcher during data analysis, in that a cut-off score of 27 out of a possible 75 on the IES-R was thought to reflect symptoms similar to PTSD. However, this was determined to be the cut-off score for the IES (Creamer, Bell & Failla, 2003; Sterling, 2008), rather than the IES-R. The recommended cut-off score for the IES-R is 33, which is a sum of the item‘s subscale scores on items measuring intrusion, avoidance and hyperarousal, and reflects symptoms similar to PTSD (Creamer, Bell & Failla, 2003). The result of this error is that three potential participants were excluded with scores near the cut-off for the IES, (27, 29 and 32), a more conservative estimate for the safety of their participation due to traumarelated symptomology than would have been the result if the researcher had used the IESR cut-off score of 33. The remaining potential participants would still have been excluded for scores of 35, 35, 38 and 49. For comparison‘s sake, the participants enrolled in the study had scores of 1, 2, 9, 10, 14, 20, and 24, in order from highest to lowest. (The highest possible score on the IES-R is 88, which would result from the participant endorsing ‗extreme' levels of distress caused by the traumatic events in the past 7 days.) Upon indicating an interest in participation in this study, potential participants were e-mailed a copy of the study‘s information sheet and consent form (see Appendix C). Once a time for the telephone interview was agreed upon, the researcher contacted the potential participant. In addition to administering the IES-R, the telephone screening interview was an opportunity to answer any questions the potential participant may have had, and to clarify what was involved with study participation. The first topic covered in 27  these telephone interviews, however, was always the meaning and limitations of confidentiality. The interviewer then asked questions designed to determine that potential participants met the criteria for the study (see Telephone Screening Interview, Appendix D.) In order to determine if potential participants met the criterion for having experienced at least one traumatic event in childhood, they were asked ―In just a few words, please tell me the nature of one trauma you experienced as a child.‖ If the potential participant could describe a traumatic experience in childhood, the researcher then read the DSM IV-TR definition for psychological trauma aloud, and asked the potential participant to indicate if the definition reflected her experience of trauma. If the response was that it did, the researcher asked if the traumatic event had impacted her life for six months or longer at the time. If the response was that it did, the researcher continued with the interview. In order to determine if potential participants met the criterion for having experienced at least one traumatic event in adulthood, they were asked ―In just a few words, please tell me the nature of one trauma you experienced as an adult.‖ If the potential participant could describe a traumatic experience in adulthood, the researcher would again follow this with the DSM IV-TR definition for psychological trauma and ask the potential participant to indicate if the definition reflected her experience of trauma. If the response was that it did, the researcher asked if the traumatic event had impacted her life for six months or longer at the time. If the response was that it did, the researcher continued with the interview. If the potential participant had any confusion about the meaning of any of these questions, the researcher would provide clarification. If the potential participant could not 28  describe at least one traumatic event in childhood and at least one traumatic event in adulthood that the potential participant herself identified as meeting the DSM IV-TR definition for trauma, the researcher explained why the study was not right for her, and then answered any questions the potential participant had about the process or about the study, and ended the interview. If the potential participant met these criteria, however, the interview would continue, and the researcher would ask if the potential participant had any current mental health diagnoses. As mentioned, this question was asked in order to determine not only that the participant was in sufficiently good mental health to be able to safely participate in the study, but because it was conceivable that a potential participant could consider herself recovered from her traumatic experiences while having had a long-standing diagnosis of depression or an anxiety disorder, which would suggest that the potential participant was not yet at the level of recovery hoped for in participation in this study. If there was a current mental health diagnosis that the potential participant felt seriously affected her functioning, the researcher would gently explain why the potential participant was not eligible for participation in the study, answer any questions she might have about the process or the study, and end the interview. If the potential participant had once had a mental health diagnosis that she felt no longer applied or affected her functioning, this was accepted as a sign of subjective recovery, and the interview would continue. After a thorough explanation, the researcher would then administer the IES-R. As mentioned, this is a scale of a person‘s current level of trauma-related symptomology. The IES-R consists of 22 questions which assess how much distress the respondent has experienced within the past seven days with regard to the specific traumatic events, in response to items such as, ―Any reminder brought back 29  feelings about it‖ or ―I tried not to talk about it.‖ The response options range from 0 to 4, where 0 = ‗not at all‘, 1 =‗a little bit‘, 2 = ‗moderately‘, 3 =‗quite a bit‘, and 4 = ‗extremely‘ distressed, in relation to the traumatic events experienced. As mentioned, a score of 33 or higher indicates trauma-related symptomology similar to PTSD, whereas a score of 32 or lower indicates trauma-related symptomology of a lower level than is usually seen in PTSD (Creamer, Bell, & Failla, 2003). A total of 23 women were excluded from participation in the study: four because they did not respond to e-mails to set up the telephone interview, and 18 due to their responses during the telephone screening interview. Of these 18, eight were excluded for current mental health diagnoses, seven for their scores on the IES-R, and three because they had experienced traumatic events in childhood but not in adulthood. 3.6  Participants A total of seven women were enrolled in the study. Their ages ranged from 22 to  54 years old, and they came from the following backgrounds: two participants selfidentified as ‗Canadian‘, one as ‗Middle Eastern‘, one as ‗Caucasian with an Irish background‘, two as simply ‗Caucasian‘, and one as ‗East Indian‘. Their occupations included, in no particular order, ‗administration‘, ‗fund-raiser‘, ‗student and counsellor‘, ‗jeweller‘, ‗student and writer‘, ‗student‘, and ‗office administration/bookkeeper‘. All but one participant listed English as their first language, and one participant listed Arabic as a second language. One participant spoke Punjabi as her first language, Hindi as her second, and English as her third, and was deemed fluent enough in English for participation in the study. The traumas experienced by these participants ranged from childhood experiences of sexual and physical abuse, witnessing abuse, having a parent diagnosed with a mental illness, or being abandoned by a parent, to traumatic experiences 30  in adulthood such as sexual assault, abusive relationships, and a miscarriage, and most participants experienced multiple traumatic events in childhood and adulthood. 3.7  Ethical Considerations Several steps were taken to ensure this research was conducted in an ethical  manner. First, full and ongoing informed consent was obtained from all participants, including a discussion of voluntary participation and the limits of confidentiality. The informed consent and information form was e-mailed to the potential participant at least 24 hours before the telephone screening interview was conducted. The limits of confidentiality were explained at the beginning of the telephone screening interview, and again in person, while going over the consent form at the beginning of the in-person interview. In exploring previous traumas, even in the positive context of recovery in which they were discussed in the in-person interviews, emotional upset is a possible outcome for participants, and so a list of resources was provided to each participant. The list included the contact information for, and an offer to debrief with, one of the counselling faculty at either the University of British Columbia (UBC) or the University of Victoria (UVic) following the interview. The resource list also included the names and contact information for free or low-cost counsellors in the participant‘s area, as well as the number for Crisis Lines and the UBC Research Subject Information Line. The phone numbers for the researcher and research supervisor were also included, as was the e-mail address for the researcher. In addition, the interviews took place in private office spaces for six of the interviews, and in a private study room for the remaining interview. Participants were provided with tissue and bottled water, and the researcher always ended the interview 31  with more general discussion to ensure that the participant was in a more neutral emotional state upon leaving the interview. Participants were asked to inform the researcher if they needed a break, or if they needed to discontinue the interview. No participants asked for a break or to discontinue the interview. One participant displayed a small amount of emotional upset, not over the trauma or the resources accessed, but over a thought related to one of her resource people being geographically distant. No other participants displayed any visible signs of upset. In keeping with both the spirit and the letter of the CPA and CCA Code of Ethics, participants were treated with dignity and respect, and were interviewed with the understanding that, regardless of the researcher‘s training and education, each participant was the expert with regard to her own experience. 3.8  Data Collection Participants were interviewed at either UVic—in a space provided by the  Educational Psychology and Leadership department or, when construction in that space necessitated finding a second space on the UVic campus, in a group meeting room in the UVic library—or at Vancouver General Hospital (VGH), in a research office provided by the researcher‘s workplace. Conducting the interviews in the participants‘ homes would have been an option, but the UVic and VGH locations were considered convenient for all of the participants. Interviews were approximately 1.5 hours in length on average, and the researcher conducted the interviews. In conducting these interviews, the researcher displayed active listening skills and appropriate empathy, but refrained from engaging in a counselling role. The researcher began each interview with a restatement of the meaning and limitations of confidentiality. The researcher then reviewed the informed consent form 32  with the participant, and both the researcher and participant signed and dated the form. One copy was given to the participant, with a list of free and low-cost mental health resources in her area to access following the interview in case she felt the need to debrief or wanted to pursue counselling (see Appendix E). The second copy was retained by the researcher for the participant‘s file. The review of informed consent was followed by a chance for the participant to ask any questions she might have, and for the researcher to further explain the interview process. Also, to protect the participant‘s confidentiality, each participant was asked to choose a pseudonym by which she would be referred to if quoted in the report of the research findings. Participants were also given the option to use their own names if they felt strongly about having their comments attributed to them. All but one participant chose pseudonyms; these names are used throughout this report. Once the participant indicated she had no further questions and was ready to begin, the interviewer would turn on the digital audio recorder and begin the interview. The interview procedure (see Appendix F for interview guideline) involved gathering a small amount of demographic data, and then the following questions about helping resources were asked, in this order: (1) Please tell me, in just a few words, about your experience or experiences of trauma as a child. (2) Please tell me, in just a few words, about your experience or experiences of trauma as an adult. (3) Considering these experiences as a whole, what actions, experiences or events did you participate in that helped in your recovery from this cumulative trauma? (4) ‗How did you participate in these actions, experiences or events?‘ (5) ‗What meaning did these actions, experiences or events have for you?‘ Questions 3 to 5 were then repeated for hindering resources. The researcher then asked if the participant had anything to add or any questions and, if not, the interview was concluded. In addition to the audio recording, the researcher took 33  extensive notes of the participants‘ replies. Interview materials were kept in a locked cabinet in the researcher‘s office, and all electronic forms of data were password protected. 3.9  Data Analysis This portion of the research project owes a particular debt of gratitude to the two  articles by Butterfield and colleagues (2005a; 2009b), as both were an invaluable aid in not only understanding and following Flanagan‘s (1954) five steps to conducting research with CIT, but also in understanding and applying the nine commonly-used credibility checks. 3.9.1  Credibility/Trustworthiness  Researchers (Andersson & Nilsson, 1964, p. 402), have studied CIT‘s reliability and validity, and have come to the conclusion that the information ―collected by this method is both reliable and valid,‖ but Butterfield and colleagues (2005a) point out that in using CIT for more post-positivistic purposes, it may be more useful and appropriate to apply the nine now commonly-used credibility/trustworthiness checks to the research data, in order to lend rigour and trustworthiness to the research findings. Butterfield and colleagues (2009b) list and explain nine checks that are important in using the CIT properly, checks which are widely used, and which aim to increase the credibility of the research findings. These checks include: (1) audiotaping participant interviews to ensure that participants‘ stories are captured accurately and completely, (2) checking for interview fidelity by having an expert in CIT methodology review every third or fourth audiotaped interview to ensure the interviewer is following the methodology correctly, (3) having independent judges review and extract incidents from 25% of the interview transcripts, (4) keeping a log to track the point at which 34  exhaustiveness of the categories is reached (5) calculating participation rates for each category, to ensure each category contains incidents from at least 25% of the participants, (6) having an independent judge place a randomly selected 25% of the critical incidents into the established categories to determine the ‗match rate‘ between the researcher and independent judge; this match rate should be at least 80% to ensure credibility of the categories created, (7) submitting the categorized resources to participants to ensure not only correct placement of resources into categories, but to allow for participants‘ comments and further participation, (8) eliciting expert opinions by submitting the categories and category descriptions to at least two experts in the field, and (9) checking theoretical agreement by stating the study‘s underlying assumptions and by comparing the emerging categories to the relevant scholarly literature (Butterfield et al., 2009b). These steps echo many of the steps Creswell (2008) suggests for qualitative research designs and, in place of the statistical validity measures used in quantitative research designs, are a responsible step toward ensuring the credibility of the more subjective results usually obtained in qualitative research. To ensure the accuracy and credibility of the data resulting from these interviews were maintained, all nine of the recommended credibility checks were undertaken. First, a digital audio recorder was used to record the interviews. This step ensures that the researcher does not have to rely on their note-taking or memory to accurately capture the participants‘ interview responses, thereby ensuring that the participants‘ information is accurate and complete. Transcribing the interviews then ensures that this complete and accurate information is transferred to the data analysis phase. The researcher transcribed the interviews verbatim, extracted the resources and their meanings from each participant‘s transcript, then transferred these resources and 35  meanings to coded index cards and also created a word document of participants‘ responses to aid in the other credibility checks. The second credibility check—checking for interview fidelity by having an expert in CIT review the audiotaped interviews to ensure CIT methodology is being followed – was attempted. Unfortunately, the first expert in CIT who was consulted was unavailable for this check. The research supervisor (who is familiar with CIT) completed this step, however, by reviewing two of the interview transcripts, the first and fifth, to ensure that CIT methodology was followed and that the researcher was not asking leading questions. The research supervisor was satisfied that the interviews were being conducted correctly. (Due to logistical difficulties, the audiotapes themselves could not be transferred to the research supervisor; review of transcripts was deemed the next best option.) The third credibility check—having independent judges review and extract incidents from 25% of the transcripts—was also performed by the research supervisor. She was able to highlight additional incidents that the researcher had missed in the first transcript (simply because it was her first interview and experience with CIT), all of which the researcher agreed with. The research supervisor extracted the same incidents the researcher had highlighted in the second transcript, resulting in a 100% agreement rate for all incidents in the sampled transcripts. The fourth credibility check has to do with tracking and logging when new categories cease to emerge from the incidents. Once all of the participants‘ resources and resource meanings were transferred to index cards for each participant, each participant‘s ‗resource cards‘ were reviewed separately by the researcher. The aim was to sort these resources into theme categories (e.g., ‗counselling‘ or ‗family and friends‘) based on the emergent themes from each participant‘s resources. As each participant‘s resources were 36  reviewed, new categories emerged, until all resources were sorted into categories. These resources and their resulting categories were tracked, so that it would be clear when new categories ceased to emerge from the addition of new resources and exhaustiveness was reached, thus satisfying the fourth credibility check. To address the fifth credibility check, in creating the categories no category was allowed to remain independent if it did not contain resources from at least 25% of the participants. Some categories were combined with other categories or collapsed into broader categories to accomplish this 25% participation rate. Although this did result in the loss of some specificity, it allowed categories to speak to the experience of more participants. For this study, a 25% participation rate was achieved whenever at least two participants‘ resources were placed into a category, so less than a 25% participation rate would result when only one participant‘s resources resulted in the creation of any given category. This level of specificity, while certainly honouring the experience of that participant, would have been less than representative of any of the other participants in the study. The sixth credibility check was addressed by submitting a randomly-selected 25% of the incidents, along with a list and description of the categories that had been created, to a fellow graduate student who served as an independent judge. This independent judge placed 36 (26 helping, 10 hindering) of the 143 incidents into the categories provided. This resulted in a ‗match rate‘ of 88.9%. When there are differences between the researcher‘s placement of the incidents into categories and the independent judge‘s placement, Butterfield et al. (2009b) suggest asking the participant to settle the matter by placing the incident into the correct category, in the next step.  37  The seventh credibility check, as alluded to, was addressed by conducting a second interview with the participants, and asking them to review the categories, the category descriptions, and the placement of the incidents (resources) into the categories. Participants were e-mailed a description of all categories, including those in which they did not have any incidents placed, and a table with their incidents placed into the applicable categories. They were then asked to review the category descriptions and the categorization of their resources. They were also asked to comment on the ‗fit‘ of the resources within the categories, on the categories themselves, and on anything else they noticed missing or which they felt had been incorrectly addressed. In particular, participants were invited to re-categorize any of the resources they felt did not fit in their current categories. For the two participants who had reported the four resources on which the researcher and independent judge did not match with regard to the categorization, the researcher included a paragraph explaining about the independent judge and the difference in opinion with regard to the categorization of responses. Without identifying who had chosen which category for each resource, the four resources were placed into both the category the researcher had chosen for the resource and the category the independent judge had chosen for the resource, and participants were asked to choose which category they felt fit better, or to indicate if they felt a different category was a better fit. (For all four resources, the participants indicated that the category the researcher had chosen for the resource was a better fit for them, and these resources were left in the categories the researcher and participant had chosen.) Participants were also given the option of discussing the resources and categories, or anything else they wished to discuss, including their participation in general, over the phone or by e-mail. The e-mail option was offered because many of the participants had 38  expressed a distinct preference for communicating by e-mail whenever possible. Two of the seven participants chose to discuss the resources, the categories and their participation by phone. The remaining five felt that e-mail was adequate to address their comments, and expressed their interest in the findings and general appreciation for the study and their participation experience. All seven of the participants provided feedback and expressed that they felt their resources had been adequately captured and were wellrepresented by the categories. Participant 1, Nadine, remarked, ―I think you have done an amazing job at identifying the helping and hindering resources, and describing them well.‖ Participant 6, Suman, commented, ―That's perfect. You summed it (up) right‖, and Participant 5, Adrienne, replied ‗I have looked over the information you provided me with and believe that the categories that you placed me in fit very well.‖ During this process, some missing information around meaning of resources was also supplied or clarified by participants. The eighth credibility check, eliciting expert opinions on the categories, was addressed by asking two counsellors at the Victoria Women‘s Sexual Assault Centre (VWSAC) to review the categories and their descriptions, and comment on how the categories fit with what they had seen in their experience in the field of sexual assault trauma. They were also asked if there were any categories they would have expected to see that were not included. Table 2 was also included for their information, to give them a sense of the participation levels for each category. The feedback received was that both counsellors ―reviewed the categories and found them to be very reflective of our experience working with clients.‖ They also included some feedback to do with the wording of the category for intimate partnerships, and based on their suggestion, that category heading was changed from ‗Romantic Relationships‘ to ‗Significant Others.‘ 39  They also commented on the fact that there were no helping resources under ‗Culture.‘ The researcher communicated to them the inductive nature of the process of category formation, with the explanation that there had unfortunately been no helping resources which seemed to fit within the ‗Culture‘ category for the research participants. The ninth and final credibility check consists of explicitly stating the assumptions at the heart of the research project, and checking the emergent themes of the research project against the applicable literature. The first aspect of this credibility check was satisfied by stating the research questions and by articulating the researcher‘s beliefs and experiences with cumulative trauma in the ‗Subjectivity‘ section of this chapter. The second aspect of this credibility check was addressed by comparing the incident categories to the literature discussed in the literature review section of this report. The results of that comparison are found in the discussion section of this report.  40  4 Results All but three of the final incident or resource categories emerged within the first 63 helping and 13 hindering resources, with the final 67 resources contributing two helping categories and one hindering category (see Appendix F). The first nine helping and two hindering categories emerged as a result of the first participant‘s 13 helping and six hindering resources. The second participant contributed seven new helping and two hindering categories with her 23 helping and three hindering resources. The third participant contributed four new helping categories and one new hindering category with her 18 helping and one hindering resources. The fourth participant contributed one new helping and zero new hindering categories with her nine helping and three hindering resources. The fifth participant contributed one new helping category and one new hindering category with her eight helping and three hindering resources. The sixth participant contributed one new helping and zero new hindering categories with her 19 helping and seven hindering resources. Finally, the seventh participant contributed zero new helping and zero new hindering resources with her 22 helping and eight hindering resources (though many of her actual resources were unique to her, they fit well within other categories that had already emerged). Flanagan (1954) advised that, in general, coverage of the area of interest is reached—and no new incidents need to be added—when an additional 100 incidents add only two or three new categories. Butterfield and colleagues (2005a), however, advised that this is just a guideline, and each researcher should adjust the guidelines for recruitment to fit the requirements of their own study. In the case of this study, 67 new incidents added only three new categories, and at that point recruitment stalled. One month later, there were still no new participants forthcoming. Given the particular 41  demands and constraints of completing a research project in a Master of Arts program, recruitment was discontinued at this point. Both the researcher and research supervisor felt that 143 incidents had contributed a satisfactory amount of information to the project, and felt comfortable that the category coverage was adequate with this amount of data. As satisfying as it would have been to have enrolled one or two more participants, it had taken six months to enrol seven participants, and it likely would have taken several months more to amass the prescribed number of incidents; this was not only impractical in this research situation, but would likely not have significantly altered the findings of the research. An expert in CIT who reviewed this study shared that he felt the researcher‘s handling of the incidents and their meanings was so careful and detailed, that not only were the seven participants adequate for the purposes of the research, but that the researcher had contributed to CIT methodology in conducting her research in this manner (N.Amundson, personal communication, October 14, 2011). Table 1 shows the categories that emerged from the participants‘ resources, along with a description of what types of resources or incidents each category contains. These were the category descriptions given to participants and the experts from VWSAC during the credibility checks mentioned in the Methodology section. (An edited version was given to the independent judge during that credibility check, with any leading or potentially biasing examples removed.) The 14 final helping resource categories that emerged were: Family/Friends, Counselling/Workshops, Own Thoughts/Behaviours, Education/Information, Escape/Seeking Safety, Community Support, Significant Others, Financial/Practical Help, Medication/Alternative Treatments, Personal Qualities, Exercise/Nutrition, Religion/Spirituality, Plans/Goals, and Arts/Self-Expression. The six final hindering resource categories that emerged were: Culture, Counselling/Workshops, 42  Family/Friends, Significant Others, Own Thoughts/Behaviours, and Staying in a Harmful Environment. Clearly, there is some overlap in the helping and hindering resource categories; this was due to the fact that some participants found a given resource helpful, while others found that same resource hindering. (Although they are separated here for ease of description, any category that contained both helping and hindering resources was considered one category with contributions from both helping and hindering resources.)  43  Table 1. Helping and Hindering Category Descriptions Helping Resource Categories in General A ‘Helping Resource’ is anything that moves someone toward recovery, whether intentionally or unintentionally. Resources can be almost anything; if it helps someone recover, it can be a resource. The definition given to participants was ‘actions, experiences or events you participated in that helped you recover’. ‘Participation’ was also explored and operationalized (e.g., “What did it look like to be ‘resilient’?” or “How did you participate in that?”), and participants were all asked what the meaning of each resource had been for them. Family/ Friends – This category refers to support mostly, from friends and family members. (It does not include romantic relationships or members of the community that participants do not have a true ‘friend’ relationship with). Talking, hanging out, being taken to appointments, hugs, whatever participants do with a family or friend that does not fit better in another category would fit for this category. Counselling / Workshops – This category refers to any type of mental/emotional/personal development or exploration that happens with a counsellor or trained facilitator, either in individual or group sessions, indoors or out. Own Thoughts/Behaviours – This category refers to thoughts, beliefs, or perspectives that participants have, or things they have done that have moved them toward recovery. This is not so much ‘actions’ (like going to the doctor) as it is the more traditional psychological view of ‘behaviour’, (e.g., standing up for yourself, self-care, getting a good night’s sleep, etc.). Behaviours in this context generally have to do with the self. This is the most general of the categories, but was deemed necessary due to resources that could not be adequately described in other ways. Education/Information – This category refers to any sort of formal or informal learning. School counts, but so do self-directed exploration or learning (e.g., self-help books or videos), or knowledge that others impart to participants. Escape/Seeking Safety – This category refers to anything that takes someone out of harm’s way, or makes them feel safe, even if they are not necessarily safe. The emphasis is on moving away physically, mentally or emotionally from harm. (In this context, disassociation could be considered a resource if the participant felt it contributed to her eventual recovery.) Community Support – This category refers to emotional, mental, or inspirational help from non-family members or people participants do not have a true ‘friend’ relationship with, (e.g., mentors, teachers, etc.) (People who are ‘Facebook friends’ would also more likely count as community members.) Significant Others – This category refers to intimate relationships, either opposite or same-sex, married or not. Financial/Practical Help – This category refers to help or support that is more concrete, (e.g. giving someone a computer, sending them money, etc). Medication/Alternative Treatments – This category refers to treatments provided by doctors, by other health care professionals, or even by oneself. Basically, treatments whose intended effect is an impact on the body or neurology, (e.g. acupuncture, light therapy, medication or massage). Personal Qualities – This category refers to innate qualities, strengths, or abilities that participants have, (e.g., resilience, courage, optimism). 44  Table 1. Helping and Hindering Category Descriptions Exercise/Nutrition – This category refers to anything that moves the body, and anything to do with food/diet. (Forms of exercise that have a spiritual component are usually weighed in favour of ‘spirituality’ if that is the meaning for the participant.) Religion/Spirituality – This category refers to any pursuit that involves worship, getting in touch with one’s ‘center’ or ‘spirit’, or that has a component of providing peace, and that is not specifically associated with seeing a counsellor. Plans/Goals – This category refers to anything the participant wants or hopes to do, plots out, or dreams of, basically. Arts/Self Expression – This category includes artistic pursuits - anything inspirational, creative or that just helps the participant ‘get something out’. It includes creating art, enjoying art (e.g. theatre, literature, films or music) or journaling. Hindering Resources in General These are actions, experiences or events the participant participates in, intentionally or unintentionally, that move them away from recovery. Even if a resource would normally be helpful, if the participant experienced it as hindering, it counts as hindering (e.g., walking could be helpful to some, but hindering for others if the path was a constant reminder of traumatic events). There is some overlap, as some participants found certain resources helpful, while others found the same resources hindering. Culture – This is a category having to do with the negative impact that one’s background can have on one’s recovery from trauma. Although ‘family’ is usually from the same culture, if the hindering factor is more about traditionally held cultural views, it’s considered more ‘culture’ than it is ‘family’. Counselling/Workshops – This aspect of this category refers to any counselling experience that has had a negative impact on someone’s recovery, or even just on their sense of self, whether because of the counsellor’s actions or the participant’s. Family/ Friends – This aspect of this category refers to family members or friends who - intentionally or unintentionally - somehow negatively affect the participant’s progress toward recovery, whether through direct actions or just through a lack of support. Significant Others – This aspect of this category refers to those intimate relationships that have had a negative effect on the participant’s progress toward recovery, whether because of the partner’s actions, the participant’s actions or just the participant’s experience in the relationship. Opposite or same-sex, married or not. Own Thoughts/Behaviours – This aspect of this category refers to the participant’s thoughts, beliefs, views, or behaviours that have kept them from moving toward recovery. (Thinking “I’m not worth anything” would count, and so would self-harm.) Again, this is behaviour, rather than ‘action. ‘Actions’ that better fit another category (e.g., staying in a harmful environment) would be put in that category. Behaviours in this context generally have to do with the self. Staying in a Harmful Environment – This category refers to those times when a participant could not (or for various reasons chose not to) leave an environment that was harmful, that triggered her, that was a reminder of traumatic events, or that just somehow hindered her progress toward recovery.  45  Table 2 shows an overview of the categories, the number and percentage of helping and hindering resources in each category, and the number and percentage of participants whose resources were placed into each category. The Family/Friends category is the largest and contains 16 helping resources from all seven (100%) of the participants, which amounts to 14.3% of the helping resources. This category also contains six hindering resources from three (42.9%) of the seven participants, which amounts to 19.4 % of the hindering resources. The Family/Friends category makes up 22 (15.4%) of the total of 143 resources. The Own Thoughts/Behaviours category is the second largest and contains 17 helping resources from six (85.7%) of the seven participants, which amounts to 15.1% of the helping resources. This category also contains 13 hindering resources from four (57.1%) of the seven participants, which amounts to 41.9% of the hindering resources. The Own Thoughts/Behaviours category makes up 30 (21%) of the total of 143 resources. The Counselling/Workshops category contains 10 helping resources from five (71.4%) of the seven participants, which amounts to 8.9% of the helping resources. This category also contains one hindering resource from one (14.3%) of the seven participants, which amounts to 3.2% of the hindering resources. The Counselling/Workshop category makes up 11 (7.7%) of the total of 143 resources. The Education/Information category also contains 10 helping resources from five (71.4%) of the 7 participants, which amounts to 8.9% of the helping resources. The Education/Information category contains no hindering resources, and so it makes up 10 (7%) of the total of 143 resources. The Escape/Seeking Safety category contains 12 helping resources from four (57.1%) of the seven participants, which amounts to 10.7% 46  of the helping resources. The Escape/Seeking Safety category contains no hindering resources, and so it makes up 12 (8.4%) of the total of 143 resources. The Community Support, Personal Qualities, Exercise/Nutrition, and Arts/Self Expression categories each contain six helping resources from four (57.1%) of the seven participants, which amounts to 5.4% of the helping resources for each category. Neither do the Community Support, Personal Qualities, Exercise/Nutrition or Arts/Self Expression categories contain any hindering resources, and so they each make up six (4.2%) of the total of 143 resources. The Religion/Spirituality category contains five helping resource from four (57.1%) of the seven participants, which amounts to 4.5 % of the helping resources. The Religion/Spirituality category contains no hindering resources, and so it makes up five (3.5%) of the total of 143 resources. The Medication/Alternative Treatments category contains six helping resources, but from three (42.9%) of the seven participants, which amounts to 5.4% of the helping resources. The Medication/Alternative Treatments category contains no hindering resources, and so it makes up six (4.2%) of the total of 143 resources. The Financial/Practical Help and Plans/Goals categories each contain five helping incidents from three (42.9%) of the seven participants, which each amounts to 4.5% of the helping resources. The Financial/Practical Help and Plans/Goals categories contain no hindering resources, and so they each make up five (3.5%) of the total of 143 resources. The Significant Others category contains two helping resources from two (28.6%) of the seven participants, which amounts to 1.8% of the helping incidents. This category contains four hindering resources from four (57.1%) of the seven participants, which  47  amounts to 12.9% of the hindering resources. The Significant Others category makes up six (4.2%) of the total of 143 resources. The Staying in a Harmful Environment category contains no helping resources, but contains four hindering resources from two (28.6%) of the seven participants, which amounts to 12.9% of the hindering resources, and so it makes up four (2.8%) of the total of 143 resources. Finally, the Culture category contains no helping resources, but contains three hindering resources from two (28.6%) of the seven participants, which amounts to 9.7% of the hindering resources, and so it makes up three (2.1%) of the total of 143 resources. Each of these categories, therefore, has a participation rate of at least 25% of the research participants.  48  Table 2 Resource Categories, Number and % of Participants, Number and % of Resources Resource Categories Number Helping % of Number Hindering (and %) of Resources Helping (and %) of Resources Participants Resources Participants  % of Hindering Resources  7/7 (100%)  16  14.3%  3/7 (42.9%)  6  19.4%  6/7 (85.7%)  17  15.1%  4/7 (57.1%)  13  41.9%  5/7 (71.4%)  10  8.9%  1/7 (14.3%)  1  3.2.%  5/7 (71.4%)  10  8.9%  _  _  _  4/7 (57.1%)  12  10.7%  _  _  _  4/7 (57.1%)  6  5.4%  _  _  _  4/7 (57.1%)  6  5.4%  _  _  _  4/7 (57.1%)  6  5.4%  _  _  _  4/7 (57.1%)  6  5.4%  _  _  _  4/7 (57.1%)  5  4.5%  _  _  _  3/7 (42.9%)  6  5.4%  _  _  _  3/7 (42.9%)  5  4.5%  _  _  _  3/7 (42.9%)  5  4.5%  _  _  _  2/7 (28.6%)  2  1.8%  4/7 (57.1%)  4  12.9%  _  _  _  2/7 (28.6%)  4  12.9%  _  _  _  2/7 (28.6%)  3  9.7%  N/A  112  100%  N/A  31  100%  Family/ Friends Own Thoughts/Behaviours Counselling / Workshops Education/Information Escape/Seeking Safety Community Support Personal Qualities Exercise/Nutrition Arts/Self Expression Religion/Spirituality Medication/Alternative Treatments Financial/Practical Help Plans/Goals Significant Others Staying in a harmful environment Culture TOTALS  49  Table 3 is a compilation of all of the participants‘ listed resources, and the meanings these resources had for them, placed into the applicable categories. Not all participants have resources in all categories, but this table provides a convenient way to view the information from the previous table as it applies to each participant. As one reads through each participant‘s listed resources, a clearer picture emerges of the participant‘s recovery process. For example, Participant 1, Nadine, accessed a total of 12 helping resources over a broad range of seven categories, including Family/Friends, Counselling/Workshops, Own Thoughts/Behaviours, Education/Information, Community Support, Personal Qualities and Plans/Goals. She encountered six hindering resources in only two categories, however: Family/Friends and Culture. Participant 2, Sher, accessed 23 helping resources over a similarly broad range of eight categories, including Family/Friends, Counselling/Workshops, Own Thoughts/Behaviours, Education/Information, Financial/Practical Help, Medication/Alternative Treatments and Exercise/Nutrition, however just over a third of her helping resources centred around one category, Escape/Seeking Safety. Interestingly, all three of the hindering resources this participant lists are centred around Own Thoughts/Behaviours. Participant 3, Diane, accessed 18 resources over an even broader range of nine categories, including Family/Friends, Counselling/Workshops, Own Thoughts/Behaviours, Education/Information, Medication/Alternative Treatments, Exercise/Nutrition, Religion/Spirituality, and Arts/Self Expression. The one hindering resource she encountered was in the area of Significant Others. Participant 4, Carly, accessed nine resources over a smaller range of five categories, including Family/Friends, Counselling/Workshops, Own 50  Thoughts/Behaviours, Community and Personal Qualities. Similarly to Participant 3, she also encountered a hindering resource under the category of Significant Others, and similarly to Participant 2, she encountered hindering as well as helping resources under the category of Own Thoughts/Behaviours, with two hindering resources in that category. Participant 5, Adrienne, accessed eight resources, with nearly an equal number of resources in each of her eight categories, which included Family/Friends, Counselling/Workshops, Community Support, Religion/Spirituality, Arts/Self Expression, Escape/Seeking Safety and Exercise/Nutrition, with one resource in each category but two in Exercise/Nutrition. She also encountered one hindering resource under each of the three categories of Staying in a Harmful Environment, Family/Friends, and Significant Others. Participant 6, Suman, accessed her 19 resources over a broad range of 10 categories, including Friends/Family, Own Thoughts/Behaviours, Education/Information, Personal Qualities, Plans/Goals, Religion/Spirituality, Significant Others, Arts/Self Expression, Escape/Seeking Safety, and Financial/Practical Help. She encountered seven hindering resources, under the three categories of Culture, Own Thoughts/Behaviours, and Staying in a Harmful Environment. Finally, Participant 7, Jane, accessed the largest number of total resources and resource categories, with 22 helping resources spread out over 13 of the 14 helping categories, including Family/Friends, Own Thoughts/Behaviours, Education/Information, Community Support, Personal Qualities, Plans/Goals, Escape/Seeking Safety, Exercise/Nutrition, Medication/Alternative Treatments, Religion/Spirituality, Significant Others, Arts/Self Expression, and Financial/Practical Help. The eight hindering resources  51  she encountered were centred around Own Thoughts/Behaviours, with one resource in each of three other categories: Family/Friends, Counselling, and Significant Others.  52  Table 3. Participant Helping and Hindering Resources and Resource Meanings Helping Resources  Participant 1 (Nadine)  Family/Friends  (1) ―Talking to... a lot of my girlfriends.‖ The meaning – ―I wasn‘t left dealing with this on my own.‖ (2) ―Knowing in my own social circle...who could be there to support was helpful that they supported me each in their different ways.‖ The meaning – ―The circle of close friends I have... (is) sort of a recreated family...and...I got different sources of support and different kinds of support.‖  Counselling/ Workshops  Own Thoughts/ Behaviours  Education/ Information  Community Support  (3) ―Reaching out to other males.‖ The meaning – ―Validation from them for my feelings.‖ ―Working through counselling... gave me a lot of the strength back that I thought I had lost.‖ The meaning – ―There was support in place for me...and...these are issues that...other people have experienced and that they‘re taken seriously.‖ (1) ―The biggest part for me was...looking at the aspects of what was lost, and gained.‖ The meaning – ―Being able to reflect back and notice everything that (I‘ve) gained, as an adult.‖ (2) ―Redefining ...what makes me a strong woman and what makes me strong in general.‖ The meaning – ―I became aware that moving forward in my healing process was a sign of strength and recovery.‖ (1) ―When my mom was...hospitalized...the psychiatrist met with my entire family and told us what was going on for my mom.‖ The meaning – ―Really understand(ing) the diagnosis better...rather than (thinking) my mom (was) neglecting me or not loving me.‖ (2) ―Information seeking was a big one for me....asking friends if they‘ve ever experienced something similar...(going) to the library...using (the internet)... to search psychology.‖ The meaning – ―It meant a lot that I could take…one hour or two hours…(to) pursue an interest or…even a need at that time to get more information about what was happening. It was a time that was sacred...this is... my own time and I could... exercise some power to I want to...spend (that) time.‖ (1) ―There were adults in my life that took my concerns seriously and actually heard me.‖ The meaning – ―That was...something that I always felt was with me.‖ (2) ―There‘s been a few...mentors in my life as the community...who fuelled (my) interest in psychology.‖ The meaning – ―It... meant that... there was an opportunity for me to...learn and grow in some way...transcend beyond just basic needs and...look at something that was intellectually stimulating for me.‖  53  Helping Resources  Participant 1 (Nadine)  Personal Qualities  ―I think all throughout my life I‘ve always...been terms of reaching out for help.‖ The meaning – ―I was committed to my own healing...I knew what I needed to do and I was able to...move forward with that.‖ ―Having something certain and something routine to look forward to.‖ The meaning – ―It just meant that there was some consistency my life. There were things that...weren‘t lost because of the trauma.  Plans/Goals  Hindering Resources Culture  Family/Friends  Participant 1 (Nadine) (1) ―My interest in psychology and wanting to... enter into the helping profession...was never really encouraged by my family because issues like that.‖ The meaning – ―(A) relative lack of support from my family...I did need that through my friends and professionals.‖ (2) ―Because of my ethnic background it was really seen as shameful to go and talk to the school counsellor about issues at home.‖ The meaning – ―There was a rule that I had broken in the worst way...that you don‘t talk about what‘s going on at home. So that...prevented any other subsequent...going in to see the counsellor.‖ (1) (After going the school counsellor) ―A social worker was sent to assess the situation at parents sort of questioned me...what I said...why did I go talk to them.‖ The meaning – ―My family is feeling embarrassed and humiliated and shamed and it‘s all my fault...that (I had a) responsibility to... rectify how my parents were perceived.‖ (2) ―Not really feeling supported... by my dad... able to openly talk about what it‘s like...dealing with a parent who‘s diagnosed with a mental illness.‖ The meaning – ―I had to remain silent for my family‘s sake. I had no other choice. My parent‘s needs outweighed my own.‖ (3) ―With the sexual assault, because of the perpetrator‘s...connections... to my family...I wasn‘t necessarily 100% supported in terms of seeking counselling.‖ The meaning - ―I guess it meant that don‘ about these...issues.‖ (4) ―Another role that was put upon me too (by my father) was...being the oldest of 3 kids...sort of a pseudo-parent.‖ The meaning – ―You have to be an adult now and...take care of others and you yourself...don‘t count anymore.‖  54  Helping Resources  Participant 2 (Sher)  Family/Friends  ―When I left (my marriage) the first thing I (did) was go back to Ontario and see my mom.‖ The meaning – ―For years I felt I only had mom. She was my sounding-board and resource.‖  Counselling/ Workshops  (1) ―Virginia Satir family reconstruction...that was huge, absolutely huge.‖ The meaning – ―I learned that I was protecting my mom...taking mom off that pedestal, and not protecting her, and looking at her as another human being.‖ (2) ―I started counselling.‖ The meaning – ―I learned about...being in touch with my feelings.‖ (3) ―I have done a lot of work at the Haven.‖ (A personal development centre.) The meaning – ―I found my heart at the Haven.‖ (4) ―I‘ve done a lot of Gestalt work...I‘ve done a lot of bodywork.‖ The meaning – ―I knew inside of me somewhere...that there was more in life than what I was getting.‖  Own Thoughts/ Behaviours  (1) ―I started doing jigsaw puzzles.‖ The meaning – ―To get my head focused, because I knew it had been played with.‖ (2) ―I bought a whole slew of (wool) and I made a bomber jacket.‖ The meaning – ―Focusing...I can do this...It‘s almost like there was a part of me that knew what to do.‖ (3) ―I started making Christmas wreaths and garlands.‖ The meaning – ―I was just focusing.‖  Education/ Information  (1) ―I applied and was accepted to get my MBA.‖ The meaning – ―I was doing what I needed to do to get better...because I knew that this was not where I was going to be.‖ (2) ―I got student loans and went back to school.‖ The meaning – ―I just learnt about my creativity.‖  55  Helping Resources  Participant 2 (Sher)  Escape/Seeking Safety (1) ―I dissociated big time.‖ The meaning – ―Looking for quietness, although quietness bothers me.‖ (2) ―Getting married.‖ The meaning – ―I got married to create a safe place for my sister...and keeping (myself safe).‖ (3) ―When I was a child I used to hide in my closet and read a book.‖ The meaning – ―(It) was an escape for me.‖ (4) ―I‘m a huge tracker of things...I always had to know where everybody was.‖ The meaning – ―To make it safe so I could survive.‖ (5) ―I always...hung around with people who...were in the public eye.‖ The meaning – ―If I could be with them I‘d be safe or something.‖ (6) ―I found this place (to live but) the guy...decided he wanted sexual favours from me. I moved out...and I slept in my vehicle for about a month...until I could find a place.‖ The meaning – ―My car was a very safe place for me, I felt safe and secure there.‖ (7) ―I created a safe house for myself...I lived in a house where nobody would ever find me.‖ The meaning –―I had looked into (government run) safe houses, but I had always taken care of myself, so I created my own. I was taking care of myself.‖  Financial/Practical Help  Medication/ Alternative Treatments  Exercise/Nutrition  (8) ―Then I literally ran.‖ The meaning – ―That‘s one of the ways I took care of myself... I just disappeared. Disassociating family.‖ (1) ―A friend of a friend of a friend...let me stay with her for a couple of months.‖ The meaning – ―It was my first step in being in a new place and starting a new career and a new life.‖ (2) ―I... applied for welfare...I got two cheques from them.‖ The meaning – ―It taught me that getting help can be ugly, it‘s better to take care of yourself.‖ (1) ―I realized that doing massages and stuff like that was good for me.‖ The meaning – ―I was pining for touch, human contact. Massage gave me this and helped to move my energy blocks.‖ (2) ―I‘ve had acupuncture.‖ The meaning – ―The first time was in my head to help me focus on a visualization in a more positive way... this too helps to move energy blocks.‖ ―The best thing for me is went to the gym every day...and then I walked whenever I could.‖ The meaning – ―It gets the endorphins going.‖  56  Hindering Resources  Participant 2 (Sher)  Own Thoughts/ Behaviours  (1) ―I always made things big...I have a hard time...making things simple. I always had to make sure my nails were perfect.‖ The meaning – ―Showing people that I can...take care of myself...I don‘t need anybody else. (And) with me...making everything perfect then you‘ll like me.‖ (2) ―My fear of being known. I would not tell you things. I would be too nice...(pretending) ‗everything‘s fine.‖ The meaning – ―I wanna be known but I‘m really afraid that once you get to know me you won‘t like me... (and) if you don‘t know me...there‘s no way you could hurt me.‖ (3) ―My self-worth was very low...I didn‘t have anything to sit on except for a real cheap chair. I just didn‘t allow myself that. I slept on the floor.‖ The meaning – ―That kept me small and safe...that kept me in my ‗victim mode‘. While at the same time saying ‗I don‘t wanna be a victim.‖  57  Helping Resources Family/Friends  Participant 3 (Diane) (1) ―It‘s important to have people in your life that are…pushing and encouraging you, and my mom was key to all of my healing…she would take me where I needed to go, and set up appointments if I needed that.‖ The meaning – ―She‘s been my lifeline. I don‘t feel like I could have done it without her, which means I might not be here today…so it means my life.‖ (2) ―Family, friends…mostly discussions and then sharing their experiences and what helped. One…introduced me to the tapes that I listened to.‖ The meaning – ―They‘ve always been so unconditionally loving. And because I‘m open with where I‘m at…they‘ve been able to…be open back with me and to share whatever they have to give. Sometimes it‘s just one statement that changes my thinking.‖  Counselling/ Workshops  (3) ―My daughter as well, she‘s been my angel.‖ The meaning – ―Unconditional love would probably be the main thing…and I need to be well for her. She distracted me from being in my own head. Focusing on her.‖ (1) ―Counselling…talk therapy has been, I would say the biggest or one of the biggest.‖ The meaning – ―Quite often you don‘t want to burden people in your life. I can share every dirty detail, not be judged, be listened to and then have positive feedback and suggestions.‖ (2) ‗‘‘Outward Bound Trips for Women of Courage‘. It was a 7 day long hiking trip in the mountains. It was about survival and teamwork.‖ The meaning – ―I felt like what I got out of it was some wonderful friendships. A feeling that I can do incredible things and survive on my own.‖  Own Thoughts/ Behaviours  (3) ―Various workshops on anxiety and depression.‖ The meaning – ―It made me feel and realize that I wasn‘t alone in this. And that there wasn‘t a need for shame. (And) to hear of different healing techniques.‖ (1) ―Being around children…I would make a point of going to my daughter‘s daycare…and it completely improved my moods.‖ The meaning – ―It‘s unconditional acceptance. It‘s the innocence, and the joy, and the expression, and I get to be present in that…they have always brought me joy.‖ (2) ―Just changing your…behaviours, which could then change your thoughts.‖ The meaning – ―You just have to do something different, your thoughts will follow.‖  58  Helping Resources Education/ Information  Medication/ Alternative Treatments  Exercise/Nutrition  Religion/ Spirituality  Participant 3 (Diane) (1) ―I listened to…these tapes…‘Attacking Anxiety and Depression‘. There was a professional talking to people who have been through traumatic experiences…and how they have gotten through.‖ The meaning – ―Feeling like I‘m not alone in what I‘m going through. And teaching me what‘s happening in my body physically to trigger that anxiety or panic attack. So…I know I‘m not going crazy or having a heart attack.‖ (2) ―Self-help books…reading and learning…new tools and how to cope and how to think positively.‖ The meaning – ―Information, learning tools, learning where these feelings are coming from…how the cycle goes. I just…couldn‘t possibly have gotten (the information) anywhere else.‖ (1) ―Medication as well…it just wouldn‘t be my first choice.‖ The meaning – ―It takes the edge off, but…medication doesn‘t do the work for you. So, it sort of numbs you so you‘re not in such a critical state.‖ (2) ―I went to acupuncture.‖ The meaning – ―I was seeing a really good friend of mine…who does acupuncture, and it was a mixture of her…love and energy and caring for me as a whole…with the acupuncture treatments.‖ (1) ―Exercise…walk(ing) outside.‖ The meaning – ―Exercise does the same thing that medication does with improving your mood…but it also…helped me feel…more positive about my self-image.‖ (2) ―Diet, good good diet. I think that‘s really important.‖ The meaning – ―It just helps you to feel more clear and well, with energy.‖ (1) ―Nature…has been my church, and many times I‘ve sat…by the ocean and feel healing energy coming from the ocean.‖ The meaning – ―It makes me feel like no matter what is going on, I am so blessed to be amongst this beauty. And that these things I‘m worrying about…I‘m giving them too much importance.‖ (2) ―I started going to Kundalini yoga…classes.‖ The meaning – ―Yoga has brought peace and a feeling of unity with…others and the planet, and taught me to breathe. A group scenario where you‘re sharing together is…pretty important.‖  59  Helping Resources Arts/Self Expression  Participant 3 (Diane) (1) ―Art – that‘s huge! I When I was younger, I started drawing when I hit my low points…and as an adult I started painting.‖ The meaning – ―It‘s letting go of what other people are gonna think and being able to express your creativity freely. And, not only did it help me out of a negative place, but…it turned it into something of beauty.‖ (2) ―Music always helps...listening to music.‖ The meaning – ―When I found that I couldn‘t find the words or express what I was feeling, I could always find music that…would pull it out of me. Again, feeling not alone, that…music (is) showing me that somebody else has felt this as well.‖  Hindering Resources  Participant 3 (Diane)  Significant Others  ―Being in a relationship with a man…at all…triggers all of my feelings of my traumatic experiences…triggers my insecurities.‖ The meaning – ―Not feeling cared for at all, or supported. A feeling of rejection. I would start to feel sort of angry with myself for letting that happen, and start to feel ashamed that…I couldn‘t be my strong self with these other people.‖  60  Helping Resources Family/Friends  Participant 4 (Carly) (1) ―My mother was assaulted when she was a teenager, and…talking (to her) about her experiences…was important for me.‖ The meaning – ―I think realizing that…sex assault and partner assault, and scary experiences with strangers happens to a lot of women, and it doesn‘t have to define you. And it doesn‘t have to be something you carry around with you for the rest of your life.‖ (2) ―My best friend. Just talking to her…about what had happened…and what a healthy relationship should be.‖ The meaning – ―It was very personalized feedback.‖  Counselling/ Workshops  Own Thoughts/ Behaviours  (3) ―Being around gentle men, seeking out gentle men was really important to me…to have that kind of support from men.‖ The meaning – ―That was about making sure I had a positive outlook and hope, that…I wouldn‘t just create a safe space for myself based on gender. That I would create a safe space for myself by finding good people.‖ (1) ―I went through some counselling in my early twenties. Dealing with my family. That was a really important experience for understanding what was okay and what was not, when men experience anger.‖ The meaning – ―It was a safe space…to kinda get to really fall apart and think about it and have some support while I did that ‗cause it was just too scary to do it alone. And to have someone give me a framework for how I could think about moving forward. And empathy and unconditional positive regard…(is) really important.‖ (1) ―Redefining myself in relation to men. I would get angry at people who weren‘t the ones that hurt me. I‘m not proud of the way I might have behaved…but I think that was part of my coping…to be angry.‖ The meaning – ―I think it meant that I…got to pursue a broader set of attributes about myself. Just learning that…how much boys like you…was just one part of me, and who cares what boys think about me? I did not have to be defined by how much I excited or disappointed…a man.‖ (2) ―Admitting to myself that my dad had really disappointed me…and had done some things that were scary…helped me…recognize the partner violence and why I had accepted it.‖ The meaning – ―Deciding that I got to be who I wanted to be. That I could have…expectations for men. Just realizing…I can make an equal world around me.‖  61  Helping Resources Community  Personal Qualities  Participant 4 (Carly) (1) ―Female companionship became very very important to me…spaces that were just female…it was really important in me trying to understand that I had agency, and I had power.‖ The meaning – ―I think it meant joy and adventures. It was a place to feel safe about wanting to learn new things. Community. Community.‖ (2) ―I became very involved with the queer community at the time. I‘m bisexual…and I had a lot of friends at that time who would just help me think through those (male/female) power dynamics.‖ The meaning – ―I think it meant that before I could really learn to trust men…I had to develop a stronger sense of myself and a stronger sense of how to access the community that wasn‘t defined by being afraid of physical anger. Acceptance. Safety. Trust. Support. Community. It‘s like a safe space.‖ ―I think that experience is a resource. And age. You know more about how to handle stress…how to reach out to people.‖ The meaning – ―Acceptance. Learning to be cool with myself.‖  Hindering Resources  Participant 4 (Carly)  Significant Others  ―Relationships where I was repeating that dynamic. I just became very passive and accepted very angry controlling behaviours.‖ The meaning – ―Every time it felt like it chipped away a bit of me…like I was allowing the chipping to happen. It meant I let people treat me like shit. I was enabling it, and so that made me feel more shame, then more denial, and more anxiety.‖ (1) ―Feeling shame about the (traumatic events) that had happened and not questioning that.‖ The meaning – ―Just anxiety. In those years before I started to really take that stuff on, there wasn‘t reflection. I would be worrying about my marks, or if someone didn‘t like me…you know, the old hamster wheel (of anxiety).‖  Own Thoughts/ Behaviours  (2) ―To not know, I guess…denial was definitely holding me back…the thoughts come and you just push them away.‖ The meaning – ―It made me very anxious, definitely. I had stomach issues and…trouble sleeping, and nightmares, and of course I didn‘t link any of this to the fact that I was pushing it away.‖  62  Helping Resources  Participant 5 (Adrienne)  Family/Friends  ―I trained (for a half-marathon) with one of my best friends, so that kind of became very much my social group.‖ The meaning – ―That was really good in terms of support ‗cause...I was extremely intimidated and I really didn‘t know if I could follow through with it. It was nice to be able to have somebody who could relate to whatever I was feeling and complete something with me.‖ ―I did some counselling as well.‖ The meaning – ―I would say something and I would hear myself talk about something and then...I would look at it in a different way...and it was extremely helpful.‖ ―I created a YouTube Channel documenting my weight-loss journey and exercising...and that kind of really gave me a connection to a...really big support group.‖ The meaning – ―Having an online community that‘s a whole support system for you...I felt like I had finally found a community and a group of friends that were accepting of who I was.‖ ―Meditation...I almost kind of became obsessed with it, because it was just something to get my mind off everything.‖ The meaning – ―I think it was just a way of being able to control my thoughts, and...not think about (my traumatic experiences) so much.‖ ―I did a lot of journaling.‖ The meaning – ―I put on music and then just wrote whatever came out. And then I would go back...later and look at what I wrote. It was a really good tool for selfreflection...seeing how I had evolved as a person.‖ ―I actually moved across the country ‗cause both of those (traumatic experiences) happened when I was living in (another province).‖ The meaning – ―I‘m somebody who definitely associates places with different memories, so...not to see the places that reminded me of (the traumatic experiences) allowed me not to think about them so much, because they weren‘t in front of me.‖ (1) ―I...participated in a lot of exercise, and just focused on being physically healthy.‖ The meaning – ―Exercise was definitely an escape...(and) a way of putting whatever I was feeling into something productive.‖  Counselling/ Workshops Community Support  Religion/ Spirituality  Arts/Self Expression  Escape/Seeking Safety  Exercise/Nutrition  (2) ―I did my first half-marathon.‖ The meaning – ―As a result of those (traumatic) events I had felt a huge loss of selfconfidence and respect for myself, so being able my half-marathon – fully complete it – gave me a really big sense of accomplishment and confidence that I could do something if I committed to it.‖  63  Hindering Resources  Participant 5 (Adrienne)  Staying in a Harmful Environment  “Probably staying in the same area made it really hard to be able to move on, ‗cause I reminded of...those (traumatic) events.‖ The meaning – ―It was very hard for me to see those places and not automatically think of what had happened during that time...I felt myself get really nervous and I started to have a physical reaction...I would have flashbacks of memories.‖ “I‘d say talking to family or friends was probably something that was not beneficial.‖ The meaning – ―I felt very alone. I felt as though there was nobody else going through the same thing. And, because of that I felt like I didn‘t have anybody to talk to.‖ ―Being in a bad relationship myself was a hindrance. I was in a few relationships that were definitely verbally abusive. I was very much manipulated…I got taken for granted, I was called names.‖ The meaning – ―It would remind me of the relationship that my mom was in. I guess I (sought) that out, not realizing that there are good relationships. It was all I knew a relationship to be.‖  Family/Friends  Significant Others  64  Helping Resources  Participant 6 (Suman)  Family/Friends  (1) ―My aunt is a strong woman, she teaches me too...that‘s one resource because she went through the same thing. She supports me. She‘s my inspiration.‖ The meaning –―She taught me to be independent. She inspires me.‖ (2) ―Talking to friends.‖ The meaning – ―Those are the things that help me stay sane.‖  Own Thoughts/ Behaviours  (3) ―I saw my cousin...I told her about my uncle. That was one big thing that helped me to get over it.‖ The meaning – ―I wanted my cousin to know it to understand me better...I wanted her support. I just wanted to let it out too...I wanted people to know. I was bursting (my uncle‘s) bubble.‖ (1) ―I realized the trauma was a gift in one way.‖ The meaning – ―It is my purpose in life. I need to study I am dying to go back to school. (2) ―Standing up, this is helping me getting over my day I said ‗no‘...I stood up (to the uncle who molested me).‖ The meaning – ―Standing up was makes me feel like a powerful woman. I don‘t just stand up for myself, I stand up for my aunt, I stand up for my mother...I stand up for every woman I left behind who couldn‘t do what I will do.‖ (3) ―Making sense of things, putting things into perspective, realizing what‘s important and what‘s not.‖ The meaning – ―When you understand different things, you add to your life...when I add those new things, I take the old things out, right? It has helped me become a new me.‖ (4) ―I accepted that it happened.‖ The meaning – ―It meant freedom to having wings. It‘s like you‘re letting go of the trauma. I don‘t look down on myself anymore. I feel like I‘m just like other girls, I respect myself, I believe in myself.‖  65  Helping Resources Education/ Information  Personal Qualities  Plans/Goals  Religion/ Spirituality  Significant Others  Arts/Self Expression  Escape/Seeking Safety  Participant 6 (Suman) (1) ―I helped myself gain knowledge by reading books. I did not waste time, I read...I listened to (authors and speakers) at conferences...they taught me so much.‖ The meaning – ―I read about these people and they inspire me, they give me the fire that I need. I read, I educate myself.‖ (2) ―If I didn‘t have my education as a tool, I wouldn‘t be here. Education was the biggest resource.‖ The meaning – ―My education means, my world to me. Because I have no one in my life, or no mentor to teach me. It takes me toward my purpose in gets me away trauma, because the more educated I am, the more established I will be.‖ ―My inner strength. The girl you‘re listening to today, she‘s aware, she‘s conscious, she knows. We were taught to say yes all the time, especially because we were women. I believed in saying ‗no‘ too, though. It builds up that frustration inside of you. And one day, when it comes out, that‘s your strength....standing up for myself and what I believed in.‖ The meaning – ―That means I‘m different....I‘m not a victim. In life you can choose to either be a victim, or to be a soldier. Either I can tell people, ‗Oh, I was a victim‘, or I can go the other way, and I chose the other way.‖ (1) ―Making a plan in my life, going for studies.‖ The meaning – ―It was just going with your gut feeling, so making choices. My plan is to make the most of this world.‖ (2) ―I kept my focus on my goal, so I was like ‗this is temporary...they can‘t do this to me forever‘...keeping my focus on continually working towards the goal (to continue my education).‖ The meaning – ―If I don‘t focus, I won‘t go anywhere. Then my journey will just end. My focus helps me to dream big things...focus keeps me going.‖ ―I would have been the biggest victim if it wasn‘t God giving me this wisdom, this brain...I prayed a lot.‖ The meaning – ―I‘m on my own...I don‘t have anyone...praying to God was believing in myself.‖ ―I met a guy. He was very very nice. He saw something in me. He understood me. He taught me everything! He made me the woman I am.‖ The meaning – ―He empowered me. He mentally healed me. He changed my lifestyle, he made me active. He changed me.‖ ―I watched a lot of movies...inspirational stuff...where I realized that I‘m not the only one who is going through this...that helped me get over it.‖ The meaning – ―That you can win! If Nelson Mandela can come out of jail...and be the president of a can be anything.‖ (1) ―I moved to the city, I left the village. I took one step and stayed at a girls‘ hostel.‖ The meaning – ―My uncle‘s influence wasn‘t there...I was far from their reach.‖ (2) ―I got a visa and I got here (to Canada).‖ The meaning – ―It took me far from my family‘s reach.‖ 66  Helping Resources Financial/Practical Help  Participant 6 (Suman) (1) ―My aunt...would send me money for my education.‖ The meaning – ―It meant freedom to me, it helped me...she always sent me money and it was always somehow related to education.‖ (2) ―(My other aunt) sent me a computer, so I researched what universities take to go to med school. I was looking for an escape from the uncle...that was the first step.‖ The meaning –―I first came to Canada through that computer. It was a great way to (get) away from the family, from everything that I didn‘t believe in.‖  67  Hindering Resources  Participant 6 (Suman)  Culture  ―The culture, people who use it to their advantage...especially men – that‘s a big thing. That‘s why a woman like me has to come to this country to be strong.‖ The meaning – ―I don‘t like it, I don‘t want to be part of it. I‘m still scared of my family. I hate my culture so much, but one day, I would love to love it.‖  Own Thoughts/ Behaviours  (1) ―Not being able to talk about it – it‘s a huge thing…that‘s just gonna kill you inside.‘ The meaning – ‗It‘s hard. It makes you really strong…but I think people should be able to talk about it more.‖ (2) ―Negative thinking.‖ The meaning – ―I thought, when I‘m achieving all these things, all those things are fake. I thought, when I am such a person of low integrity, how can I be doing all these good things? There are fake, this is not me, that‘s the real me, the bad me.‖  Staying in a Harmful Environment  (3) ―Not accepting (the trauma)…there‘s a huge part of my life.‖ The meaning – ―It was like living in a delusional world...just questioning the reality of your own world…like ‗are you real? Are you faking it? Is this really you?‘‘ (1) ―People do bad things to you, firstly, they play with your brain. It‘s the worst thing someone can do to you….I was not happy but I was going through it because…I thought I had to.‖ The meaning –―I felt like…I didn‘t belong…it (makes you) question your integrity.‖ (2) ―The more amount of time if you stay in … environment…the harder it is going to be for you to come out of it.‖ The meaning – ―It didn‘t have any meaning to me…I knew I had to go through it, sometimes you just don‘t have any choice. But when you‘re a kid, when you‘re not even conscious, that‘s hard. I like myself now, I did not like myself for a long time.‖ (3) ―If I didn‘t walk away from it…it hindered (me). If you can‘t walk away from it, if you can‘t stop it, it‘s going to take over you.‖ The meaning – ―It kills you inside when you can‘t walk away when you want to. I just judged myself as a girl who has no morals, who has no values, a girl who‘s not (pure). I felt being sexually abused, I knew some things …my classmates didn‘t…I wasn‘t like them.‖  68  Helping Resources  Participant 7 (Jane)  Family/Friends  (1) ―My Grandma was a huge resource…a huge, huge support. Keeping me…having me talk about everything.‖ The meaning – ―That I didn‘t need to be ashamed.‖  Own Thoughts/ Behaviours  (2) ―Meeting new people and engaging and making friendships through work.‖ The meaning – ―It helped me to know that there‘s room for this world. With all my colour and flavour. ‗Cause there‘s just such a variety out there.‖ (1) ―My language is just really important. (I) started using ‗fantastic!‘ and people respond well…and I…give praise where I can find chance to give praise, and thank people when I can find reason to thank.‖ The meaning – ―It gave me the chance to positively influence my interactions with people. A sense of control, and the opposite of ‗victim living‘.‖ (2) ―My relationship with my mother. We did end up meeting 8 years after she left…I go to Toronto specifically to see her. And I‘ve been able just to say to her ‗leaving was the best thing you ever did for me.‘‘ The meaning - ―A sense of growing up, and a sense of freedom. And a sense of release, and, instead of saying ‗I don‘t have a mother‘ and ‗I was abandoned by my mother‘, I got to change the story. And I get to control the situation…(she doesn‘t) get to (hit me) anymore and that‘s been huge‖ (3) ―Global travel…going to Mexico (and China and England).‖ The meaning – ―Seeing what shit lives so many people out there are living, desperation, poverty, with no sense of hope puts it into perspective. (And) it made me hungry to have more in my life. There‘s such a big world out there. And it showed me…how good we have it here.‖  Education/ Information  (4) ―I don‘t hang out with other people who are depressed, I don‘t join groups, I don‘t read books about it.‖ The meaning – ―It meant I could move forward.‖ (1) ―School – taking classes…and learning.‖ The meaning – ―It gave me a means to achieve all the cool stuff that I wanna do.‖ (2) ―The Myers-Briggs was fantastic…it helped me realize…chances are I‘m going to continue not fitting in in my workplace. I need to find an environment where people are, if not more similar…at least more tolerant.‖ The meaning – ―(It) gave me another validation that I am not broken because…the last couple of years I‘m getting lots of signals from…bureaucrats, that I am broken.‖  69  Helping Resources Community Support Personal Qualities  Plans/Goals  Escape/Seeking Safety  Exercise/Nutrition Medication/ Alternative Treatments  Religion/ Spirituality  Significant Others  Participant 7 (Jane) ―Having people pray for me. Didn‘t make much sense to me…when I was younger, but I get it now.‖ The meaning – ―I felt like…they had me, covered.‖ (1) ―Not being afraid to say (I‘m just depleted) and go (to the doctor) for help.‖ The meaning – ―I‘m grateful I have a doctor who trusts me with (the medication)…I know without a question she‘s never judged.‖ (2) ―Just maturing and having more life experience has been huge.‖ The meaning – ―My world at 36 is much different than 16.‖ (1) ―I make lists of amazing things that I wanna do… a ‗bucket list‘.‖ The meaning – ―A sense of fun accomplishment.‖ (2) ―I started really looking (at) ‗what do I want?‘ and learning to get specific about it, and that has been instrumental.” The meaning – ―The difference of getting it done or not. I have a vision…(and I‘m) making it happen.‖ ―(My) motorbike. (When I was young) we were always on the road…and even to this day, I just wanna leave. So now...I can go for a ride on my motorbike. I don‘t have to shut down my life and abandon everyone.‖ The meaning – ―It means I can have something for me, and an escapist tool that doesn‘t require me to abandon my life.‖ ―Walking (for) hours.‖ The meaning – ―A sense of escape. And motion. Not being stuck.‖ (1) ―Prozac when necessary. I learned to be okay with antidepressants.‖ The meaning – ―Life and death. Coming out of the clouds. And getting back to functioning.‖ (2) ―Sunshine. I started going down to Mexico…(for a) period of five years.‖ The meaning – ―I stopped needing pills because I was getting this amazing sun therapy.‖ ―My conversion to Islam…and my practice of Islam has been a very big help.‖ The meaning – ―It means I have a formal relationship with God….and it‘s giving me a sense of peace. There‘s a recipe for me to follow, and the more I follow the recipe, the better the cake.‖ ―My husband…he‘s been lovely. He is one of the kindest, and most compassionate people I‘ve ever met.‖ The meaning – ―He accepts me. We‘re about to start our life together, and that‘s terribly exciting. I have a partner.‖  70  Helping Resources Arts/Self Expression  Financial/Practical Help  Participant 7 (Jane) (1) ―Journaling.‖ The meaning – ―It got all those mind thoughts out of my head.‖ (2) ―Painting.‖ The meaning – ―It was very cathartic…a release I needed at the time…(I) just let it all come out.‖ ―The inheritance from my grandma.‖ The meaning – ―It allows me some financial freedom, so I can leave jobs if I don‘t like them.‖  Hindering Resources  Participant 7 (Jane)  Family/Friends  ―The people I was hanging around with.‖ The meaning – ―It meant I wasn‘t spending my time doing things that actually made my life stronger, like my studies, or working or reading. Or being creative.‖ (1) ―Shutting the people out in my life, not letting them in in ‗live time.‖ The meaning – ―It meant I didn‘t have to listen to them.‖  Own Thoughts/ Behaviours  (2) ―Victim thinking‘ and just sort of constantly living the story.‖ The meaning – ―It meant I couldn‘t go forward, and that I couldn‘t see my potential. And it helped keep me very insecure and feeling broken. And not valuable.‖ (3) ―I dropped out of school. I thought I had enough credits…(but) I didn‘t and I had to go to night school for one class. (That) added to my dorky sense of esteem.‖ The meaning – ―I felt the stigma of high school dropout…even though nobody cared. But I did, and I felt like it really mattered.‖ (4) ―Hurting myself, cutting myself.‖ The meaning – ―It was a private way to sort of like externalize what I was feeling inside.‖  Counselling  Significant Others  (5) ―Drug use…pot, LSD, mushrooms, smoking, drinking.‖ The meaning – ―It means I was buzzed out a lot of the time, and I feel I wasted a lot of my time – my mind power time – because it made me slower.‖ ―I went to therapy for three sessions and she filmed my crying like a baby and that was it.‖ ―Cause that‘s all the MSP would cover or something.‖ The meaning – ―A sense of unfinished business, like we had just started something. Actually, I felt like a statistic.‖ ―Being in relationships with boyfriends who are jealous and controlling.‖ The meaning – ―It meant I was very insecure and not feeling free to do the things I wanted to do, and that included being successful.‖  71  5 Discussion Perhaps the greatest challenge in qualitative research is to summarize the experiences participants have shared, with all of their richness and texture, and try to determine the meaning of these experiences within a research context without losing the meaning they had for the participants. This research examined the resources women used in recovering from cumulative trauma, how they used these resources, and what the resources meant to them. Because the meaning of these resources was such an important part of this research project, a later section of the discussion section is devoted to the subject of that meaning. Having reviewed the results of this research, it is clear that the women interviewed used a broad range of resources which both helped and hindered them in their recovery from their traumatic experiences, and that their experiences fit with many of those studied by previous researchers. 5.1  Similarities to the Reviewed Literature 5.1.1  Helping resources  In terms of helping resources, all seven participants indicated that support from Family/Friends was an important component of their recovery. Nadine and Carly both reported talking to girlfriends and reaching out to male friends as resources in their recovery, and all participants commented on how important their friends and family were to their recovery. Diane found her daughter a particularly important resource, and Sher, Carly and Diane all indicated that their moms were an invaluable resource for them. And, although the categorization is slightly different, several other studies have similarly reported that various types of social support were helpful to their participants.  72  Schumm and colleagues (2006) reported that for the participants in their study, social support predicted lower levels of PTSD severity. The Social Provisions Scale used in that study seems to focus more on the different types of support than on the people giving the support, but the idea of being supported by people close to you is one that seems consistent across both studies. Murthy‘s (2007) review of 28 studies showed similarly positive outcomes for accessing various types of social support, as did the work of King and colleagues (1999). Ullman and colleagues‘ (2007) research found that talking about the trauma may be helpful, and the earlier the better. This seemed to be Carly‘s experience, as talking to her mom and her best friend specifically about her trauma was important to her. Suman also found that talking to her cousin about the trauma helped in her recovery, and Jane found that her grandma‘s emphasis on talking about Jane‘s trauma with her from the time Jane was young was a huge resource for her. These experiences also resonate with Smith and Kelly‘s (2001) finding that reaching out to others was an important aspect of recovery, and family and friends were among those the women in their study reported reaching out to. Six of the seven participants reported that resources related to Own Thoughts/Behaviours had also played an important role in their recovery. Examples include Nadine‘s sense that ―redefining…what makes me a strong woman and what makes me strong in general‖ was an important resource for her, and her statement that ―the biggest part for me was…looking back at the aspects of what was lost, and gained‖. Similarly, Carly felt ―redefining myself in relation to men‖ was an important aspect of her recovery. These all fit well with Smith and Kelly‘s (2001) findings, that redefining one‘s sense of self after trauma and reflecting on the elements of the self that may have 73  been lost, as well as the personal growth that may have been gained, were important parts of their participants‘ journey of recovery. Suman and Jane also found it helpful to make changes to how they thought about their traumatic experiences. Suman remarked, ―I realized the trauma was a gift in one way‘, and that ‗making sense of things, putting things into perspective, realizing what‘s important and what‘s not‖ was helpful to her in her recovery. Jane shared that it was helpful for her to be able to say to her mother—who was the source of some of her early traumas—that ―leaving was the best thing you ever did for me.‖ These three examples echo the reframing of trauma that Smith and Kelly (2001) reported in their research findings, and are certainly consistent with common practices of cognitively-based therapies. Community Support was a separate category that emerged in this research, one that seemed qualitatively different from the category of Family/Friends for the four participants who reported the resources within this heading. Nadine reported that adults in her community who took her concerns about her home life seriously were resources, as were mentors in the community who encouraged her interest in psychology. Carly also found that she felt a sense of community within female spaces and the queer community, that they felt like safe places where she was accepted. Adrienne reported creating her own online community, one that gave her access and connection to a large support group, and in which she felt accepted for who she was. The five studies just mentioned also report support from community members as an important aspect of recovery for their participants, though again for these studies it falls under the broader heading of social support. Duma and colleagues (2007), however, found that the support of the community specifically was an important part of the 74  recovery process for one of their participants. This participant found that the support her community gave her, through their fundraising efforts for her transportation to court, gave her the strength to pursue justice against her attackers. Clearly, this is one case where support took a practical form, but was nevertheless felt on the level of community. A study that has interesting implications for the category of Community Support found in the current research, as well as the category of Counselling, is that of Parker and colleagues (2007). They reported that women in a counselling and trauma recovery group, in addition to the therapy they received, found the connection they had formed with other women in the group to be helpful in their recovery, as it gave them a sense of acceptance rather than of being judged. Many of the participants in the current research program found both community and counselling helpful in their recovery, and one participant found that she experienced a similar sense of community within two group counselling settings. Diane found that her Outward Bound survival experience was rewarding in terms of both its therapeutic and community aspects, and reported that various workshops she attended gave her the feeling that she was not alone in her experience, in addition to learning valuable healing techniques. Counselling group and workshop leaders have long known that the group itself has power to heal its members, and that seems to resonate with Diane‘s experience. As mentioned, Counselling/Workshops was another category that emerged from the resources participants reported, and it was one that five of the seven participants found useful in their recovery. Nadine reported ―working through counselling…gave me back a lot of the strength that I thought I had lost‖. Sher indicated that ―Virginia Satir family reconstruction…was huge, absolutely huge‖ in her recovery. Diane felt that ―talk therapy…has been, I would say the biggest or one of the biggest‖ resources in her 75  overcoming the effects of her trauma, and both Carly and Adrienne reported that counselling had been helpful for their recovery as well. This is encouraging and, perhaps not surprisingly, it is also reflective of current research findings. In terms of specific treatment modalities, Schnurr and colleagues (2007) found that the CBT treatment of prolonged exposure was effective in treating PTSD, and both Bisson and colleagues (2007) and Seidler and Wagner (2006) have found support for the efficacy of traumafocused CBT and EMDR treatment. VanDeMark and colleagues (2004) also found CBT and solution-focused therapy helpful for their participants, while Duma and colleagues (2007) found that working with a social worker was helpful for one of their participants. Murthy (2007) reported the benefits of psychological help for survivors of trauma, and Botwin (2001), a therapist herself, reported that she found the love and acceptance she felt from her own therapist was instrumental in her recovery from trauma. Personal Qualities was another category in which four participants listed helping resources. Nadine listed resilience as helpful in her recovery, which fits with Bradley and Davino‘s (2007) findings. King and colleagues (1999) also found that constructs such as hardiness were related to better recovery outcomes, and hardiness seems similar to resilience. Again, resilience and recovery are separate concepts according to Bonanno (2004), but for Nadine, it seems that an ability to maintain her equilibrium was part of her recovery process. Suman‘s experience of ‗inner strength‘ as a resource perhaps fits with this concept as well. Three participants listed helping resources that fit under the heading of Financial/Practical help. From Sher‘s experience of having a place to stay, to Suman receiving money for her education and a computer from her aunts, to Jane inheriting her 76  grandma‘s estate, all three participants found these resources helpful in practical, tangible ways. This fits with other the findings of other researchers. Duma and colleagues‘ (2007) report of the woman who used the support of her community to pursue justice against her attacker, for example, indicated that the support of the woman‘s community was helpful, but also that this support came in the practical form of money to help with the transportation costs of travelling to court. Also in Duma and colleagues‘ study, another participant used the financial resources provided to her to buy new shoes and have her hair done before meeting with a social worker in the first step toward moving on with her life. Murthy‘s (2007) findings around social support also listed practical help as resources, including the creation of income-generating programmes for women who had experienced trauma. VanDeMark (2004) also included employment skills as part of his program for women recovering from abuse and addiction. Of the seven participants in this study, four also indicated that resources to do with religion or spirituality were part of their recovery. Diane‘s experiences of spirituality occurred in nature or while participating in yoga, and Adrienne found that meditation gave her some peace as well. Suman and Jane had more traditional religious experiences, and found that prayer and a relationship with God were helpful in their journey of recovery. This echoes the findings of both Murthy (2007) and Hassouneh-Philips (2003). Murthy‘s review also found that religious practices played an important role in reducing the effects of trauma, while Hassouneh-Philips found that spirituality was an important coping tool for the American Muslim women in her study.  77  5.1.2  Hindering resources  In terms of hindering resources, the participants‘ Own Thoughts/Behaviours were the most often reported obstacles to recovery, with four participants citing these. Carly found that ―feeling shame about the (traumatic events) that had happened and not questioning that‖ was hindering for her. Suman similarly felt that her negative thoughts about herself in relation to her trauma were a hindrance in her recovery. These experiences correspond with Feinauer and Stewart‘s (1996) research, in which they found that blaming oneself for one‘s abuse was related to higher scores on a measure of traumarelated symptomology, and led to decreased functioning, especially in childhood. Interestingly, Ullman and colleagues (2007) found that self-blame related to one‘s own character after traumatic events was associated with higher levels of PTSD symptoms, whereas self-blame related to one‘s own behaviour was not, which fits with Suman‘s experience but not as much with Carly‘s. If, however, we take the perspective that embarrassment is related to one‘s actions whereas shame is related to oneself, perhaps this finding fits better with Carly‘s experience as well. The same researchers found that delayed disclosure of trauma was also related to poorer outcomes, and this certainly seems to capture the hindering experience Suman was referring to when she said that, ―not being able to talk about it…it‘s a huge thing…that‘s just gonna kill you inside.‖ Family/Friends were also seen as hindering resources by three of the participants, including Nadine‘s experience of not feeling supported by her dad in talking about her experience, of not feeling supported by her family in seeking counselling, and of feeling that she had to take on a parenting role with her siblings while her mother was hospitalized for mental illness, even though she herself was struggling with the 78  experience. Adrienne had a similar experience, in that she did not feel she could get support from friends or family around her trauma and felt alone in what she was going through, and Jane found that the friends she was hanging around with were a hindrance to her recovery. These experiences reinforce what other researchers have found, in terms of the negative side of social support. Schumm and colleagues (2006) found that, just as high levels of perceived social support contributed to recovery from trauma, low levels of perceived social support led to increased difficulties with recovery. Ullman and colleagues (2007) also found that negative social interactions were related to higher PTSD symptomology. Another resource category that corresponds with the current trauma literature is that of the Significant Others. Four participants reported these types of relationships as hindering their recovery. Diane felt that ―being in a relationship with a man…at all‖ was an obstacle to her recovery from trauma, and Carly found that relationships in which she was ―passive and accepted very angry controlling behaviours‖ were similarly problematic for her. Adrienne also found that bad relationships were a hurdle for her to overcome in her recovery process, as did Jane. This parallels Bradley and Davino‘s (2007) finding that damaged relationships were a source of difficulty in recovery from trauma. Finally, Staying in a Harmful Environment was a category in which two participants listed resources that had hindered them in their recovery. Adrienne reported that staying where she was and seeing the places that reminded her of her traumatic events made it difficult for her to move on from the trauma, whereas Suman reported that she felt she had to stay in abusive environments at different times in her life, and that these places made it more difficult to get over her trauma. These experiences seem 79  similar to those of the participants in Hassouneh-Philips‘ (2003) study. These American Muslim women‘s spiritual practices reinforced values such as remaining with their abusive partner, and so some of these women stayed in these violent and harmful environments, unable to create the safety for themselves that would allow them to begin to recover from their traumatic experiences. 5.2  Differences from the Reviewed Literature 5.2.1  Helping resources  There were several findings from this research that differed from what was found in the literature reviewed, with respect to helping resources. First, in the area of Own Thoughts/Behaviours, Roth and Newman (1992) found that their participants had to come to a point where they accepted their helplessness in the abuse they experienced in order to recover. This did not seem to be part of the experience of any of the participants in the current research, though it is possible that this was an aspect that was important but was not mentioned. As well, Feinauer and Stewart (1996) found that attribution of blame played a large and important role in recovery from trauma, in the sense that participants who blamed their attackers for the trauma had lower scores on a measure of traumatic symptomology. Again, none of the participants in the current research mentioned that thought process as a resource in their recovery, but it is certainly possible that this attribution of blame took place and was just not reported. Escape/Seeking safety was an important resource category for the four participants who used the resources that fell under this heading. Jane found it extremely helpful to be able to climb on her motorbike and escape for short periods of time, and both Adrienne and Suman found escaping their respective traumatic environments instrumental in their recovery. Sher engaged in a variety of behaviours, including 80  dissociating, hiding in her closet, marrying in order to get her and her sister out of her parents‘ home, and ‗running‘ or ‗disappearing‘ from the environments in which she found herself. Ullman and colleagues (2007), however, found that avoidance coping was related to higher levels of PTSD symptomology. It may be that all of the escape and safety-seeking strategies mentioned here have more to do with survival or coping than they do with recovery, or perhaps they are a lower level activity with regard to recovery, but they were felt to have been a valuable part of these participants‘ recovery process. Given the previously-mentioned findings for the hindering effect of staying in a harmful environment, perhaps escape is a valid strategy in some cases. Returning to the Hassouneh-Philips (2003) study once more, participants in that research found that spirituality was a double-edged sword which contributed to both their coping and to their lack of safety. Participants in the current research project found spirituality to be only a helping resource, with none of the associated problems the women in the Hassouneh-Philips study encountered. Perhaps this has to do with the fact that the spiritual experiences described by these seven women were, for the most part, less restrictive in nature. However, given the cultural context the Muslim women may also have been operating within, it raises the question of how much of what they experienced had to do with religion, and how much had to do with culture. 5.2.2  Hindering resources  The category of Culture is another difference between the findings of this research and that of other research in the area of trauma recovery. Murthy‘s (2007) review reflected the valuable role that culture played for survivors of violence, whereas those participants in this research for whom culture was a factor, found that it was to a barrier to their recovery. Both Nadine and Suman found that the traditionally-held values of their 81  culture held them back from recovery. Nadine found that culture was a factor in her parents not supporting her pursuing her interest in psychology, and in discouraging her from accessing further counselling at school as well. And Suman felt that men from her cultural background used the values and practices of their culture to get away with a variety of abuses, including sexual abuse. It is unclear why there is not more mention in the literature reviewed of the cultural factors that can hinder women in their recovery from trauma. Given that there were only two women in this study who self-identified as being from an ethnic background other than ‗Caucasian‘ or ‗Canadian‘, the fact that both cited culture as a hindrance to their recovery seems to suggest that culture can have a negative effect on recovery if it serves to oppress those who have experienced the traumatic events. Finally, the category of Counselling/Workshops provided one experience that was a hindering resource, which does not find a parallel in the literature reviewed for this study. Jane describes a situation in which she was given only three sessions with a counsellor due to limited funding from MSP, and she was filmed crying during those sessions. She came out of those sessions with a sense of unfinished business, and feeling like a statistic. This is in direct contrast with the findings of those researchers mentioned in the above section on Counselling/Workshops as a helping resource. Clearly, this is not the experience any counsellor wants for their client, but unfortunately, for various reasons it may not be as rare as we would like. Employee Assistance Programs (usually operated by large corporations which provide counselling as a benefit to employees of organizations who contract with them for their services), for example, often provide a very limited number of sessions, regardless of the severity of the client‘s issue or the depth of their distress. This is usually much to the chagrin of the 82  counsellors who work for these organizations, but the people in charge are often following a corporate profit-based model, and the counsellors have little to no say in how many times they can see a client. Regardless of the reason for the limits placed on this participant‘s access to counselling, this finding was not a match with those of the literature reviewed on this topic but may be a topic for further research. 5.3  New Findings There were several categories which emerged as a result of this research, which  do not seem to have an equivalent in the literature reviewed. The first category that seems to be a new finding is that of Education/Information. This was an important category for many of the participants, and seemed to contribute a great deal to their recovery. Some of the resources accessed had to do with gaining a better understanding of a traumatic situation, as in Nadine‘s case, whereas for Sher it had to do with education as a way to improve her situation. For Diane, education and information was a way to help understand the psychological effects of trauma that she was experiencing, and a way to gain new coping skills. For Suman, it was a way to inspire and teach herself, and to change her reality. For Jane, it was a way to understand herself better and to achieve her goals. It seems strange that education and information have not been researched before as valuable resources in helping women recover from cumulative trauma. It may be the case that psychological education and information provision has been studied as more of a positive and empowering resource in general rather than specifically to do with trauma. Regardless, its positive effect on the recovery of many of the participants in this study seems clear.  83  Similarly, it seems unlikely that Medication/Alternative Treatments have not been explored as resources for women recovering from cumulative trauma. It may be that much more of the research on the helpful effects of medication appears in the medical literature than in the psychological literature, or it may be that medication is more commonly researched and prescribed for the conditions associated with trauma, such as anxiety and depression, than it is for ‗trauma‘ per se, especially cumulative trauma. For the two participants who reported medication as a resource, it was used to treat other conditions, but was certainly seen as a resource in their recovery from cumulative trauma as well. In addition to medication, the use of alternative treatments such as acupuncture, massage therapy and light therapy (in the form of sunshine) were reported by the participants in this research. These treatments undoubtedly have a solid research background, but they may have been studied more in terms of general wellness, or even depression and anxiety, than with respect to cumulative trauma. Exercise/Nutrition was reported as important for four of the participants in this study. Sher found that yoga, working out in the gym, and walking were all beneficial for her, and both Jane and Diane found that walking outside was helpful. For Diane, it had the same effect as medication, and she also felt that nutrition was an important part of her recovery. Similarly, Adrienne found that exercise in general, and running a half-marathon in particular, were both a big part of her recovery experience. This category does not appear in the reviewed literature, though it is certainly one commonly acknowledged among counsellors as linked to improvements in depression and anxiety. Another category of resources that many of the participants endorsed as helpful but which did not appear in the literature reviewed was that of Arts/Self Expression. The resources under this category included participating in artistic pursuits such as painting 84  and drawing, or engaging in journaling, all as a means of self expression. This category of resources also included an enjoyment of the arts, such as listening to music as a way to improve mood, or watching movies as a way to inspire oneself. These resources are so commonly reported—and recommended—in counselling settings that it is difficult to imagine that they have not been explored in cumulative trauma research, but perhaps they have been mostly explored in counselling contexts, and there have been few empirical studies conducted. Significant Others was a category of resources that two participants found quite helpful in their recovery. Suman and Jane both reported having relationships in which they felt accepted and understood, and which were helping resources for them. Although the literature reviewed was mostly silent on this topic, there is an intuitive appeal to the idea that a relationship in which one feels understood and accepted allows for the healing that could lead to recovery from trauma. Certainly, this is the type of relationship that many counsellors attempt to form with their clients, and to which at least some of the success of counselling can be attributed. Finally, the category of Plans/Goals was one in which nearly half of participants listed helping resources. Nadine reported that it helped her to have planned activities to look forward to, and for Suman, goals provided a focus beyond her grim day-to-day reality, one that helped her move forward through difficult times. Jane used her plans and goals in two different ways. First, she used her ‗bucket list‘ to imagine and plan amazing experiences. Second, she used specific goals to create a vision for herself and to move toward the things she wanted in her life, including buying her motorbike. Having goals and plans did not come up in the literature reviewed, and this is somewhat puzzling. Given the inspiration it seems to have given these participants, and knowing what we 85  already know in the counselling field about creating attainable goals as a way to move away from undesirable mood states and toward better mental health, having goals and plans would seem to be a natural fit with cumulative trauma recovery. Perhaps the absence of this resource from the literature is simply a sign that this resource is already so well-known with respect to other presenting issues that no one is studying it with respect to cumulative trauma. Another possibility for all of these resources is that their use in trauma recovery has been well-researched, just not their use in cumulative trauma recovery. As previously suggested, cumulative trauma is not simply the experience of multiple traumas but rather a particular type of trauma, in which later traumas reactivate earlier traumas, resulting in greater psychological symptomology and subjective distress, as well as greater difficulty in effecting recovery. It may be the case that these resources have been helpful in recovery from trauma, and so mental health professionals and researchers have not examined their use in cumulative trauma. While it may be that many resources which are helpful in trauma are also helpful in cumulative trauma, this may not be true for all resources, for all cumulative trauma survivors. It is also possible that, in looking for effective treatments for cumulative trauma, researchers have overlooked the importance and meaning of the small day-to-day things clients can do for themselves to aid in their recovery. Certainly, we advise our clients who are dealing with the effects of trauma and cumulative trauma to access the support of family and friends as well as other resources, but we need to be aware that, perhaps especially for survivors of cumulative trauma, family and friends can be a double-edged sword, as can relationships with significant others, spirituality, and a myriad of other  86  potentially helpful but also potentially harmful resources. As stated, the meaning of these resources may matter as much as the resources themselves. 5.4  Meaning If the meaning of these resources does matter as much as the resources  themselves, it is important to examine the meaning these resources had for these participants. When participants‘ own thoughts and behaviours were helpful to them in their recovery, for example, the meaning of these resources seemed to play an important part. Meanings such as ―being able to reflect back and notice everything that (I‘ve) gained as an adult‖ seemed an important part of this resource for Nadine. The mental focus that Sher‘s projects created seemed an important part of those resources for her; she felt that ―it‘s almost like there was a part of me that knew what to do.‖ Diane found it important to be around children for the sense of joy they brought to her and how that would improve her mood, and she focused on changing her behaviours when she was starting to feel suicidal, because she knew ―you just have to do something different, your thoughts will follow.‖ For Carly, coming to terms with her father‘s violent and scary behaviour meant ―deciding that I got to be who I wanted to be…that I could have expectations for men…that I can make an equal world around me.‖ When Suman accepted that her sexual abuse had happened, she said,‖ it meant freedom to me…like having wings…like letting go of the trauma.‖ Jane found many of her own thoughts and behaviours to be helpful, but one that stands out is her choice to use language in very mindful ways to, as she says, ‗‗positively influence my interactions with people‖ which for her means ―the opposite of victim thinking.‖ Resources from the category of family and friends had similarly important meanings for the participants who accessed the resources. Feeling that ―I wasn‘t left 87  dealing with this on my own‖ and gaining ―validation from (males) for my feelings‖ were both important parts of these resources to Nadine. Sher went straight to see her mom upon leaving her own marriage, because her mom was her sounding-board, and Diane highlighted the importance of the unconditional love she received from friends and her daughter as an important part of accessing them as resources. Carly found that, after her own traumatic experiences, talking with her mom about her mom‘s traumatic experiences helped her realize that ―sex assault and partner assault…happens to a lot of women, and it doesn‘t have to define you.‖ Adrienne found that training with one of her best friends for a half marathon meant she was ―able to have somebody who could relate to whatever I was feeling and complete something with me.‖ About the meaning of her aunt‘s support of her, Suman said simply but eloquently, ―my aunt…taught me to be independent. She inspires me.‖ Jane was raised by her grandma when her own mother abandoned her, and the fact that her grandma took care of her and encouraged her to talk about her sexual abuse had a profound meaning for Jane, and likely would have for many survivors of childhood sexual abuse. Jane shares that, to her, it meant ―that I didn‘t need to be ashamed.‖ That is a meaning which goes far beyond the simple description of ‗support from family and friends‘. Most of the resources listed under the other categories (see table 3 for the full list of resources and resource meanings) had similarly important meanings for the participants who accessed these resources in their journey of recovery. It seems clear that the meaning these resources had for participants was an essential part of their use of these resources, and of their recovery from cumulative trauma, much more so than the resource descriptions or category descriptions are capable of conveying. It is this meaning that 88  almost certainly moved these women toward the level of recovery they have achieved, and it is this meaning which counsellors need to be aware of and able to access, if they want to help their clients determine the resources that will be most helpful to them in their recovery from cumulative trauma. 5.5  Implications for Counselling Psychology There are several implications of this research for the counselling field, as long as  we keep in mind that the findings of a qualitative study—especially one this size—cannot be generalized to working with other groups, but that they may have some transferability if handled appropriately. The first implication is that it seems important for counsellors to work on a ‗meaning‘ level in the area of resources when working with at least their female clients recovering from cumulative trauma. It seems that it would be helpful, for example, to explore with these clients the resources they have already accessed, whether or not they were helpful or hindering, and how they were accessed, and then to take this one step further and ask about the meaning the resource had for the client. This meaning may be the key to helping the client identify more successful resources, or to accessing those resources more successfully. For example, if we know that a client signed up for a dance class hoping it would help her in her recovery, it may help us as counsellors if we know that what she was searching for but did not find was a sense of community. This understanding could then inform the counsellor‘s exploration of other potential resources the client could use to attain that sense of community. To highlight how effective it could be for counsellors to work with clients on the level of meaning, it seems worthwhile to share the experiences of by two participants who reported, during the participant feedback portion of this research, that they had 89  already used the discussion of resources and resource meanings to further their own recovery processes. Sher informed the researcher that she had taken an important step in her recovery following the interview by participating in a workshop centered on sexuality and healing. She felt that this workshop had opened her up in a new way, and indicated that friends have seen a remarkable difference in her. She has also begun a relationship as a result of that workshop, something that she had indicated during the research interview she was readying herself to do. Suman used the table of resources and meanings e-mailed to her by the researcher during the credibility check to disclose her abuse to her family, by forwarding the tables to them in an e-mail. Suman‘s family has decided to press charges against the uncle who sexually abused her, and Suman shared that, as a result, ‗I feel like I have wings today - I'm crying and being happy at the same time. Everything happens for a reason. Thanks a lot for listening to me and asking me the right questions.‘ Suman has also begun a video project in which she is interviewing other young women in her Indo-Canadian community about their experiences of abuse. As Suman‘s comments suggest, these positive results are likely attributable in part to being able to share one‘s story with someone trained in listening. However, the researcher was careful not to enter into the role of counsellor in these interviews, and Suman‘s comment about ‗asking the right questions‘ seems to suggest that the focus of these interviews on resources and resource meanings was also at least partly responsible for the motivational effect she experienced. And if this is the effect that talking to a researcher about the meaning of resources one has used in recovering from cumulative trauma can have, the possibilities for working at a meaning level with a counsellor in a therapeutic setting seem even greater.  90  The new resource categories that emerged from this research and which were not reflected in the literature reviewed, could also point to potential resources for other clients. Again, the findings of this research should not be assumed to apply broadly, but they may be helpful in illustrating resource options counsellors may not have considered, which may be helpful to explore with clients recovering from cumulative trauma. The categories of education and information, of plans and goals, or of arts and self expression, for example, may be useful as starting points for further exploration with female clients recovering from cumulative trauma. As well, the meanings that some of the participants discussed around encountering cultural barriers to their recovery at a young age and as young adults, suggest that counsellors who work with children and women from various cultural backgrounds may need to be particularly sensitive to cultural values that could make it difficult for young women to share their experience of trauma with someone outside their own culture, or outside the family. Nadine‘s experiences highlight the possibility that school counsellors may need to be especially careful in following up with the families of young women from cultures that do not value outside help. Suman‘s experiences, meanwhile, highlight a possible need for more counselling and social services for women from India who immigrate to Canada, and for more awareness of the issue of sexual abuse in that culture. Again, while we cannot assume that these participants‘ experiences are typical for women from their respective cultures, never mind for women from other cultures, it seems reasonable to suggest that they may not be alone in having encountered these obstacles in their recovery from cumulative trauma. Putting the questionable technique of filming a client aside, for those familiar with the current state of social services provision the story of Jane‘s difficulty in trying to 91  access an appropriate amount of affordable counselling services reflects a common theme in the area of mental health. This is a problem for all too many low-income British Columbians, and one that has been allowed to go on for too long. With only general medical practitioners and psychiatrists covered under B.C.‘s Medical Services Plan, B.C. residents dealing with mental and emotional difficulties often face the choice of either talking to their family doctor or trying to access the services of a specialist in mental disorders, with all of the stigma attached to that choice. In either case the only solution offered may be medication, when psychotherapy with a trained counsellor may actually be more appropriate and have greater long-term efficacy. Given these choices, many may choose to self-medicate with alcohol, drugs, or other unhelpful activities, thereby placing an even greater strain on B.C.‘s hospitals and family medical practices. To address this gap in mental health service provision, government policies with regard to the provision of health benefits must be examined and revised. If counsellors were regarded as valid health care providers—with appropriate regulations in place regarding education and training and, if necessary, reasonable upper limits as to the number of visits allowed per year, similar to massage therapists and other health care providers—those who need mental health services would be able to access them. The documented negative health outcomes of cumulative trauma alone suggest that addressing the psychological issues that lead to these serious health conditions would be money well spent. For British Columbians to be physically healthy enough to perform their jobs each day, and to raise healthy families and be contributing members of a productive society, we need to be mentally healthy, and recognizing counsellors as the health services providers they are would go a long way toward accomplishing that goal.  92  5.6  Future Research Whatever contributions these research findings may have made to the area of  cumulative trauma counselling, there are many more aspects of cumulative trauma recovery to investigate. For example, Critical Incident Technique methodology could be used to study similar cumulative trauma recovery with men. The findings may be similar, or they may be completely different than the results of this research project. A larger scale study could also be attempted than was possible in this research context, particularly one where participants from more diverse backgrounds could be enrolled, as this would likely result in findings with more richness and variety. Diversity in backgrounds need not refer only to ethnicity either, as research with groups from a variety of socioeconomic backgrounds, or members of the LGBTQ community could contribute a great deal to the literature on cumulative trauma. Alternatively, one aspect of the modern application of CIT which was not applied in this study but which could be very informative, is the inclusion of a ‗wish list‘ item, as mentioned in the work of Butterfield and colleagues (2009). The wish list item is a question included in the interview regarding what resources the participant wishes they could have had access to. This could provide very specific information about what participants might have found helpful in their recovery. Finally, a large-scale review of current research comparing resources used in recovery from trauma with those used in recovery from cumulative trauma was beyond the scope of this research but, if undertaken, may provide useful information for counsellors with regard to effective ways of working with clients recovering from cumulative trauma. This study was undertaken with the goal of exploring the resources women have used in their recovery from cumulative trauma, how they used these resources, and the 93  meaning these resources had for them. New resources have emerged that counsellors may find useful to explore with their female clients who are recovering from cumulative trauma, and the importance of the meaning of these resources was explored, highlighting the need for counsellors to work on a ‗meaning‘ level in their work with these clients and their use of resources. It is hoped that the findings of this research will contribute to a greater understanding of the role of these resources and their meaning in the cumulative recovery process for these women, an understanding with the potential to inform counselling approaches when working with women who have experienced cumulative trauma.  94  References  American Psychiatric Association (2004). Diagnostic and statistical manual of mental disorders: DSM-IV-TR. Washington, DC : American Psychiatric Association Bedi, R.P., Davis, M.D., & Arvay, M. (2005). The client‘s perspective on forming a counselling alliance and implications for research on counsellor training. Canadian Journal of Counselling, 39 (2), 71-85. Bisson, J.I., Ehlers, A., Matthews, R., Pilling, S., Richards, D., & Turner, S., (2007). Psychological treatments for chronic Post-traumatic Stress Disorder: Systematic review and meta-analysis. British Journal of Psychiatry, 190, 97–104. Blanchard, E. B., & Hickling, E. J. (2004). After the crash: Assessment and treatment of motor vehicle accident survivors (2nd ed.). Washington DC: American Psychological Association. Bonnano, G.A. (2004). Loss, trauma and human resilience: Have we underestimated the human capacity to thrive after extremely aversive events? American Psychologist, 59, 20-28. Botwin, S. (2001). A warrior prevails. Eating Disorders: The Journal of Treatment & Prevention, 9, 177-183. Bradbury-Jones, C., Sambrook, S. & Irvine, F. (2007). The meaning of empowerment for nursing students: A Critical Incident study. Journal of Advanced Nursing, 59, 342-351. Bradley, R. & Davino, K. (2007) Interpersonal violence, recovery, and resilience in incarcerated women. Journal of Aggression, Maltreatment & Trauma, 14, 123-146. Breslau, N., Chilcoat, H. D., Kessler, R. C., Peterson, E. L., & Lucia, V. C. (1999). Vulnerability to assaultive violence: Further specification of the sex difference in Post-traumatic Stress Disorder. Psychological Medicine, 29, 813–821. 95  Brewin, C. R., Andrews, B., &Valentine, J.D. (2000). Meta-analysis of risk factors for Posttraumatic Stress Disorder in trauma-exposed adults. Journal of Consulting and Clinical Psychology, 68, 748–766. Briere, J., Kaltman, S., & Green. B.L. (2008). Accumulated Childhood Trauma and Symptom Complexity. Journal of Traumatic Stress, 2, 223-226. Butterfield, L.D., Borgen, W.A., Amundson, N.E., & Maglio, A.T. (2005a). Fifty years of the critical incident technique: 1954-2004 and beyond. Qualitative Research, 5(4), 475-497. Butterfield, L.D., Borgen, W.A., Maglio, A.T. & Amundson, N.E. (2009b). Using the Enhanced Critical Incident Technique in counselling psychology research. Canadian Journal of Counselling, 43, 265-282. Cloitre, M., Scarvalone, P., & Difede, J. (1997). Post-traumatic Stress Disorder, self and interpersonal dysfunction among sexually traumatized women. Journal of Traumatic Stress, 10, 435-450. Cloitre, M., Cohen, L. R., Edelman, R. E., & Han, H. (2001). Posttraumatic Stress Disorder and extent of trauma exposure as correlates of medical problems and perceived health among women with childhood abuse. Women and Health, 34, 1–17. Creamer, M., Bell, R. & Failla, S., (2003). Psychometric properties of the Impact of Event Scale – Revised. Behaviour Research and Therapy, 41, 1489-1496. Cresswell, J.W. (2008). Research Design: Qualitative, quantitative, and mixed methods approaches, third edition. Thousand Oaks, CA: Sage. Durand, V.M., & Barlow, D.H. (2003). Essentials of Abnormal Psychology. Toronto, Ontario: Wadsworth-Thomson Learning. 96  Duma, S.E., Mekwa, J.N., & Denny, L.D., (2007). Women‘s journey of recovery from sexual assault trauma: A grounded theory. Parts 1 and 2. Curationis, 30, 4-20. Eid, J., Larsson, G., Johnsen, B.H., Laberg, J.C., Bartone, P.T. & Carlstedt, B. (2009). Psychometric properties of the Norwegian Impact of Event Scale-Revised in a nonclinical sample. Nordic Journal of Psychiatry, 63, 426-432. Feinauer, L.L. & Stuart, D.A, (1996). Blame and resilience in women sexually abused as children. American Journal of Family Therapy, 24, 31-40. Feinstein, A., Owen, J., & Blair, N. (2002). A hazardous profession: War, journalists, and psychopathology. American Journal of Psychiatry, 159, 1570-1575. Flanagan. J.C. (1954). The Critical Incident Technique. Psychological Bulletin, 51, 327-358. Follette, V. M., Polusny, M. A., Bechtle, A. E., & Naugle, A. E. (1996). Cumulative trauma: The impact of child sexual abuse, adult sexual assault, and spouse abuse. Journal of Traumatic Stress, 9, 25–35. Grubaugh, A.L., & Resick, P.A. (2007). Posttraumatic growth in treatment-seeking female assault victims. Psychiatric Quarterly, 78, 145-155. Haeri, S. (2007). Resilience and post-traumatic recovery in cultural and political context: Two Pakistani women's strategies for survival. Journal of Aggression, Maltreatment & Trauma, 14, 287-304. Harvey, M. R. (1996). An ecological view of psychological trauma and trauma recovery. Journal of Traumatic Stress, 9, 3–23. Hassouneh-Philips, D. (2003). Strength and vulnerability: Spirituality in abused American Muslim women‘s lives. Issues in Mental Health Nursing, 24, 681-694.  97  Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C.B. (1995). Posttraumatic Stress Disorder in the National Comorbidity Survey. Archives of General Psychiatry, 52, 1048–1060. King, D.W., King, L.A., Foy, D.W., Keane, T.M., & Fairbank, J.A., (1999) Posttraumatic Stress Disorder in a national sample of female and male Vietnam veterans: Risk factors, warzone stressors, and resilience-recovery variables. Journal of Abnormal Psychology, 108, 164-170. Lisak, D., & Miller, P.M. (2003). Childhood trauma, Posttraumatic Stress Disorder, substance abuse, and violence. In P. Ouimette & P.J. Brown (Eds.), Trauma and substance abuse causes, consequences, and treatment of comorbid disorders. Washington, DC : American Psychological Association. Morley, J.G. (2003). Meaningful engagement in RCMP workplaces: What helps and what hinders. Unpublished doctoral dissertation, University of British Columbia, Vancouver, B.C. Markoff, L.S., Reed, B.G., Fallot, R.D., Elliott, D.E., & Bjelajac P. (2005). Implementing trauma-informed alcohol and other drug and mental health services for women: Lessons learned in a multisite demonstration project. The American Journal Of Orthopsychiatry, 75, 525-539. Murthy, R.S. (2007) Mass violence and mental health: Recent epidemiological findings. International Review of Psychiatry, 19, 183-192. Nishith, P., Resick, P.A., & Griffin, M.G., (2002). Pattern of change in prolonged exposure and cognitive-processing therapy for female rape victims with Posttraumatic Stress Disorder. Journal Of Consulting And Clinical Psychology, 70, 880-886.  98  Ozer, E. J., Best, S. R., Lipsey,T. L., & Weiss, D. S. (2003). Predictors of Posttraumatic Stress Disorder and symptoms in adults: A metaanalysis. Psychological Bulletin, 129, 52–73. Parker, A., Fourt, A., Langmuir, J.I., Dalton, E.J., Classen, C.C., (2007). The experience of trauma recovery: A qualitative study of participants in the Women Recovering from Abuse Program (WRAP). Journal Of Child Sexual Abuse, 16, 55-77. Radan, A. (2007). Exposure to violence and expressions of resilience in Central American women survivors of war. Journal of Aggression, Maltreatment & Trauma, 14, 147-164. Rogers, C. (1961). On becoming a person. Boston, MA: Houghton Mifflin Company. Roth, S. & Newman, E. (1992). The role of helplessness in the recovery process for sexual trauma survivors. Canadian Journal of Behavioural Science, 24, 220-232. Schnurr, P.P., Friedman, M.J., Engel, C.C., Foa, E.B., Shea, M.T., Chow, B.K., Resick, P.A., Thurston, V., Orsillo, S.M., Haug, P., Turner, C., & Bernardy, N. (2007). Cognitive behavioral therapy for Posttraumatic Stress Disorder in women: A randomized controlled trial. Journal of the American Medical Association, 297(8), 820–830. Schumm, J.A., Briggs-Phillips, M., Hobfoll, S.E., (2006). Cumulative interpersonal traumas and social support as risk and resiliency factors in predicting PTSD and depression among inner-city women. Journal of Traumatic Stress, 19, 825-836. Seidler, G.H., & Wagner, F.E., (2006). Comparing the efficacy of EMDR and trauma-focused cognitive-behavioral therapy in the treatment of PTSD: A meta-analytic study,‖ Psychological Medicine, 36(11), 1515–1522. Smith, M.E. & Kelly, L.M., (2001). The journey of recovery after a rape experience. Issues in Mental Health Nursing, 22, 337-352.  99  Stenius, V.M.K., Veysey, B.M., Hamilton, Z., & Andersen, R. (2005). Social roles in women's lives: Changing conceptions of self. The Journal of Behavioral Health Services & Research, 32, 182-198. Sterling, M., (2008). The Impact of Event Scale (IES). Australian Journal of Physiotherapy, 54, 78. Ullman, S.E., Filipas, H.H.,Townsend, S.M., &Starzynski, L.L., (2007). Journal of Traumatic Stress, 20, 821-831. VanDeMark, N., Brown, E., Borneman, A., & Williams, S. (2004). New directions for families: A family-oriented intervention for women affected by alcoholism and other drug abuse, mental illness and trauma. Alcoholism Treatment Quarterly, 22, 141-160. van der Kolk, B.A. (2002). The assessment and treatment of complex PTSD. In R. Yehuda (Ed.), Psychological trauma (pp. 127-151). Arlington, VA: American Psychiatric Press. Williams, S.L., Williams, D.R., Stein, D.J., Seedat, S., Jackson, P.B., & Moomal, H. (2007). Multiple Traumatic Events and Psychological Distress: The South Africa Stress and Health Study. Journal of Traumatic Stress, 20 (5), 845-855.  100  Appendices  101  Appendix A  Impact of Events Scale - Revised  Impact of Events Scale – Revised Below is a list of difficulties people sometimes have after stressful life events. Please read each item, and then indicate how distressing each difficulty has been for you DURING THE PAST SEVEN DAYS with respect to___________________________. How much were you distressed or bothered by these difficulties? Not at all 0  A little bit 1  Moderately 2  1. Any reminder brought back feelings about it. 2. I had trouble staying asleep. 3. Other things kept making me think about it. 4. I felt irritable and angry. 5. I avoided letting myself get upset when I thought about it or was reminded of it. 6. I thought about it when I didn‘t mean to. 7. I felt as if it hadn‘t happened or wasn‘t real. 8. I stayed away from reminders about it. 9. Picture about it popped into my mind. 10. I was jumpy and easily startled. 11. I tried not to think about it. 12. I was aware that I still had a lot of feelings about it, but I didn‘t deal with them. 13. My feelings about it were kind of numb. 14. I found myself acting or feeling as though I was back at that time. 15. I had trouble falling asleep. 16. I had waves of strong feeling about it. 17. I tried to remove it from my memory. 18. I had trouble concentrating. 19. Reminders of it caused me to have physical reactions, such as sweating, trouble breathing, nausea or a pounding heart. 20. I had dreams about it. 21. I felt watchful or on-guard. 22. I tried not to talk about it.  Quite a bit 3  Extremely 4  0 0 0 0 0  1 1 1 1 1  2 2 2 2 2  3 3 3 3 3  4 4 4 4 4  0 0 0 0 0 0 0  1 1 1 1 1 1 1  2 2 2 2 2 2 2  3 3 3 3 3 3 3  4 4 4 4 4 4 4  0 0  1 1  2 2  3 3  4 4  0 0 0 0 0  1 1 1 1 1  2 2 2 2 2  3 3 3 3 3  4 4 4 4 4  0 0 0  1 1 1  2 2 2  3 3 3  4 4 4  102  Appendix B  Craigslist Advertisement and Poster  Volunteers Needed Be part of a study researching how women have overcome psychological trauma  Are you a woman 19 years of age or older?  Have you experienced or witnessed traumatic events both in childhood and as an adult? (e.g. physical/sexual abuse, assault or serious accidents)  Have you overcome the psychological effects of these events? If you answered yes to these 3 questions, you may be eligible to participate in a study examining how women have used resources to overcome the effects of psychologically traumatic events. This study is voluntary and confidential, and is being conducted on Vancouver Island and in the Lower Mainland by Dr. Marla Buchanan, PhD (UBC) and Elizabeth Holland, an M.A. Counselling Psychology student (UBC). PLEASE NOTE - this study is not appropriate for women who are experiencing Posttraumatic Stress Disorder (PTSD). Participants will be entered into a draw for a $50 gift certificate. Please e-mail --------------------- with your name, a number where you can be reached, and times you can be reached for more information or to volunteer to participate in this study.  103  Appendix C  THE UNIVERSITY OF BRITISH COLUMBIA Department of Educational and Counselling Psychology, and Special Education Faculty of Education 2517-2125 Main Mall Vancouver, BC, Canada V6T 1Z4  Project Title: What Helps and What Hinders in Recovery from Cumulative Trauma Principal Investigator: Dr. Marla Buchanan, PhD, Department of Educational and Counselling Psychology and Special Education, University of British Columbia. Phone -----------------. Co-Investigator: Elizabeth Holland, Master of Arts student, Department of Educational and Counselling Psychology and Special Education, University of British Columbia. Phone ------------. This research is being conducted as a requirement for the Master of Arts, Counselling Psychology degree. Purpose of this study: This study seeks to explore the resources women have used in their process of recovering from cumulative psychological trauma, in the hope that a better understanding of these resources will contribute to how counsellors work with other women who have experienced multiple incidents of psychological trauma. As a woman who has experienced psychological trauma both in childhood and as an adult, your experiences and input are extremely valuable to this study. Compensation: In appreciation for your participation in this study, you will be entered into a draw for a $50 gift certificate.  104  Study Procedures: This study will be conducted primarily through individual interviews with participants like yourself who have contacted the co-investigator to indicate their willingness to be part of this research. The interviews will be conducted in one session, lasting approximately 1 to 1.5 hours. These interviews will be audiotaped and transcribed, keeping participants’ identities private. Participants’ names will not be mentioned in any reports or in the completed study. Some participants may prefer that their comments are attributed to them; in this case only a first name with be used. All data will be kept in locked filing cabinets and any electronic data will be password-protected. Please note – the information you share in this research will be kept private and confidential. There are some instances in which it cannot be kept confidential, however, and these include if you disclose intent to harm yourself or another person, or if you disclose current or imminent abuse or neglect of a child. In these instances, the researcher has a legal responsibility to report this to the appropriate authorities. The interview will focus on the participant’s experience of recovery from traumatic experiences both in childhood and in adulthood. Although the interview is expected to be largely a positive experience, these are questions that can bring up upsetting emotions. The co-investigator, Elizabeth Holland, is trained in interviewing and counselling, however, and will sensitively explore these issues and help keep this upset to a minimum. If at any time during the interview you would like to take a short break, this will be arranged. If at any time during your participation you feel you do not want to continue, you may discontinue your participation. You will still be entered into the draw for the $50 gift certificate. After the interview, you will be contacted once more (by either e-mail or phone, whichever you prefer) to be given an opportunity to give us feedback on how your interview replies have been categorized. This is a very important aspect to this type of research, as it gives you the chance to tell the researchers if they have understood and analyzed your input accurately. If you would like to receive a copy of the research once it is completed, this will be arranged. During the interview, you will be given an information sheet with names and contact information for free and low-cost counselling resources in case you feel you’d like to debrief with a counsellor about the interview experience or pursue further counselling around your traumatic experiences. Contact for information about the study: If you have any questions about this study or would like more information, please contact Elizabeth Holland by phone at ----------------- or by e-mail at ----------------------------------- or Dr. Marla Buchanan by phone at -------------------------. 105  If you have any questions or concerns about your treatment or rights as a research participant, you may contact the Research Subject Information Line in the UBC Office of Research Services at -------------------------. Consent: I understand that my participation in this study is entirely voluntary and that I may refuse to participate or withdraw from the study at any time. I have received a copy of this consent form for my own records, and I consent to participate in this study. I understand the three limits to confidentiality mentioned above. Signature: __________________________ Date: _______________________ Co-Investigator Signature: _____________________Date: ________________ Would you prefer to have your comments expressed during the interview attributed to you, rather than kept anonymous? ____ No, I would prefer them to be anonymous. ____ Yes, I would prefer them to be attributed; I would like my first name to be used. Signature: _______________________ Date: ___________________________  106  Appendix D  Telephone Screening Questionnaire  (to be completed by the interviewer and kept in a locked filing cabinet with Impact of Events Scale) Date: _________________ Participant‘s name: _________________________________ If enrolled, participant‘s chosen pseudonym: _____________ First: -Explain the nature of the study -Explain that the person‘s answers to these questions will be kept confidential (and the exceptions to that confidentiality) -Answer any questions the potential participant has, and then ask the following questions: 1) What year were you born? 19____ Is the participant 19 or older (born before this date in 1992)? Yes – proceed with screening No - exclude 2) In just a few words, please tell me the nature of one trauma you experienced as a child.  3) The following is a commonly used definition of psychological trauma, please tell me if you feel this reflects your experience of trauma: ―the person has been exposed to a traumatic event in which both of the following were present: a) the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury or a threat to the physical integrity of self or others, (and) b) the person‘s response involved intense fear, helplessness or horror‖ (APA, 2004). Yes – proceed with screening  No - exclude  4) Would you say this traumatic event impacted your life for 6 months or longer?  5) In just a few words, please tell me the nature of one trauma you experienced as an adult. 107  6) Do you feel the previous definition reflects your experience of trauma? (Read again if needed.) Yes – proceed with screening  No - exclude  7) Would you say this traumatic event impacted your life for 6 months or longer?  8) Do you currently have a mental health diagnosis? Yes – exclude  No – proceed with screening  9) Complete Impact of Events Scale. Score of 26 or less – proceed with screening  Score of 27 or more - exclude  Were you able to communicate effectively with this potential participant? Yes – enrol No - exclude  108  Appendix E  The University of British Columbia  Project Title: What Helps and What Hinders in Recovery from Cumulative Trauma Following your participation in this study, if you would like to access further services to either debrief about your interview experience or to obtain counselling, or if you are in crisis, please see the following list of resources. Resources - Victoria For a free one-time debriefing session, please contact one of the following counselling psychologists: Dr. Timothy Black University of Victoria, Department of Educational Psychology and Leadership Studies --- --- ---Dr. Marvin Westwood, University of British Columbia, Department of Educational and Counselling Psychology, and Special Education - --- --- ---For trauma counselling with a sliding fee scale: Victoria Counselling Centre 1740 Richmond Ave Victoria, B.C. --- --- ----  If you are in crisis, please contact the Vancouver Crisis Centre toll-free at: - --- --- ---Note - if you are a student at the University of Victoria or Camosun College, you can access free counselling in their counselling centres: UVic – --- --- ---Camosun – Lansdowne Campus, Dawson Building 202 – --- --- ---Interurban Campus, Campus Centre 2nd floor – --- --- ----  109  The University of British Columbia Project Title: What Helps and What Hinders in Recovery from Cumulative Trauma Following your participation in this study, if you would like to access further services to either debrief about your interview experience or to obtain counselling, or if you are in crisis, please see the following list of resources. Resources – Greater Vancouver For a free one-time debriefing session by phone, please contact one of these counselling psychologists: Dr. Marvin Westwood --- --- ---Dr. Timothy Black University of Victoria, Department of Educational Psychology and Leadership Studies - --- --- ---For free counselling, contact: New Westminster Counselling Centre - Masters counselling students, supervised by UBC faculty. (Open from September to June.) 707 Eighth Ave, New Westminster --- --- ---For trauma counselling with a sliding fee scale or reduced fees: Lana Rados, Registered Clinical Counsellor --- --- ---(offices in Vancouver and Burnaby) The Adler Centre – Masters counselling students in training, supervised by UBC faculty. 230-1818 West Broadway, Vancouver --- --- ---If you are in crisis, please contact the one of the following Crisis Centres: Vancouver – --- ---- ---Coquitlam/New Westminster – --- --- ----  Richmond/Delta – ---- ---- ---Surrey/White Rock/Langley – --- --- ----  Note, if you are a UBC student you can access free counselling services at the UBC Counselling Services office on the ground floor of Brock Hall, room 1040. Phone – --- --- -----  110  Interview Questionnaire (To be completed by the interviewer and kept in a locked filing cabinet.)  Appendix F  Date: ______________________ Participant‘s Name: _______________________________ Participant‘s Chosen Pseudonym: ____________________ First, review study and go over consent form. Demographic Information: 1) What is your occupation? _________________________________ 2) What is your age? ___________________ 3) To what ethnic group or heritage would you identify yourself as belonging? _________________________________________ 4) Where were you born? _________________________ 5) What is your first language? _____________________ Second language?___________________  Research Questions: 1) Please tell me, in just a few words, about your experience or experiences of trauma as a child.  2) Please tell me, in just a few words, about your experience or experiences of trauma as an adult.  111  3) Considering these experiences as a whole, what actions, experiences or events did you participate in that helped in your recovery from this cumulative trauma?  4) How did you participate in these actions, experiences or events?  5) What meaning did these actions, experiences or events have for you?  112  6) Considering these experiences as a whole, what actions, experiences or events did you participate in that hindered your recovery from this cumulative trauma?  7) How did you participate in these actions, experiences or events?  8) What meaning did these actions, experiences or events have for you?  113  Appendix G  Incident Tracking Log  Participant #  Date Categorized  New Helping Categories Emerged  1  September 12, 2011  9  2  September 12, 2011  7  3  September 12, 2011  5  4  September 12, 2011  1  5  September 12, 2011  1  6  September 12, 2011  1  7  September 12, 2011  0  Participant #  Date Categorized  New Hindering Categories Emerged  1  September 13, 2011  2  2  September 13, 2011  2  3  September 13, 2011  1  4  September 13, 2011  0  5  September 13, 2011  1  6  September 13, 2011  0  7  September 13, 2011  0  114  


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