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The effect of trauma work on the spirituality of the counsellor : a critical incident analysis Moosmann, Sandra 2000

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The Effect of Trauma Work on the Spirituality of the Counsellor: A Critical Incident Analysis by SANDRA MOOSMANN B.A., The University of British Columbia, 1989 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS in THE FACULTY OF GRADUATE STUDIES Department of Counselling Psychology and Special Education We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA April 2000 © Sandra Moosmann, 2000 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of CcXA^H i X K.V^ T * V y C H f M / V ^ y The University of British Columbia Vancouver, Canada DE-6 (2/88) I ABSTRACT The present study employed a modified critical incident technique to examine the effects that working with victims of violence may have on the spirituality of trauma counsellors. Individual interviews were conducted with 7 trauma counsellors. These counsellor co-researchers were asked to recount incidents that occurred in their workplace that had a significant impact on their sense of spirituality and then to describe that impact. The interviews were analyzed to extract the effects on spirituality. The effects were divided into 2 broad groupings which yielded a total of 11 categories, which were then subjected to 4 validation checks. Results indicated that the relationship between trauma work and counsellors' spirituality appears to be complex and reciprocal. TABLE OF CONTENTS Abstract 11 List of Tables vii List of Figures v m Dedication l x Chapter I: Introduction 1 Definitions 4 Spirituality 4 Vicarious Trauma 5 Chapter II: Literature Review 9 Vicarious Trauma 9 Exploring the Construct 11 Factors in the Environment 15 Factors in the Individual 17 Vicarious Trauma and Spirituality 24 Meaning 26 Relationship 31 Play 34 Mystery, Conception of Divinity, and Experience 35 iv Purpose of the Study 38 A Case for Qualitative Methodology 40 Research Question 4 3 Chapter III: Methodology 4 4 The Critical Incident Technique 4 4 Preparation for the Study 4 7 Participants 4 8 Interview Procedures 50 Analysis of the Data 54 Extraction of Effects 54 Forming the categories 58 Validation procedures 60 Chapter IV: Results 64 Demographic Information 64 Overview of Findings 67 The Categories 73 Into the Light 74 Into the Fire 77 Validation procedures 84 Exhaustiveness 84 V Follow Up Interviews 85 Participation Rates 86 Independent Raters 89 Chapter V: Discussion 90 Demographic Variables 90 General Findings 93 Categories 97 Meaning 97 Relationship 98 Play 99 Mystery, Experience and Conception of Divinity 100 Limitations of the Study 102 Implications for Research and Clinical Practice 103 Conclusion 107 Reference List 109 Appendices 115 A. Flyer 115 B. Basic Information for Initial Contact by Telephone 116 C. Basic Information for Initial Contact by Fax or Mail 117 D. Informed Consent Form 118 vi E. Explanation of Demographic Information 120 F. Opening Statement and Potential Questions 121 G. Additional Interview Questions: 122 H. Resources 123 I. Figure 8 Used in the Follow-Up Interviews 124 J. Protocol for Follow-up Interviews 125 K. Protocol for Independent Raters 128 vii LIST OF TABLES Table 1: Example of the Initial Break Down of the Transcripts 57 Table 2: Range of Responses to Demographic Questions 66 Table 3: List of Categories 83 Table 4: Participation Rates 88 viii LIST OF FIGURES Figure 1: Illustration of the Organizing Statement, 69 Dedicated to my parents Heidelinde and Kilian old souls young spirits 1 Chapter I: Introduction In the summer of 1986,1 volunteered in an orphanage in Guatemala City. I was 19 at the time, and had lived in Guatemala for six years. I knew the culture and the language quite well, but I was emotionally unprepared for working with the children who lived at Casa Guatemala. The histories of illness, poverty and neglect, and the overcrowding and meagerness of life in the orphanage shocked and depressed me. They paled, however, before the horror of the abuse some of the children had suffered before they were lucky enough to arrive at the orphanage. I knew that children in Guatemala have no rights, by law or by culture. I had heard stories of the tragedy of street children in Guatemala City. That knowledge did nothing to cushion me from the emotional trauma of hearing stories of abuse, in one case of torture, from the mouths of children. I felt bewildered and helpless, enraged and exhausted. My faith in the fundamental goodness of people and of life was irrevocably shaken. An emotional reaction such as mine, to greater or lesser degrees, may occur among people who work with victims of violence. An awareness of the impact of trauma work on the selves of therapists is beginning to emerge among both practitioners and researchers in the field of trauma. Attention has centered on a construct termed vicarious trauma. At this stage in the research, it appears that vicarious trauma is a complex group of symptoms experienced by the therapist that parallels the symptoms of post-traumatic stress disorder experienced by their clients (Figley, 1995). Research in this area is just beginning. Preliminary results (Brady 1997; Chrestman, 1995; Gamble et al, 1995; 2 Follette et al, 1995; Walton, 1997) indicate that much work remains to be done toward clarifying both the nature and the process of vicarious trauma. Other aspects of the trauma counsellor's experience, such as the possible positive effects of trauma work on the self of the therapist, remain largely unexplored (Kassam-Adams, 1995). An aspect of counsellor experience which has so far received little direct attention through research is that of the impact of trauma work on the spirituality of the therapist. Some of the literature on vicarious trauma suggests that trauma work can have a devastating effect on the therapist's sense of meaning and connection. Laurie Anne Pearlman and Karen Saakvitne (1995), in a recent theoretical article, state: We have come to believe over time that the most malignant aspect of vicarious traumatization is the loss of a sense of meaning for one's life, a loss of hope and idealism, a loss of connection with others, and a devaluing of awareness of one's experience. This constellation of experience seems best described as spirituality (Neumann and Pearlman, manuscript in preparation). For some, spiritual needs are addressed through religion, while others maintain a private, non theistic belief system that provides a context for joy, hope, wonder, meaning and connection. We believe this larger sense of meaning and connection is crucial for psychological well-being in general, and a critical tool for anyone trying to face the darkness of childhood sexual abuse. Disruptions in this realm may be the most troubling, and perhaps the least explored, aspect of the experience of both trauma survivor and trauma therapist, (p. 160-161) Unfortunately, the effect of trauma work on the spirituality of the therapist has been directly researched in only one recent study (Brady, 1997). The reason for this absence appears to me to lie in the ambivalence that seems to exist in the counselling field towards spirituality and its appropriate role both in the counsellor and in counselling research and practice. One reason for this absence is that spirituality seems almost impossible to 3 define, let alone quantify, and thus many social sciences have been reluctant to attempt to include aspects of spirituality in research (Bensley, 1991; Goodloe & Arreola, 1992; Seaward, 1991). Beyond science's discomfort with intangible experience, it seems to me that there is an interesting duality among my colleagues and in counselling classes; the spirituality and religion of clients are to be respected as an aspect of their culture and their experience, yet there seems to be almost a taboo about the open discussion of our own spirituality among counselling students. There is a flavor of reluctance about sharing this part of our personal experience. Mary Lynne Mack (1994) suggests that part of the reason for such reticence is the concern that the therapists' spirituality, i f it were to be openly expressed, might alienate or inappropriately impose itself on the client. In fact, a review of the Council for Accreditation of Counseling and Related Educational Programs in 1988 recommended that counsellor education should not include references to religion or spirituality (Ingersoll, 1994). There is, however, a growing recognition and acceptance of the importance of spirituality as an essential aspect of human experience and of counselling practice and research (Hinterkopf, 1994; Ingersoll, 1994; Mack, 1994; Saakvitne, 1995). As a student of counselling psychology considering entering the field of trauma work, I am interested in exploring how therapists' spirituality is affected by the stories of trauma that they witness. Do therapists lose their sense of connection with something greater? Are therapists able to maintain and even strengthen their sense of spirituality 4 through their work? Do therapists experience cycles of connection and disconnection? I interviewed counsellors who are currently working predominantly with survivors of violence, asking for their perceptions of how their spirituality has been affected by their work. By understanding the impact of trauma work on the spirituality of therapists, I hope to learn how to maintain my own sense of centeredness and connectedness as I enter this very challenging field. The references to the impact of trauma work on the spirituality of the therapist are contained in the literature on vicarious trauma, wherein an impaired sense of spirituality is considered to be a symptom of vicarious trauma. In this study, however, I will ask participants about the effect of their work on their spirituality, without the possible middle step of describing vicarious trauma experiences. The exclusion of vicarious trauma terminology simplifies the study, as well as hopefully avoiding some of uncertainties and contradictions of the research in this very new field of study. Definitions Spirituality Before proceeding further, it will be useful to clarify what is meant by the term 'spirituality' as used here. For the purposes of this thesis, spirituality will be very broadly defined, allowing for the extreme variety and individuality of this intangible yet fundamental aspect of human experience. Spirituality could mean time spent in nature, or a sense of connection with humanity, or it could be experienced through the enactment of religious observances. Laurie Anne Pearlman (1995) defines spirituality very broadly, as 5 "an inherent human capacity for an awareness of an elusive aspect of experience" (p.57). I invited the seven participants in this study to each define spirituality in their own way, according to their own experiences and beliefs. Spirituality was viewed in this thesis as a separate concept from religiosity. Religiosity implies a connection to an organized religion. While practicing a religion may be a part of an individual's experience of spirituality, such an affiliation is not a necessary component of spirituality. Spirituality is seen as a broader aspect of human nature and experience of which the practice of a religion may or may not be a part. In this study, several of the participants defined their spirituality at least partially in terms of an affiliation with, and practice of, an organized religion; others did not belong to organized religions and defined their spirituality in other ways. Vicarious Trauma As the references to the impact of trauma work on spirituality are contained in the literature on vicarious trauma, it will also be helpful to define vicarious trauma as it is currently understood. Vicarious trauma is referred to as secondary traumatic stress disorder, compassion fatigue and tertiary traumatic stress disorder. For the purposes of this thesis, I will use the terms vicarious trauma or secondary traumatic stress, as those are the terms which appear most frequently in the literature. While the terminology varies, there appears to be some agreement regarding the definition and symptoms of vicarious trauma. Charles Figley (1995), in the introduction to a collection of theoretical articles exploring vicarious trauma, defines it as: 6 the natural consequent behaviors and emotions resulting from knowing about a traumatizing event experienced by a significant other - the stress resulting from helping or wanting to help a traumatized or suffering person. ( p.7) The helping professional experiences a syndrome of symptoms similar to that experienced by their traumatized client. For example, the anguish that I felt working in Casa Guatemala, the bewilderment and rage, mirrored the emotions experienced by a nine year-old boy who told me how his mother had tortured him, and how he feared for his younger siblings, still trapped at home. Other symptoms of post traumatic stress disorder and vicarious trauma include difficulty sleeping, isolation from family and friends, sadness, intrusive imagery, nightmares, and bursts of irritability and anger. A shift in world view such as I experienced, typified by a heightened suspicion of others and an increased sense of personal vulnerability, is one of the more lasting effects of vicarious trauma (McCann & Pearlman, 1990; Pearlman, 1994). Theorists have questioned whether vicarious trauma can be considered a separate phenomenon, or whether it is simply a manifestation of more established concepts, such as countertransference or helper burnout (Figley, 1995; McCann & Pearlman, 1990; Saakvitne, 1996). In their review of current and past literature, McCann and Pearlman (1990) distinguish between differing conceptualizations of the negative effects of counselling on counsellors. They postulate that vicarious trauma is both a concept distinct from countertransference and burnout, and unique to working with victims of trauma. Countertransference, originally identified and defined by Sigmund Freud, describes the danger of the therapist overidentifying with the client, and confusing the 7 client's concerns with the therapist's own issues. While vicarious trauma certainly results from identification with, and empathy for, the client, it does not involve a projection of the therapist's issues onto the client. Vicarious trauma is a consequence of caring and does not imply a flaw in the therapist or in the therapeutic method. Burnout refers to a long-recognized and well-documented syndrome of emotional and physical exhaustion resulting from sustained exposure to emotionally demanding situations (McCann & Pearlman, 1990). While burnout is a process which develops slowly, increasing in intensity over time, vicarious trauma can emerge suddenly and usually has a faster recovery rate. While burnout and vicarious trauma have some symptoms in common, such as irritability and difficulty concentrating, the effects are quite distinct. Burnout involves dehumanizing and intellectualizing clients, cynicism, decreased investment in work and feelings of ineffectiveness. In contrast, therapists suffering from vicarious trauma retain their empathy for clients and attachment to work, and feelings of detachment and cynicism are directed more at the therapists' worlds outside of work (Figley, 1995). The research on vicarious trauma indicates that trauma work has a particular and potentially serious effect on the self of the therapist, distinct from that of other stressful counselling situations (Gamble, Pearlman, Lucca & Allen, 1995). This very new area of study is still in the exploratory stages, however, and much remains to be done towards defining the construct. Key issues, such as possible mediating or compounding variables in the therapeutic environment and in the therapist, remain very much under debate 8 (Chrestman, 1995; Kassam-Adams, 1995; Walton, 1997). These controversial issues are discussed further in the following literature review. 9 Chapter II: Literature Review Vicarious Trauma The last two decades have witnessed a rising interest in the psychological impact of traumatic events. The common effects of a variety of traumatic events were officially recognized by the inclusion of post-traumatic stress disorder in the Diagnostic and Statistical Manual. The concept has received wide-spread validation and support through both research and practice since the publication of D S M III in 1980, and its revision in 1987 (Figley, 1995). In the wake of interest in post-traumatic stress disorder (PTSD) has come an increasing awareness of the cost of trauma work among helping professionals in a variety of fields including medicine, disaster work, counselling, and social work. The very recent, burgeoning research in vicarious trauma, a term coined by Lisa McCann and Laurie Anne Pearlman (1990) in a landmark article describing a theoretical construct for vicarious trauma, has both illuminated and complicated the description of secondary traumatic stress offered by early writers in this new field. In researching this very new construct, the majority of studies which I have so far been able to locate have been surveys, some published, some not. They focus on further defining the symptoms and nature of vicarious trauma, confirming the unique effects of trauma work on the self of the therapist, and identifying possible mediating and/or compounding variables either in the environment or in the therapists themselves. 1 0 One of the most immediately apparent and frequently discussed limitations of the research in vicarious trauma is the lack of appropriate testing instruments to measure this new construct (Chrestman, 1995; Gamble, Pearlman, Lucca & Allen, 1995; Nicholls, 1997). The most frequently cited tests in the following studies are the Impact of Events Scale (IES), the Symptoms Checklist - 90 - R (SCL-90-R) and the Traumatic Stress Institute Belief Scale (TSI Belief Scale). The IES and the SCL-90-R are designed to measure post-traumatic stress symptoms. Kelly Chrestman (1995) suggests that tests designed to measure post-traumatic stress symptoms may not be sensitive enough to measure the much milder symptoms of vicarious trauma. The TSI Belief Scale was developed specific to vicarious trauma, but is of such recent origin that no literature concerning its validity and reliability is yet available (Nicholls, 1997). Defining the construct of vicarious trauma and developing appropriate measures are among the foremost challenges facing researchers in this field today. Several researchers have recommended that one of the ways to begin constructing appropriate measures is through qualitative, exploratory research (Gamble et al, 1995). The qualitative approach proposed in this thesis may offer a first step in illuminating an aspect of trauma counsellor experience upon which quantitative measures may be built. A second concern expressed by several researchers (Charney & Pearlman, 1996; Gamble et al 1995; Follette, Polusny & Milbeck, 1994; Kassam-Adams, 1995; Pearlman & Mclan, 1995) is that currently all trauma work is being considered as potentially causative of vicarious trauma symptoms. Parallels have been drawn between the 11 experiences of helpers working with a broad variety of trauma survivors, including rape victims, child abuse survivors, veterans, political refugees, and survivors of torture and war. Survivors in all of these situations may develop symptoms of post-traumatic stress and their therapists, in parallel, may develop vicarious trauma symptoms. This is a hypothesis that has not, however, been tested. More research is needed regarding what kinds of work situations are particularly difficult for therapists and why. Exploring the Construct One of the aims of many of the recent studies of vicarious trauma have been to distinguish vicarious trauma from general work-related stress and burnout. In a recent presentation describing the results of an unpublished study (Gamble et al., 1995), in which she was involved, Gamble discussed the implications of their survey findings pertinent to construct development. Of the 120 respondents, 39% were female, 60% were male, their average age was 45.6, and an average of 32% of their caseload was made up of trauma survivors. The respondents were asked to complete two Traumatic Work Questionnaires (an unpublished measure developed by the researchers), one considering their trauma clients and one considering their non-trauma clients. Factor analysis was conducted on the twenty-five item test to reveal five coherent clusters. Respondents indicated that their trauma clients engaged more frequently in behaviours that the therapists found stressful, such as hostile acting-out, flashbacks and self-destructiveness. Even more interestingly, using co-variance analysis, the researchers found that "therapists report significantly more stress in working with trauma clients compared to non-trauma 12 clients, even when the frequency of distressing behaviours was held constant" (p.4). Specific symptoms thought to be indicative of vicarious trauma, including feeling helpless and experiencing intrusive imagery, were significantly related to work with trauma survivors. Gamble and her associates conclude from these results that trauma work with survivors is experienced by therapists as being "distinctly different (and on the whole, more distressing) than their work with non-traumatized individuals" (p. 5). Gamble (1995) states that much more research is required to articulate the specific realms in which vicarious trauma is experienced. We need to narrow the construct of vicarious traumatization... while also developing valid ways of assessing disruptions in therapists' frame of reference (p. 19). Gamble and associates recommend in-depth interviews as a way of accessing specific aspects of trauma work which may be particularly difficult for counsellors to process. Munroe (1995), in a summary of the findings of his unpublished doctoral dissertation, completed in 1990, states that his results support the hypothesis that vicarious trauma is a construct distinct from burnout. One hundred and thirty-eight therapists, all working with Vietnam veterans, completed a demographic questionnaire and two post-traumatic stress instruments, the Impact of Events Scale (IES) and the Symptom Checklist-90-R (SCL-90-R). A combination of high current and cumulative exposure to combat veterans suffering post-traumatic stress symptoms was significantly correlated with post-traumatic stress symptoms in the therapist. Munroe also stated that post-traumatic stress symptoms were not related to burnout, but may be compounded by burnout. As no figures or tables were included in the summary and the dissertation is 13 unavailable for loan, I am unable to analyze Munroe's conclusions, and therefore merely repeat them. Munroe's dissertation is, however, cited in other studies as demonstrating both that exposure to PTSD clients results in vicarious trauma reactions in therapists and that vicarious trauma is distinct from burnout (Kassam-Adams, 1995; Pearlman & Mclan, 1995; Pearlman & Saakvitne, 1995). Further support differentiating burnout from vicarious trauma was offered by a later study by Schauben and Frazier (1995). Schauben and Frazier (1995), in exploring vicarious trauma among counsellors working with sexual violence survivors, investigated the experience of vicarious trauma on four fronts: differentiating vicarious trauma from burnout and negative affect (such as anxiety and depression), assessing the effects of working with survivors of sexual violence, examining whether a personal trauma history effects counsellor experience of vicarious trauma, and identifying coping strategies. One hundred and eighteen psychologists and thirty sexual violence counsellors, all women, predominantly Caucasian, responded to mailed questionnaires. An average of 45% of the psychologists' caseload was comprised of sexual violence survivors, as compared to an average of 94% for sexual violence counsellors. The Maslach Burnout Inventory was used to assess degree of burnout and four sub-scales from the Brief Symptom Inventory were used to measure negative affect. Neither scale was found to correlate with number of survivor clients. On the other hand, PTSD symptoms, measured by a symptom checklist developed by the authors based on the DSM III-R, did correlate with number of survivor clients. Self-report of vicarious 14 trauma experience and five sub-scales chosen from the Traumatic Stress Institute Belief Scale (an unpublished measure designed to assess disruptions in cognitive schema associated with vicarious trauma) likewise demonstrated a positive correlation with number of survivor clients. These results suggest that the experience of PTSD-like symptoms do occur in relation to high degree of exposure to traumatic material and that this experience is unrelated to burnout or negative affect. Unfortunately, in Schauben and Frazier's (1995) study the percentage of caseload may be confounded with other variables, a concern which was not addressed by the authors. The higher caseload typical of the sexual violence counsellors was only one variable which differentiated this group from the psychologists. Psychologists tended to be older, more educated, better paid, and to have worked with survivors an average of 5 years longer than the sexual violence counsellors. Such traits could very well affect counsellors experience of, and resistance to, vicarious trauma. The relationship identified between caseload and test scores could be as much a product of experience and age as high caseload. Exposure to trauma clients, experience and age are all variables which have been studied in other research projects. In support of Schauben and Frazier's (1995) interpretation that percentage of survivor clients correlates with vicarious trauma symptoms, several other studies have yielded similar results, while the results regarding the influence of age and experience are mixed. These studies are discussed below. 15 Factors in the Environment Several other studies have explored the issue of whether amount and/or duration of exposure to traumatic material increases experience of vicarious trauma. Munroe (1995) suggests that "just as intensity and duration of exposure to traumatic experiences is related to PTSD in clients, it would also be related to secondary effects in therapists" (p.32), a supposition supported by his dissertation results. This finding has been confirmed by several other studies (Arvay & Uhlemann, 1996; Battley, 1995; Brady, 1997; Chrestman, 1995; Kassam-Adams, 1995; Pearlman & Mclan, 1995). In fact, I have not yet discovered a study which did not support the idea that the percentage of trauma survivors in a therapist's caseload is related to increased vicarious trauma symptoms. A hypothesis suggested by the relationship between high survivor caseload and vicarious trauma symptoms is that a balanced caseload and/or a balance in therapist activities can greatly ameliorate the experience of vicarious trauma. A work place which fosters and encourages the opportunity for research, educational and preventative activities as well as balanced caseload may be promoting greater mental health in its therapists (Rosenbloom, Pratt, & Pearlman, 1995; Traumatic Stress Institute, 1995). Along with promoting balance in work activities and caseload, the workplace can also help therapists cope with trauma clients in another way. One of the mediating variables suggested in the literature is that of perceived support (Bustos, 1990; Catherall, 1995; Herman, 1992; McCann & Pearlman, 1990b; Munroe et al, 1995; Walton, 1997). The forms which may be most relevant to vicarious trauma are those in which the 16 therapist is able to process the client stories that they hear, namely by discussing them in a supportive environment of colleagues and supervisors. Such relationships, if they are supportive, offer the opportunity of professional input while protecting the confidentiality of clients. It is currently thought by some that therapist support at home and through friendships may not be as relevant as professional support. Some researchers hypothesize that therapists are unlikely to process traumatic stories with family and friends for fear of breaking client confidentiality as well as wanting to protect loved ones from the reality of trauma (Bober, 1995; Chrestman, 1995). So far, the research into the effects of supervision and support have yielded mixed results. Pearlman and Mclan (1995) included supervision as one of several variables in their survey study. Seven hundred and eighty surveys were distributed to three groups of potential participants: therapists attending a training seminar for trauma professionals, therapists belonging to an international association of trauma professionals, and graduate students in clinical training. One hundred and eighty-eight self-identified trauma therapists returned usable surveys. Several measures were used to assess vicarious trauma symptoms, including the TSI Belief Scale, the SCL-90-R and the IES. On the supervision variable, a subset of respondents (those with a personal trauma history) showed a negative correlation between supervision and scores on the three above mentioned measures. The authors conclude that supervision can play a protective role for trauma counsellors, helping to prevent the development of secondary traumatic stress disorder. This conclusion has been supported by other studies, where increased 17 supervision was found to be associated with lower symptamology (Kassam-Adams, 1995). Denise Walton's (1997) dissertation yielded a different result, using the Impact of Events Scale - Revised, among several other instruments. Out of the 900 research packets sent out to therapists belonging to the International Society for Traumatic Stress Studies, 165 usable packets were returned. Walton included supervision, perceived social support and self-disclosure about the effects of providing trauma therapy as three of several variables being studied. None of the three were found to be related to scores on the IES-R. As the populations and scales used were quite similar, it is difficult to reconcile such opposite results. More research needs to be done involving the variable of supervision and support in order to clarify this issue. Factors in the Individual As well as the possible influence of work place variables on experience of vicarious trauma, researchers have begun to investigate the possible influence of individual variables. Of particular interest have been age and experience, gender, personal history of trauma and use of a variety of coping strategies. One of the variables being considered is whether or not experience in trauma work prevents or reduces vicarious trauma symptoms. Most of the studies reviewed below did not separate the potential mediating factors of age and experience in the field of trauma. It is conceivable that the two may have differing influences on the experience of vicarious trauma, but, perhaps because age and experience frequently occur together, they have not 18 often been studied separately. Hence, I will treat age and professional experience together, as they have most frequently been addressed in the research. In a survey of therapists belonging to three different professional organizations, Kelly Chrestman (1995) examined several potential mediating variables, one of which was professional experience. She states that "increased professional experience was associated with decreased avoidance, dissociation, anxiety, and sexual abuse trauma symptoms" (p.31) as measured by the IES and the Trauma Symptom Checklist. While scores on these measures did not reach clinical levels, as they would among people suffering from post-traumatic stress disorder, they did differentiate significantly between therapists working with predominantly trauma survivors and therapists with mixed or non-trauma caseloads. Chrestman points out the need for comprehensive measures specific to vicarious trauma. It is possible that post-traumatic stress measures may only measure more extreme symptoms of vicarious trauma, while milder experiences of vicarious trauma symptoms may be missed. Arvay and Uhlemann (1996), in a survey of 161 British Columbian trauma counsellors, developed a demographic profile of counsellors who tended to score higher on measures of stress, including the Impact of Events Scale. With regards to age and experience, they found that counsellors "who are younger and with less experience in the field of trauma reported higher trauma symptoms" (p.202). In addition, counsellors with higher stress scores tended to be less educated (less than a master's degree), to have higher caseloads, and to seek less supervision than counsellors with lower stress scores. 19 Interestingly, 14% of the counsellors in Arvay and Uhlemann's sample endorsed traumatic stress levels comparable to those experienced by clients suffering from Post Traumatic Stress Disorder, in contrast to Chrestman's (1995) study, described above, where counsellors did not endorse clinical levels of PTSD symptoms on the same scale. Unfortunately, Chrestman's article did not include detailed demographic information, so it is not possible to meaningfully compare her sample with Arvay and Uhlemann's sample. Susan Battley (1995), in an unpublished doctoral dissertation, surveyed 88 therapists, comparing and contrasting those with and without trauma survivor clientele. The survey included a demographic questionnaire and two trauma symptom measures: the World Assumptions Scale and an adapted version of the Modified Post Traumatic Stress Disorder Symptom Scale. Symptamology was found to be negatively correlated with therapist age on both measures. This is consistent with Pearlman and Mclan's (1995) findings that increased age and professional experience were associated with decreased scores on trauma symptamology measures. As Pearlman and Mclan point out, however, it is difficult to determine, in the absence of a longitudinal study, whether these scores suggest that vicarious trauma will decrease as therapists learn over time how to cope with traumatic material. An alternative explanation could be that newer therapists who experience high levels of vicarious traumatization simply leave the profession. A third possibility is that those therapists who last longer in the field may comprise a select group who never experienced high levels of vicarious trauma at any point during their careers, due to variables which are at this point unidentified. 20 Interestingly, Kassam-Adams (1995), in a survey of 100 graduate level psychotherapists, found that, in her sample, experience was not correlated with either increased or decreased symptamology. The measures used were the Impact of Events Scale (IES) and the Personal Strain Questionnaire. Kassam-Adams' sample ranged in years of experience and in age, with 8.7 mean years of experience, similar to the above mentioned studies. Here again is an unanswerable conundrum. Kassam-Adams did not offer any explanatory suggestions. Kassam-Adams (1995) was also the only researcher that I have found so far who addressed the issue of gender. In her sample, three quarters of whom were women, the three variables of gender, personal trauma history and exposure to trauma clients was found to be predictive of trauma symptamology as measured by the Impact of Events Scale. Even though the percentage of personal trauma history and exposure to trauma clients was equivalent for both male and female respondents, women were found to demonstrate higher levels of trauma symptoms. Nancy Kassam-Adams states that this is a puzzling finding and one that should be interpreted with caution, particularly since only 25 men were included in the study. Other studies which included a majority of men in the sample (Munroe, 1995; Follette et al, 1994; Gamble et al, 1995) did not report any gender related differences in trauma-like symptamology. One of the variables under consideration in most of the studies which I reviewed was that of whether or not a personal history of trauma affects how therapists react to the traumatic material presented by their clients. Several studies found significantly 21 higher levels of vicarious trauma symptomatology among therapists with a personal history of trauma (Battley, 1995; Follette, Polusny & Milbeck, 1994; Schauben & Frazier, 1995). Munroe (1995), however, found that therapists who were combat veterans themselves did not experience significantly higher levels of vicarious trauma than their non-veteran colleagues. Kassam-Adams' (1995) findings may offer an explanatory suggestion. Respondents in her sample were asked to list which of six different categories of trauma they had experienced, if any. Of the six, only childhood trauma was found to be significantly predictive of higher scores on trauma symptom measures. Kassam-Adams echoes the suggestion posed by Gamble (1995) and others (Follette, Polusny & Milbeck, 1994; Pearlman & Saakvitne, 1995) that more research is required regarding which specific work-related events are triggering for therapists as well as how those events interact with personal trauma history. Finally, coping strategies have been of interest in some studies as a potential mediating influence. Schauben and Frazier's (1995) research suggests that there are several coping techniques which are common among counsellors who work with survivors of violence. In their research, the issue of coping was addressed in two ways. A list of fifteen coping strategies were provided and counsellors were asked to indicate on a five point scale to what extent they engaged in each strategy. Respondents were also asked to list any other coping strategies they employed. Schauben and Frazier organized the responses to the open-ended question into four categories. Taking both types of 22 responses into consideration, Schauben and Frazier reported the five most common and the three least common coping strategies. The most common coping techniques listed in Schauben and Frazier's (1995) study include: active coping (i.e., I concentrate my efforts on doing something about the problem); seeking emotional support (i.e., I try to get emotional support from friends or relatives); planning (i.e., I make a plan of action); seeking instrumental social support (i.e., I try to get advice from someone about what to do); and humor (i.e., I laugh about the situation), (p.59 - 60) The least common coping strategies included the use of alcohol and drugs, denial of the problem and disengaging from the client. Schauben and Frazier (1995) correlated the coping strategies with the respondents' scores on the measures thought to be indicative of vicarious trauma symptoms. Counsellors who stated that they frequently used the five most common coping strategies showed lower scores on the measures of vicarious trauma. Negative correlations ranging from -.14 to -.36 were demonstrated between experience of vicarious traumatization and the five most common coping strategies. One of the least common coping strategies, behavioural disengagement, was shown to be positively correlated with currently experiencing vicarious trauma (coefficients of .22 and .17 respectively). These findings suggest, as one might hope, that counsellors tend to use those strategies which are most effective in preventing vicarious trauma most frequently. A study comparing the reactions of law enforcement officials and mental health professionals to working with trauma survivors also addressed the possible mediating 23 effects of coping strategies. Follette, Polusny, and Milbeck (1994) surveyed 225 psychologists and 47 police officers. Particularly helpful coping strategies included humour, education of self and others about abuse, support of others, and consultation with colleagues. Use of negative coping strategies such as aggression against significant others, use of alcohol and drugs and negative responses to clients (self-reported) were found to be predictive of higher trauma symptamology. As in Schauben and Frazier's (1995) study, positive coping strategies were reported by respondents as being more commonly used than negative coping strategies. Many researchers have stated concerns regarding the adequacy of current measures for vicarious trauma (Chrestman, 1995; Gamble, Pearlman, Lucca & Allan, 1995; Kassam-Adams, 1995). Only one of the above mentioned measures, the Symptoms Checklist - 90 - R, was listed in Tests in Print IV (Murphy, Conoley, & Impara, 1994). The SCL-90-R received generally supportive reviews in Tests in Print IV. with a caution about the validity of the SCL-90 for diagnostic purposes (Pauker, 1985; Payne, 1985). Only one measure, the TSI Belief Scale, was cited specific to vicarious trauma. I have not yet found any reviews of the Traumatic Stress Institute Belief Scale, although with its many recent uses in studies of vicarious trauma, research regarding the validity and reliability of this measure may not lag far behind. Several studies have suggested that the next step in developing research measures may be to conduct more qualitative research. The detailed and comprehensive information which in-depth interviews can 24 provide may be of use in constructing future measures (Chrestman, 1995; Gamble, Pearlman, Lucca & Allan, 1995; Kassam-Adams, 1995; Pearlman & Mclan, 1995). The findings regarding vicarious trauma raise many questions. Much work clearly remains to be done in fully exploring and explaining what is emerging as a very complex construct. One of the least mentioned and least researched aspects of secondary traumatic stress is the effect of trauma work on the spirituality of the therapist. Aspects of spirituality, when they are mentioned at all, are usually included in the introductory paragraphs briefly describing the effects of vicarious trauma. Only three studies which I have discovered so far include aspects of spirituality. Both theory and research are summarized below. Vicarious Trauma and Spirituality Much of the unpublished research was made known and/or available to me through the Traumatic Stress Institute in South Windsor, Connecticut, one of the foremost institutions currently involved in vicarious trauma research. The references to the effect on spirituality as an aspect of vicarious trauma are primarily contained in the literature originating from the Traumatic Stress Institute, written by Laurie Anne Pearlman and her associates. This literature employed a very broad definition of spirituality, consistent with the definition used in this thesis proposal. Neuman and Pearlman (manuscript in preparation) are currently devising a construct and language for spirituality as used in the literature on trauma and vicarious trauma (Nicholls, 1997). Unfortunately this manuscript is unpublished and currently unavailable. 25 Pearlman and Saakvitne (1995b) have also developed a measure which they hope will aid in the effort to include spirituality in the study of vicarious trauma. The Life Orientation Inventory uses a six point scale to measure respondents' level of agreement with a variety of statements designed to tap aspects of spirituality and spiritual experience. I have not yet discovered any studies or literature using or citing this very new measure. Given the reluctance of the psychological world to address issues of spirituality through research, there exist very few studies in vicarious trauma that include aspects of spirituality. I have so far been able to find only one study which examines spirituality specifically, and two qualitative studies which include aspects of spirituality in their results. The first study is an unpublished dissertation by Joan Laidig Brady (1997) which utilizes a survey design to compare the spiritual well-being (among other variables) of trauma counsellors with that of counsellors in other areas of practice . The second research project is an unpublished, qualitative study by Cynthia Bettcher (1996) exploring therapists' perceptions of how they have been affected by their work with trauma survivors. Portions of Bettcher's results are included in the sections on meaning, relationship and play, below. The third study is a dissertation by Maria J. Arvay (1998) which uses narrative analysis to examine the meaning that therapists construct of their experiences of secondary traumatic stress. In reviewing the literature on vicarious trauma and spirituality, a framework for viewing spirituality was necessary, as various wording and approaches were used in 26 describing what seems to me to be related subjects. An article by Elliot Ingersoll (1994) provided this framework. Ingersoll describes seven dimensions to spirituality as the term is currently being used in the counselling and psychology literature. The dimensions include meaning, play, relationship, mystery, experience, conception of divinity and dimensional integration. The seventh dimension, dimensional integration, describes the interconnectedness of these dimensions. As became evident through this review, the dimensions overlap and interconnect considerably, and in some ways this division of the literature according to dimensions feels artificial. Some way of organizing the vague bits and pieces of literature was necessary, however, and the dimensions are a useful way of conceptualizing the multifaceted, intangible construct of spirituality. Together, they provide a language for describing the varied and individual experiences of spirituality. The experience of trauma and vicarious trauma can disrupt spirituality across the dimensions. Meaning The first dimension, meaning, can be understood as whatever the individual experiences as making life worth living. Ingersoll (1994) suggests two possibilities; a feeling of purpose and an experience of beauty. Amy Charney and Laurie Anne Pearlman (1996), in a recent paper exploring the common effects of disaster and trauma work on the self of the therapist, state that one of the most significant effects of psychological trauma and, in parallel, vicarious trauma, is the disturbance to spirituality. As therapists, "our personal sense of meaning and hope can and probably will be disrupted as we engage with people's despair and loss of that which they held meaningful and as we witness and 27 connect with individuals straggling to recreate their lives" (p. 19). This statement anticipates a portion of the results of Bettcher's (1996) master's thesis. Bettcher's (1996) findings from her master's thesis exploring the impact of trauma work on the self of the therapist touches on themes which are relevant to spirituality. Bettcher, in a focus group involving five women counsellors who work with victims of sexual violence, defined four themes (Challenges and Changes in World View, Dis/Connection with Others, Heightened Self Awareness, and Finding Balance) which arose from the group discussion, each of which were divided into sub-themes. A common experience that the counsellors described was an ongoing effort to find meaning, which they addressed in different ways. Some found attending workshops and educational seminars helpful as a way of learning to understand the 'why' of abuse. Some of the women talked about adopting a feminist philosophy as a way of understanding men's violence, although they found that such a philosophy did not help them grapple with the reality of women abusers. The counsellors described this struggle for understanding as an ongoing process of attempting to confront and integrate the horrors they were consistently exposed to. Karen Saakvitne (1996), in a presentation at the Sixteenth Annual Spring Meeting of Division of Psychoanalysis (39) in New York, states that the most insidious and yet most important challenges facing trauma counsellors are those which involve the effort to find meaning in trauma work. She states: 28 In our own searches for meaning we will be forced to integrate the realities of cruelty, indifference, and abuse that we have heard and to which we have been empathically and humanly connected in our offices, (p.9) Such a confrontation can be devastating for those counsellors who enter trauma work with idealism about people and about healing. Most counsellors enter trauma work unprepared for the toll it will take on them, the loss of their most fundamental beliefs about life, loss of hope and purpose, loss of direction (Bettcher, 1996; Saakvitne, 1996). Many counsellors may find themselves at times feeling adrift, confused and lost. It was in the dimension of meaning, however, that the most hope for healing was also offered, fast on the heels of descriptions of how devastating trauma work can be. Transformation and resolution may be possible. Victor Frankl (1959) states that the way through suffering and trauma is to find meaning in it. Finding hope and understanding are necessary in surviving horror. This statement is echoed by the five counsellors in Cynthia Bettcher's (1996) focus group. They emphasized the power that the work had for them, in watching and understanding the tremendous ability of people to heal, to transform and redefine themselves in ways which integrate and use their tragedies. "Acknowledging the power of the work provided these women with a sense of renewed hope and purpose" (p.84). Arvay (1998), in a narrative analysis of four women's stories of secondary traumatic stress, detailed both the struggle to find meaning in secondary trauma, and the hope that witnessing transformation can provide. Ruby, a character in the fictional conversation that comprises Arvay's discussion section, states: 29 I can't say that I have experienced intrusive thoughts in the way that I believe they represent a traumatic symptom. There are some stories that will probably always stay with me, particularly the stories told to me in South Africa, by the victims of apartheid. But even then there seemed to be another story, a transformative story juxtaposing the apartheid story. The people I spoke with also had great hopes and were so courageous that I left the country not feeling despair but inspiration. I got to see the other side of trauma, the transformative, inspiring stories of survival. I am not trying to diminish the intrapsychic struggles we are talking about, but there is the other side of trauma that keeps us doing this work, the capacity of the human spirit to heal and recover from traumatic events, (p. 178) The struggles and hope of trauma work are woven throughout the four stories and the fictional conversation in which the findings are discussed. Pearlman and Saakvitne (1995b), in their book Trauma and the Therapist, discuss this potential for finding meaning in the face of confronting the very darkest side of humanity. Witnessing healing, having a part in the transformation of people struggling with their histories of abuse, recognizing that they have had a part in protecting a future generation through breaking the cycle of abuse: all of these aspects of their work create a sense of purpose and hope for therapists. People survive trauma, they can transcend trauma, and trauma therapy can facilitate that process - therein lies the hope and the purpose that the therapist must cling to when confronted with a new story of horror, another devastated and shattered soul. Pearlman and Saakvitne offer this as the touchstone of meaning for therapists entering the trauma field, both as a way of understanding the damage trauma work can do to a therapist's sense of meaning and the possibility of transformation and healing of that damage. Interestingly, the survey by Joan Laidig Brady (1997) suggests that trauma counsellors may in fact develop a stronger, more profound sense of meaning and purpose 30 than non-trauma counsellors. Brady surveyed a randomly selected sample of 1000 women therapists belonging to either the American Psychological Association or the American Professional Society on the Abuse of Children. Brady had an overall response rate of 46.7%; of the surveys which were returned, 446 were useable. Brady used the TSI Belief Scale and the Impact of Events Scale to measure vicarious trauma symptoms and the Spiritual Weil-Being Scale and the Gorsuch Adjective Checklist to measure effects of trauma work on spirituality. According to Brady, the Spiritual Well-Being Scale is the most extensively researched measure of perceived spiritual well-being available and has been found to correlate positively with measures of life purpose, as well as measures of "intrinsic religious orientation, religiosity, spiritual maturity, self-esteem, internal locus of control, assertiveness, self-confidence, and self-ratings of physical health to name a few" (p. 52). Brady cites several studies which yielded high test-retest coefficients (ranging from .73 to .96) and high internal consistency (over .84 for seven different samples). According to a review by Ayres D'Costa (1995) in the Mental Measurements Handbook, "a large number of concurrent validity studies have been conducted to substantiate the validity of the instrument as a direct general measure of spiritual well-being" (p.984). D'Costa points out, however, that the instrument has a ceiling effect; it has limited utility in discriminating among people who score in the upper range of the scale. It would appear that the instrument is useful in identifying people who are not spiritually healthy, rather than discriminating among people who are relatively healthy. 31 Brady states that, as her sample was not a "religious sample" (p.53), the ceiling effect of the Spiritual Well-Being Scale should not effect the validity of the study. Patricia Schoenrade (1995), in her review, notes that the normative sample used by the authors of the Spiritual Well-Being Scale were predominantly Christian. Schoenrade states that "this homogeneity is somewhat unfortunate, given the authors regard the scale as nonsectarian and recommend its use with individuals with a variety of beliefs" (p.85). This concern is not addressed by Brady (1997). Interestingly, Brady (1997) found that exposure to trauma material was positively correlated with scores on the Spiritual Well-Being Scale. Brady states that "psychotherapists with greater current and cumulative exposure to sexual trauma clients did not receive significantly lower scores on the Spiritual Well-Being Scale. In some cases, the exact opposite was true...several of the exposure variables were significant in the other direction" (p.67). Brady concludes that "the more exposure to trauma material, the higher the respondent's spiritual well-being" (p.68). This finding suggests that the potential benefits, spiritually speaking, of trauma work may in fact outweigh the potential dangers. Brady states that "this study's empirical findings call for a new paradigm in regard to vicarious trauma and spirituality" (p.79). Relationship Relationship, the second of Ingersoll's (1994) dimensions, refers to "a striving for and infusion with the reality of the interconnectedness among self, other people, and the Infinite/Divine" (p. 102). The first theme of Cynthia Bettcher's (1996) thesis, Challenges 32 and Changes in World View, described the ways in which the women's perceptions of humanity were colored by the atrocities experienced by their clients. For a therapist whose sense of spirituality involves a feeling of connection with humanity, such a loss of innocence might taint a very centering connection. Such was my experience in Guatemala, where my faith in the fundamental beauty and power of people was lost. For some time after that summer, humanity, outside of the people I knew closely, felt ugly and dangerous to me. It was many years before I learned to see people in a balanced way, recognizing both the potential for goodness and for harm. One of the counsellors in Bettcher's focus group described her experience in a similar way: I'm affected by this work at a whole existential, spiritual level. For the longest time I thought nobody's bora evil, that it's a product of our culture or our society. I think of all of the acts that take place, whether I hear it through work or through the news.... it feels like an existential crisis, you know, of maybe there is evil, maybe there are bad people, (p.83) Karen Saakvitne (1995), in an article describing therapist responses to dissociative clients, labels this phenomenon as disruptions of core beliefs about the world, particularly disruptions to cognitive schema regarding humanity and relationships. Many therapists experience impaired ability to be close to significant others. Chrestman (1995) noted a tendency among trauma therapists to withdraw from personal relationships as quantified by a decreased interaction with family and friends. Pearlman and Saakvitne (1995), however, offer a hopeful note in response to the concern regarding disruption to trauma therapists' sense of connection. They suggest that reconnecting with others, taking relational risks and pursuing love can be "a potent 3 3 antidote to the toxic malevolence childhood sexual abuse therapists can encounter in their work (p.3)". Mindfully building strong personal and professional relationships may help to buffer the potential effects of trauma work. Another aspect of the dimension of relationship (Ingersoll, 1994) is relationship to the self. Several theorists discuss both the potential to become dissociated or severed from a sense of self through vicarious trauma and also the possibility of greater connection, self-understanding and growth. Saakvitne (1995) describes the possibility of becoming de-sensitized and cut off from emotion and from the self, a concern which has been expressed by other theorists as well (Figley, 1995; McCann & Pearlman, 1990b; Pearlman, 1994; Pearlman & Saakvitne, 1995b). This dissociation is perceived as an act of self-preservation, protecting therapists from powerful and painful feelings engendered by their work. Pearlman and Saakvitne (1995b) point out that trauma work can also lead to greater self-understanding and awareness. This idea was supported by one of Bettcher's (1996) findings. Several of the counsellors in her focus group discussed the element of increased self-awareness generated through their work. Some suggested that their clients act as "mirrors, reflecting the areas of personal work they too had to complete" (p.73). Trauma work also, by forcing counsellors to confront the shadow side of humanity, brought the counsellors to greater awareness of their own shadow side and potential for violence. While this was by no means a pleasant awareness, the women who expressed 34 this experience felt that this understanding was a part of their growth as therapists and as people. Plav The third of Ingersoll's (1994) dimensions, play, refers to the capacity for joy and unpurposeful, mirthful experience or activity. Nearly all of the sources which discussed spirituality referred to an impaired ability for play and joy (Charney & Pearlman, 1996; Figley, 1995; Pearlman & Saakvitne, 1995; Pearlman & Saakvitne, 1995b; Saakvitne, 1996). Pearlman (1994) notes that the heaviness, cynicism and bitterness that can accompany trauma work inhibit our ability to be playful and joyful. It can feel almost disrespectful and insensitive to feel happiness in the knowledge that others experience such pain and devastation. Yet "play is essential to being fully human" (p. 18) and can do much to counter the despair of exposure to trauma. An aspect of play (and also of relationship) as described by Ingersoll (1994) is sexual play and intimacy. The counsellors in Bettcher's (1996) focus group, all of whom worked with victims of sexual violence, described the impact of their work on their sexuality. One woman described how, when she felt tired and depressed by her work, it affected her spontaneity and enjoyment of sexual activity with her partner. Another stated that she occasionally suffered intrusive imagery and thoughts during sex, tainting her enjoyment with feelings of vileness and corruption. The spontaneous intrusion of images of client stories is currently thought to be a common experience among counsellors 35 suffering from vicarious trauma (McCann & Pearlman, 1990; Pearlman & Saakvitne, 1995b). Mystery. Conception of Divinity and Experience The last three dimensions - mystery, conception of divinity and experience - have been discussed very seldom in the literature on vicarious trauma and spirituality. Mystery refers to the ambiguity and inability to know with certainty the nature of the divine. Such a tolerance for doubt and uncertainty has been little cultivated in Western cultures and religions (Keats, quoted in Ingersoll, 1994). The dimension of mystery has not yet been addressed in the literature on vicarious trauma and spirituality as far as I have been able to ascertain. Experience refers to the lived and felt aspects of spirituality, beyond an intellectual understanding of a belief system. Many organized religions create opportunities for daily experience of spirituality through ritual, as well as providing the possibility of peak experiences (Maslow, quoted in Ingersoll, 1994). I was unable to find reference to this dimension in the theoretical literature on trauma work and spirituality. The dimension of experience was, however, included in Brady's (1997) study through use of the Spiritual Well-Being Scale. The Spiritual Weil-Being Scale includes questions regarding sense of satisfaction through prayer and the experience of communion with God. As discussed above, Brady found that exposure to trauma material was positively correlated with scores on the Spiritual Well-Being Scale. 36 Conception of divinity, which can be as diverse as are people themselves, was mentioned (briefly) in only one article in the theoretical literature on trauma work and spirituality. Charney and Pearlman (1996) state that many survivors and, in parallel, many responders will struggle with the question, "Where was God"? One's connection with something beyond oneself may be deeply threatened or, for some, annihilated by severe losses. (P.20) This was certainly my experience working in the orphanage in Guatemala. I take a deep breath here and dare to share my own spiritual views and experiences, as they form both part of my interest in the connection between vicarious trauma and spirituality and part of my biases. In my own experience, the challenges to my (then) Catholic faith presented by the experiences of children in Casa Guatemala were overwhelming. It was inconceivable to me that the all-forgiving and merciful God that I had been raised with, the Jesus who loved little children, could allow such things to happen to innocents. It was the final blow to my already tenuous connection with the religion of my family and my childhood. In its place, over many years, developed a different sense of spirituality. What I consider to be my spiritual growth (or what Sister Mary Mercy, my third grade teacher, would consider my descent into heresy) involved an expansion of understanding to include the possibility of darkness in people, that encompassed the potential in all of us to do harm to one another. Instead of the black and white view of humanity taught to me in grade school, I developed an understanding, a connection with and acceptance of the many shades of gray in other people and in myself. Instead of a personified conception of God, there is now a faith in something greater and an 37 acceptance that it cannot perhaps be fully defined in terms understandable to human experience. In a way then, my vicarious brush with trauma proved to be both a fatal blow to an old sense of spirituality and the impetus for a development of new, stronger connection better suited to myself and my experiences. I experienced both the destruction and the transformation of spirituality described by Pearlman and Saakvitne (1995b). Brady (1997) addressed the dimension of conception of divinity in her study. The Gorsuch Adjective List, according to Brady, is designed to measure respondents image of God. Brady used only five of the eight primary factors from the Checklist, including Benevolence, Wrathfulness, Deisticness, Irrelevance, and Potency. Unfortunately, Gorsuch's Adjectives List was not listed in Tests in Print IV. so I was unable to independently evaluate this measure. Brady was able to cite reliability coefficients from Gorsuch's research for only three of the five factors that she used in her study, including .71 for Deisticness, .49 for Irrelevance, and .83 for Wrathfulness; coefficients for the other factors were apparently not reported in Gorsuch's research. The only reference that Brady makes to other research involving the Gorsuch Adjective List is the following: "Hall, Tisday and Brokaw (1994) report the Gorsuch Adjective Checklist's use in research, measuring God concept and level of object relations development, types of psychopathology, religious behaviour, and religious beliefs" (p.54). There is no additional data supporting either the validity or reliability of this measure. Brady (1997) found that higher exposure to trauma material was significantly related to only two of the five factors on the Gorsuch's adjective list. Higher exposure 38 correlated positively with measures on the Potency factor and correlated negatively with the Irrelevance factor. Brady concludes that "though [trauma] exposure variables were not significantly related to other factor scores, the general trend of results indicated that the more respondents were exposed to sexual abuse survivors the more likely they were to experience God/Higher Power as benevolent and potent and the less likely they were to experience God/Higher Power as wrathful, deistic, or irrelevant" (p.70). Brady (1997) notes that only 84% of her respondents completed the Gorsuch Adjective List. Several of those that did not complete the questionnaire noted that they did not hold an anthropomorphized view of the divine. Although Brady's instructions include the words "God or Higher Power" (p. 107), the nineteen adjectives listed on the questionnaire do appear to me to assume a monotheistic, anthropomorphized image. It is hard to imagine this list being relevant for someone who follows a polytheistic belief system, such as Hinduism or paganism, for example, or for someone whose spirituality is based more on connection to others or to nature, or who has a more diffuse, less concrete view of the divine. Brady states that "since respondents were less likely to complete the scale if they did not hold to a personal image of God, inferences must be applied more directly to those whose faith includes an anthropomorphized God/Higher Power" (p.80). Purpose of the Study The research regarding vicarious trauma yields as many questions as it does answers. For several of the variables researched, what one study posits, another contradicts. Looking specifically at the effect of trauma work on counsellor spirituality, the picture is even more murky. While Bettcher's (1997) study and Arvay's (1998) 39 study describe both positive and negative effects, Brady's (1997) study suggests that in fact, trauma counsellors may be more spiritually healthy than counsellors that work in other fields. This finding conflicts significantly with the existing literature on vicarious trauma and spirituality which, although allowing for the possibility of strengthening spirituality, emphasizes the spiritual dangers of trauma work. How then are we to understand the interaction between trauma work and counsellor spirituality? Are we, as Brady (1997) suggests, overemphasizing the dangers of trauma work and downplaying the positive aspects? Can working with victims of violence actually strengthen counsellors' sense of spirituality? Do counsellors experience both positive and negative effects? If so, which predominate? Brady's study certainly encourages us to question the assertions made in the literature and in the research. More study is needed in this area. While Brady's (1997) research yielded interesting and surprising correlations between exposure to traumatic material and therapists' spiritual well-being, it does not provide the descriptive detail that would be useful in illuminating what may be a very complex relationship. The logical next step in examining the effect of trauma work on counsellor spirituality is research which uses qualitative methodology to provide the description and depth that quantitative methods do not. In this study, I asked trauma counsellors to describe the impact, either positive or negative, that their work has had on their sense of spirituality. By keeping questions open-ended and non-directive, and by asking specifically for both positive and negative effects, I hoped to elicit a full, detailed description of the interaction between trauma work and counsellor spirituality. 40 A Case for Qualitative Methodology Qualitative methodology is appropriate for this study for several reasons. First, the research on trauma work and spirituality is still very much in the exploratory stages. Ponterotto and Casas (1991) noted the usefulness of qualitative research methods in exploring topics about which little is known. Oftentimes when not much is known about a particular topic, qualitative methods can be of great value in exploring the topic and raising more specific questions and hypothesis to be pursued in subsequent research (Ponterotto and Casas, 1991, p.138). In my opinion, we do not know enough yet about the interaction between trauma work and spirituality to ask specific, closed questions. General, open-ended questions need to be asked and can provide the basis on which specific questions can later be developed. Qualitative research methods are appropriate when general, rather than specific questions need to be asked (Hadley and Mitchell, 1995; McMillan and Schumacher, 1993; Patton, 1987). Furthermore, a qualitative study would provide a useful addition to the current research. Ponterotto and Casas (1991) state that "ideally, each research topic in counseling ... would be studied by both [quantitative and qualitative] methods" (p. 138). If a subject has been studied by predominantly one method, use of another method will likely yield unique and useful material. The research in vicarious trauma is predominantly quantitative and the need for qualitative studies have been noted by researchers in the 41 field (Gamble et al, 1995). The only study I was able to find which specifically examines trauma work and spirituality is quantitative. Brady's (1997) study involved a large sample size offering some generalizability; this study will be a useful complement, involving a very small sample size, but providing depth and descriptive detail. Michael Parton (1987) suggests the use of qualitative methodology when "no acceptable, valid, and reliable quantitative measures exist" (p.37). The measures used in the vicarious trauma research involve self-report questionnaires, most of which are not designed specifically to measure the construct "vicarious trauma" and none of which examine the impact of trauma work on spirituality. The one measure which is designed to quantify vicarious trauma (the TSI Belief Scale) is too new to have sufficient research backing its validity and also does not specifically address impact on spirituality. As discussed in the literature review above, the two measures used by Brady (1997) to measure disruption to spirituality, the Spiritual Well-Being Scale and Gorsuch's Adjective List, examine spirituality primarily in terms of involvement in organized religion. As I want to allow for a very broad understanding of spirituality, these two measures are too narrow in their definition of spirituality for the purposes of this study. Qualitative methodology is flexible enough to allow participants to define spirituality in their own terms and to encompass a broad range of belief systems. By using a qualitative approach and allowing participants to define spirituality according to their own experience, I hope to plumb a breadth and depth of experience which may not be accessible through quantitative methods. As research in spirituality is still very much in the exploratory stages, a qualitative approach is appropriate. The rich, 42 detailed description of the impact that trauma work can have on this fundamental aspect of human experience will provide a broad basis upon which further research can then be built. A qualitative approach can incorporate highly individual experiences and perceptions, whereas survey research is by its nature uniform and standardized. The flexibility of a qualitative approach is the most effective way to capture commonalities of the impact of trauma work, while allowing for considerable individuality in spiritual experience. Although frequently described as messy, subjective and unpredictable (Denzin & Lincoln, 1994), a qualitative approach seems the route most likely to yield a complete, accurate picture of how trauma work affects the spirituality of therapists. Given the increasing number of safeguards that have been developed to ensure the validity of qualitative research, I feel confident that this method will lead to usable, reliable results. In the following description of the methodology used in this study, I have included techniques to help ensure the trustworthiness and soundness of the research throughout the study. This study was guided by the literature and research on vicarious trauma and spirituality, but not limited by it. The term 'vicarious trauma' was not used with my participants. Participants were simply asked how their work effects their spirituality, without the possible middle step of describing vicarious trauma experiences. In this way, I hoped to avoid some of the complications and assumptions regarding the impact of trauma work on counsellors' spirituality inherent in the current literature and research on the subject. 43 Research Question The purpose of this study was to explore the effects, either positive or negative, of trauma work on counsellors' spirituality. Participants were asked to recount events that occured in the workplace that had a significant impact on their sense of spirituality and to describe that impact in detail. The following chapter describes the qualitative methodology, the critical incident technique, which was employed in the present study. Chapter III: Methodology 44 The purpose of the present study was to investigate the perceived impact of trauma work on counsellor spirituality. The current chapter describes the design of the study, beginning with the reasons that the critical incident technique was chosen, outlining its history and development, and detailing how it was applied in this study. The description of the present study details the selection of participants, the interview process, the analysis of the data, and concludes with a description of the four validity checks which were employed in the study. A few modifications to the critical incident techniqe were necessary; these are identified throughout the current chapter. The Critical Incident Technique I had decided, very early on in the formulation of the research proposal, that the research would be based on individual interviews. I chose an interview format primarily because it provides for the emotional safety of research participants, which a survey format cannot do. The questions that were asked of participants could have felt quite personal and private to them, and potentially could have been painful for them to answer. Asking those questions in person rather than on paper provided the opportunity for immediate support and intervention if necessary. As a counsellor, I have the training and experience to assess and intervene in crises. Should a participant have reacted to any of the questions posed in the interviews, I could have terminated the interview and provided immediate support and follow-up resources. Once an interview format had been chosen, 45 I searched for a way to structure the interviews which would address two challenges that I anticipated in examining the impact of trauma work on counsellor spirituality. One of the challenges that I anticipated in examining the impact of trauma work on spirituality was the challenge of isolating the influence of work from the influence of all the other contexts in participants' lives. So many things - family, childhood, culture, education, personal experience - influence our experience and understanding of spirituality that I anticipated that it might be difficult for participants to isolate the particular influence of work. Another challenge that I anticipated was to develop specific and detailed descriptions of impact on, or change in spirituality, to find ways of illuminating and illustrating that process in concrete, clear detail. Spirituality is so complex and intangible, I was concerned that without some way of specifying change, discussion might remain vague, confusing and general. I wanted some way of tying spirituality to real, lived experiences. The critical incident approach, as described by John Flanagan (1954) and Lorette Woolsey (1986), provided a framework for the interviews which addressed these challenges. The critical incident technique offers the detail and depth of information provided by other qualitative approaches, while also offering the specificity of descriptions of significant events. The critical incident technique is a flexible set of principles for "collecting observed incidents having special significance" (Flanagan, 1954, p.327) and detailing the effect of those events. In the present study, participants were asked to recount incidents from their work which had an impact on their sense of 46 spirituality and then to describe that impact in detail. By asking for descriptions of significant work-related events, I hoped to isolate the influence of trauma work on spirituality and to evoke detailed, specific descriptions of that influence. John Flanagan published an article in 1954 describing the critical incident technique, a method which has since been successfully used by several others (Woolsey, 1986; Alfonso, 1996; McCormick, 1994). The critical incident technique has its beginnings in American Army Air Forces research (Flanagan, 1954). Researchers wished to discover what behaviour constituted effective and ineffective leadership during combat missions. Participants in the study were asked to describe in detail specific examples of behaviour which they felt to be either effective or ineffective. Several thousand incidents were collected, analyzed, and categorized to yield a list of descriptive critical requirements of combat leadership. A similar strategy was used in several other Armed Forces related research projects (Flanagan, 1954). The development of the critical incident technique, among others, was continued after the close of World War II through the efforts of the American Institute for Research. Their mandate was "the systematic study of human behavior through a coordinated program of scientific research", continuing the research started in the Armed Forces during World War II (p.329). Rather than consisting of a series of proscribed steps or rules, the critical incident technique is described by Flanagan (1954) as a "flexible set of principles which must be modified and adapted to meet the specific situation at hand" (p.335). In brief, the technique involves interviewing participants for their view of situation-specific behaviour 47 or experiences. Participants are chosen from among people who are likely to have experience with, or be informed about, the experience and situation in question. Participants are asked to recount incidents which were very significant, detailing what led up to the incident, the incident itself, and the impact of the incident. Incidents are included in the analysis only if they are deemed by the participant to be significant and if all three phases of the incident are described (Borgen, 2000). Objectively accurate results are achieved by comparing specific incidents and behaviours or experiences across informants. Bengt-Erik Andersson and Stig-Goran Nilsson (1964), in a study examining the reliability and validity of the critical incident technique, supported the efficacy and accuracy of this method. Andersson and Nilsson conducted a critical incident study exploring the kinds of behaviour employed by successful and unsuccessful managers in a large grocery store chain in Sweden. They then compared the results of their study to data obtained through a questionnaire and to the literature available for training managers. The critical incident results were found to be both comprehensive and accurate in comparison to other sources of data. Preparation for the Study Before beginning my research it was necessary to be explicit about my expectations and biases in doing this study. John Osborne (1990) suggests bracketing biases at the outset of research. By being open and precise about biases, the conscientious researcher may hope to remain aware of the potential influence of those biases. For example, in this study, I expected to discover that trauma work does have a 48 devastating effect on the spirituality of the therapist. In my own experience, my sense of connection with the beauty in life and in people was lost as well as the connection with my childhood religion. I expected that many therapists experience the same questioning and loss of innocence and faith, the "existential crisis" described in Bettcher's (1996) focus group. I thought that facing those questions and actively grappling with them can create a more realistic and more profound sense of connection and meaning. Further, I expected that therapists experience cycles of connection and disconnection, perhaps in response to continuing challenges in their work. Recognizing my expectations at the outset of research helped me to remain watchful of their influence in interviews with participants and in interpretation of data. Janice Morse (1994) recommends creating an audit trail by specifically documenting the entire process of research, from conception to data analysis and reporting. Assumptions and opinions are clarified throughout the study as they evolve and as they affect the course of research. By describing dilemmas in the research process and how decisions were made, anyone reading the research may understand how the research results and conclusions were reached (Miles & Huberman, 1994). To this end, I wrote an essay summarizing my reactions to the initial interviews, the analysis and the follow-up interviews. Writing the essay helped me to remain clear and open about my own reactions and how they might influence the course of research. Participants The seven participants for this study were sought from among counsellors who have a high caseload of victims of violence. If the effects on the self of the therapist are 49 intensified by more frequent exposure to traumatic stories, it is logical to assume that the most intense impact on therapists' spirituality would be experienced among trauma therapists. I therefore enlisted participants by contacting agencies such as the Rainbow Clinic, North Shore Family Services, the Vancouver Incest and Sexual Abuse Center (VIS AC) and Victims of Abuse and Survivors of Torture (VAST), among others, all of which specialize in working with victims of violence. I faxed notices (Appendix A) to explain my project to agencies that expressed an interest in participating. Four of the seven participants were contacted in this way. The remaining three were contacting through recommendations and suggestions of participants and colleagues, a process which Patton calls "snowball or chain sampling" (1987, p.56). Individuals who expressed an interest in participating were given a more detailed description of the project during the initial phone contact, including a brief explanation of the inclusiveness of the term spirituality as it is being used in this study. The time commitment for volunteers, a brief description of methodology and assurances of confidentiality were also provided. This information is listed in Appendix B. A written summary of this information was faxed to interested counsellors (Appendix C). There were four inclusion criteria. The first was made explicit in the notices and was later clarified in the initial phone contact with potential participants. All seven participants work currently and primarily with victims of violence. Individual or group work with trauma survivors comprised the majority of the participants' work load (50 % or more). The second and third inclusion criteria, which were made explicit during the initial personal contact (either over the phone or during meetings), were that participants 50 felt comfortable discussing issues of meaning and spirituality and should feel that their work has had an impact (either positive or negative) on their spirituality. The inclusiveness of the term 'spirituality' was clarified during the initial contact. Finally, participants all had one or more years of experience working in the trauma field. As it is still uncertain when during a counsellor's career vicarious trauma occurs most frequently or most intensively, a minimum number of years seemed the safest criterion to secure participants who have felt and are aware of the impact of their work. Interview Procedures I conducted two individual interviews with seven counsellors who are currently working with victims of violence. Questions were open-ended and non-directive, focusing on particular work-related incidents which the participant felt had an impact on their experience of spirituality and discussing and describing that impact. When arranging the interviews, participants were invited to choose the venue for the interview, including the option of using a counselling room on campus if a neutral location was preferred. All of the participants chose to use either their office or their home for the interviews. The first task of each interview was to explain and discuss the informed consent form (Appendix D). Two copies were signed by each of the participants and myself; the participants retained a copy. Information previously discussed, such as the purpose of this research, who will have access to the data, potential costs and benefits to the participant, time commitments and any limitations of confidentiality was explicated in the consent form. Assurances were also given that the audiotapes of the interviews would be 51 destroyed upon completion of the thesis, as would computer records of demographic information and interviews. Paper copies would be shredded and securely disposed of. The first interview was viewed as a pilot interview (Woolsey, 1986; Haverkamp, 1997; Borgen, 1997). The transcript was reviewed by members of the thesis committee to ensure that neither the wording nor tone of my questions had been in any way leading to the participant. As my interviewing style was judged to be appropriate, this interview was included in the data analysis. The pilot interview followed the format I had envisioned in the research proposal and described in Appendix E and F. After reviewing the interview with Dr. Beth Haverkamp and Dr. Maria Arvay, it was decided that three initial questions needed to be added to help ground and direct the interview (Appendix G). The subsequent six interviews followed the same basic format, described below. I began the interviews with a short review of the research question (although by this time, I had already clarified the purpose with each participant over the phone and in writing) and an outline of the agenda of the interview (Appendix G). I then solicited demographic information which the literature on vicarious trauma suggests might be relevant to how strong an impact trauma work might have on the self (and by extension the spirituality) of the therapist. The relevance of such information to the data analysis, as described in the above literature review on vicarious trauma was explained to participants. This explanation is included in Appendix E. Demographic questions included age, education, years of experience, peer support and/or supervision and percentage of caseload involving victims of violence. Gender was also noted. 52 As discussed above, past research (Arvay & Uhlemann, 1997; Battley, 1995; Brady, 1997; Chrestman, 1995; Kassam-Adams, 1995; Pearlman & Mclan, 1995) suggests that the number of trauma survivors in the therapists' caseload appears to affect the degree of vicarious trauma experienced by the therapist. One of the key areas of demographic information, therefore, was to ascertain the approximate percentage of survivors in each participants' caseload. Participants were asked to estimate the percentage of survivor clients in their current caseload. One of the issues currently of interest in the vicarious trauma research is whether or not having a personal history of victimization affects the impact of trauma work on the therapist (Schauben & Frazier, 1995; Follette, Polusny & Milbeck, 1994; Pearlman & Mclan, 1995). While this is clearly an issue of importance to therapists, I felt uncomfortable simply including such a question in my demographic information without providing more context and time to discuss the issue fully and ensure the emotional safety of my participants. To do so adequately and ethically would require more time than I was willing to ask of my participants and myself and was unfortunately beyond the scope of this study. Participants who felt that their personal history was relevant to this study certainly had the opportunity to raise this issue during the interview. Issues of safety could have been assessed and addressed at that time in the course of the interview. Should the participant have experienced high levels of distress during the discussion of this or any other issue, the interview could have been terminated. I could then have addressed the immediate crisis and referred the participant to appropriate resources, listed 53 in Appendix H. As it happened, although the interviews were emotionally rich, occasioning a few tears (and much more laughter), there were no crises. I then explained that the rest of the interview would be much more open-ended, and that the interviews tended to move between descriptions of particular incidents that had an impact on spirituality, and discussion of impact in a more general sense. I then asked participants to briefly describe their view of spirituality, and then to briefly describe the impact that they feel trauma work has had on their spirituality overall. I then invited participants to choose situations from work that exemplify that impact, assuring participants that care would be taken to guard client confidentiality by avoiding use of identifying aspects of client stories in any written materials. Other critical incident studies (Alfonso, 1996; McCormick, 1994) examined each incident included in the study in three phases: what led up to the significant incident, description of the incident itself, and impact of the incident. As the main focus of this study was to examine the impact of the incidents rather than the incidents themselves, it was decided to ask participants to recount the incident and the impact of the incident, without describing what led up to the incident. In the opinion of this researcher, examining what led up to the incident was unlikely to yield additional information which would be directly relevant to examining impact. I invited participants to tell stories in whatever order felt best to them, explaining that some participants preferred a chronological approach, starting with stories from early in their career and working forward, while others felt more comfortable jumping around in time. Questions tended to be open-ended and broad, with specific, closed questions used 54 primarily for clarification. Examples of the types of questions which were asked are included in Appendix F. The language used in describing spirituality and impact was guided by the participants' language and varied considerably from interview to interview. Although I noted common themes and experiences which emerged early on during the interviews, formal analysis did not begin until all seven interviews were complete. The procedure used in analyzing the data is described below. Analysis of the Data As suggested by Patton (1990), the process of analyzing the data overlaps with data collection. Analysis of the data may begin with the very first interview, expanding and evolving to incorporate data from subsequent interviews. Victoria Alfonso (1997), in a critical incident analysis of depression in response to an HIV+ diagnosis, analyzed data after every third interview. In this way, she was able to manage the data so that it did not become overwhelming as well as constantly checking to see whether saturation had been reached. Alfonso continued interviewing new participants until the interviews yielded no new information. Morse (1994) states that the indices of saturation are "repetition in the information obtained and confirmation of previously collected data" (p.230). Interestingly, common themes began to suggest themselves by the second interview and continued to do so throughout subsequent interviews. Extraction of the Effects The first step in extracting the effects was to transcribe the interviews from audiotape to written text. The first interview was transcribed in November of 1998, so that it could be reviewed by members of the committee. The remaining six were 55 transcribed in the fall of 1999. I transcribed verbatim, noting long pauses, laughter or tears, stutters, and interruptions, without the use of punctuation. While transcribing, I listened primarily for meaning, noting possible themes and categories. Once the transcripts were finished, I listened to all seven interviews again to check the accuracy of the transcripts and also to immerse myself in the interviews in a group. To assist with later cross-referencing, I numbered the paragraphs in each interview. Each transcript was then transferred onto a simple table (Table 1, below) with each row in the INTERVIEW column containing dialogue describing and discussing a particular story and its impact on the participant's sense of spirituality. The rows varied in length; some rows contained many paragraphs of dialogue, some rows contained only one or two paragraphs. Each row was coded (CD column) with the first letter of the participant's pseudonym and the corresponding paragraph numbers so that I could easily locate the row in the original transcripts if needed. Some of the dialogue discussed the impact of trauma work on the participant's spirituality in a more general sense, without reference to a particular incident. These more general pieces of dialogue were allotted a row as well and included in the analysis. Including these pieces of dialogue in the analysis represented a modification to the critical incident technique, as they departed from focus on significant incidents. I decided, however, to include general discussion of impact in the analysis, as these pieces of dialogue were useful in clarifying and illuminating effects on participants' spirituality. Each chart was then printed and reviewed. I highlighted story elements in yellow, impact elements in pink, description of self-care strategies in blue, and dialogue that I 56 didn't understand or that I had questions about in green. I then noted comments, questions, and key words in handwriting in the COMMENTS column. Separating the incidents from the impacts was surprisingly challenging. Using highlighting to distinguish the story elements of the interviews from the impact of those stories on the participant's spirituality proved a valuable exercise, as I found I was constantly confusing the two. The highlighting and the handwritten comments and notes created the basis for the formulation of the categories, described in the following section. 57 Table 1 Example of the Initial Break Down of the Transcripts CD INTERVIEW COMMENTS (a) (b) (c) (a) participant and interview paragraph code (b) interview text (c) researchers notes to self, including tentative themes 58 Forming the Categories The categories emerged slowly from the raw data, through roughly three stages. The first, and most unsettling, stage involved complete immersion in the data. Through the process of reviewing the transcripts, transferring each onto a table and identifying the effects, I had reviewed each interview in detail at least three times and felt thoroughly immersed in the material and thoroughly overwhelmed by its complexity. The themes that had seemed so immediately, so simply, evident during the interviews appeared much more complicated and ambiguous on closer examination and comparison. Throughout the analysis process, I found myself constantly struggling to balance the need to categorize and summarize with the desire to respect the complexity and richness of the material. In the second stage of forming the categories, an organizing statement emerged which suggested a division of the raw data into two broad groupings. This organizing statement was the first summary which described and encompassed all of the effects without oversimplifying the material. Woolsey (1986) describes an "'aha' response" (p.250) when the researcher reaches an intuitive sense of fit between the categories and the raw data. The organizing statement and the two groupings which ensued elicited the first "aha" response for this researcher. I then went back to the printed tables (Table 1) and cut each table into rows. Each row contained dialogue describing and discussing a particular impact and contained my comments about that dialogue. I sorted the rows from each interview into the two broad groupings, marking those that could belong to both groupings with a sticky note. 5 9 The third stage of forming the categories involved summarizing and categorizing the effects within each grouping. At this point, the rows became too cumbersome to work with; summaries were needed. I read each row again (for the fourth time) and wrote a brief summary in point form for each, labeling each summary with the code identifying the participant and the paragraph number identifying the dialogue's place in the interview. Each summary included a few words to remind me of the story. The rest of the summary focused on capturing the impact of that story on the participant's sense of spirituality, using as many of the participant's words as possible. I made note of any questions that I had in the summary as well, marking those with a question mark. Once the summaries were written, it was easier to review and sort them into impact categories. The process of creating the categories was challenging; again there was the tension of summarizing without oversimplifying. Marshall and Rossman (1995) suggest that once the categories and the patterns between them are established, the researcher should review the interviews to search for data which may invalidate both the descriptive categories and the interpretations that the researcher has made to explain them. Reviews of the original transcripts proved useful in this regard. Indeed, initial formulations of categories were challenged both through review of the transcripts and through discussions with the supervisor of this study. Examination of my expectations and biases, explicated in the personal essay written for this purpose, was also useful in clarifying my decision making process during the formulation of the categories. Once the categories had been finalized, I reviewed the summaries again, coding each summary with the number of the category or categories to which it belonged. I listed 6 0 what I felt was the most salient category first, and any additional categories second. Some summaries contained only one theme, some contained many. Some of the summaries included impact categories for both of the broad groupings. I marked categorizations I was uncertain about with a question mark. The final formulation of the categories, followed by sorting the summaries into those categories, yielded the second "aha" response. The categories appeared to me to fit intuitively, subjectively, with the effects that they described. The final stage in the analysis was to subject that intuitive sense of fit to four validation procedures, described below. Validation Procedures Several validation procedures have been developed specific to the critical incident technique. In this study, four validation procedures were used to corroborate the results. In order of their use, these procedures include: confirming exhaustiveness, checking results with participants, tabulating participation rates and independently categorizing effects. These four procedures are described below. Exhaustiveness encompasses both saturation and comprehensiveness (Alfonso, 1996). I checked for exhaustiveness during the initial interview by summarizing the participant's experience at the end of each interview and then inviting the participant to add incidents or effects as needed to provide a complete account of the impact of trauma work on their sense of spirituality. If incidents or effects were added, I summarized again, and asked again for additions. Interviews were terminated only once the participant stated that a complete account had been given. In addition, at the end of the follow-up interviews (described below), participants were again invited to add incidents or effects. 61 In addition to checking exhaustiveness with the participants, following McCormick (1994), Alfonso (1996) and Borgen (2000), a portion of the incidents were withheld from the analysis to be used in verifying the comprehensiveness of the categories. In this study, approximately 10% of the summaries were not included in the initial formulation of the categories. These were summaries which did not immediately or obviously fit within any of the emerging themes. One to six summaries for each participant were included in this group. Once the categories were finalized and the other summaries sorted and coded, I sorted the last ten percent into the categories. According to Alfonso, "if the incidents [can] be placed within existing categories, the category system [can] be considered comprehensive" (p.123). Alfonso (1996) introduced the use of follow-up interviews as a validity measure in her critical incident study. Alfonso states that it is "important to treat participants as experts in their history and individual perspective of the world" and that "such expertise is needed for testing the validity of the categories" (p. 121). In order to verify the categories and the categorizations with participants involved in this study, individual follow-up interviews were arranged. The format of the follow-up interviews is described briefly below; a detailed protocol for the follow-up interviews is included in Appendix K. The seven follow-up interviews followed this protocol very closely. Each follow-up interview began with an explanation of the general findings of the study and a request for feedback on several general observations of the data. I then described the two broad groupings and the eleven impact categories, working from written descriptions, and invited feedback on these. We then reviewed how I had categorized the 62 participant's particular interview. I had attached a copy of each summary to its corresponding row; we read and discussed each summary and I invited participants to read the row as well if they wished. I had also brought a copy of the full transcript if they preferred to work from that. I explained how I had categorized each row and then invited participants to revise categorizations and to choose which category was most salient for each row. I also asked any questions which had been marked on the summary. When we had reviewed each of the summaries in the participant's interview, I asked the participant which impact category felt most important to them in describing their experience overall. This was noted, and is discussed in the following chapter. If the question had not already been addressed, we discussed the categories the participant had not endorsed. Finally, I asked the participants if they had any further incidents to add, any further questions or comments and if they wanted a copy of part or all of the finished thesis or a copy of the transcript. Once the categorizations and categories had been confirmed, participation rates, the third validity measure, could then be calculated. The percentage of participants which endorse each category can be considered an important indicator of the validity of the categories. Alfonso (1996) suggests that a 25 % participation rate is sufficient in verifying the validity of the categories. To calculate the participation rates in this study, I tabulated categorizations for each participant, based on a suggestion offered by Dr. Maria Arvay (1999). For each participant, I listed (by number) which summary fit into which category or categories. This table (Table 2) is included in the following chapter. 63 Finally, two raters, unconnected with the present study, were provided with a written description of the categories and invited to independently categorize a portion of the summaries. This technique was first used by Andersson and Nillson (1964) and has since been used in other critical incident studies (Alfonso, 1996; Woolsey, 1986). Each of the raters participating in this study have a background in counselling; one is a family counsellor, the other has worked with battered women and is currently a student. The independent raters were given a copy of the description of the categories and a short explanation of how the categorizations were reached, including a few examples. This explanation is included in Appendix K. In addition, raters were invited to ask questions or request clarification on any of the categories. The raters were then invited to categorize one third of the summaries. The summaries had been revised for this purpose, first to make certain that any information which could potentially identify either a client or a participant was removed and also to ensure that there was sufficient clarity and detail provided so that the raters could make a determination based on the summary alone. According to Anderson and Nilsson (1964), a 75 - 85% agreement rate between the independent raters and the researcher is sufficient to confirm the validity of the categories. The outcomes of all four validation procedures are included at the end of the following chapter, describing the results of the current study. 64 Chapter IV: Results The current chapter describes the answer that resulted from the question: what is the impact of trauma work on counsellor spirituality? The results of this study are reported on four fronts: a demographic description of the participant group, an overview of the findings, a description of the categories, and a description of the outcomes of the validation procedures. Demographic Information The seven participants, six women and one man, were asked seven demographic questions which the literature suggests might have an influence on the experience of secondary traumatic stress and, by extension, on the effect of trauma work on counsellor spirituality. These variables included age, education, years of experience in counselling, years of experience in trauma counselling, peer support, supervision, and percentage of clients who are survivor of violence. Two additional demographic variables were suggested by participants during the course of the interviews as potentially being important to understanding the effect of trauma work on counsellor spirituality. These variables - the age of clients and exposure to clients who are perpetrators of violence -were included in the study. Table 2 (below) summarizes the range of responses to the demographic questions. Although all of the participants met the basic inclusion criteria for the study (including: comfort discussing the effect of their work on their sense of spirituality, minimum of one year working with victims of violence, and a minimum of 50 % of 65 caseload comprised of victims of violence), they nonetheless varied widely in their responses to the demographic questions. For example, although the participants all have a caseload of 50 % or greater of victims of violence, they vary in the number of hours they spend with victims of violence. Some participants worked part-time, some did other kinds of work in addition to counselling. One participant, for example, had a caseload with a high percentage of victims of violence, however, counselling comprised only a third of this participant's total working hours. Other participants worked full-time, with a full caseload of victims of violence. The potential influence of such variability on the results of this study is explored further in the discussion chapter. Participants varied also in terms of their belief systems. Some participants, in describing their sense of spirituality, identified themselves with one (or more) organized religion, including, for example, Christianity, Wicca, Judaism, and Buddhism. Other participants did not identify themselves with an organized religion and defined their spirituality more in terms of connection with self, other people, the divine (varying labels were used), and/or nature. Some participants described a set of values and beliefs in defining their spirituality. All of the participants, at some point during the interview, talked about the importance for them of lived spirituality as opposed to theoretical or cognitive beliefs or values. Their work was both an expression of those beliefs, and a venue where those beliefs were lived. 6 6 Table 2 Range of Responses to Demographic Questions DEMOGRAPHIC VARIABLES RANGE OF RESPONSES Age Ages ranged from 35 to 56, with a median age of 47. Education One participant held an undergraduate degree, four participants held Masters level training in social work or counselling, two had play therapy training in addition to a graduate degree. Experience in counselling or related field Experience ranged from 4 to 32 years, with a median of 12 years of experience. Experience in trauma work Experience ranged from 1.5 years to 28 years, with a median of 5 years of experience. Peer Support Four participants received daily peer support, two participants received approximately 2 hours of peer support monthly, one participant receives infrequent peer support. Supervision Hours of supervision monthly ranged from 0 to 6, with a median of 1 hour monthly. % of Caseload Comprised of Survivors of Violence Percentage of caseload ranged from 50 % to 100%, with a median of 80 %. Frequency of Exposure to Offenders Two participants never work with offenders, one works rarely with offenders, two participants work occasionally with offenders, one participant works often with offenders, one participant works primarily with offenders. Child/Adult Three participants work with children and their families, one participant has a mixed caseload, three participants work with adults. 67 Overview of findings The first organizing statement which emerged during the analysis was as follows: Participants described being exposed to the extremes of human nature and experience through their work, and described the effect that that exposure had on their sense of spirituality. This statement encompassed both the story elements and the impact elements of the interviews. Beth Haverkamp (1999) suggested a figure which illustrates this statement (Figure 1, below). Initially I had hoped to analyze both the impact elements of the dialogue and then also analyze the incidents that counsellors told to illustrate that impact. Analyzing the incidents, separate from the effects, would have offered a beginning answer to the question raised by many researchers (Charney & Pearlman, 1996; Follette, Polusny & Milbeck, 1994; Gamble, 1995; Kassam-Adams, 1995; Pearlman & Saakvitne, 1995) of which kinds of work-related incidents have the greatest impact on counsellors. However, it was soon evident that this task was beyond the scope of the present study, or at least beyond the time constraints of this researcher. I therefore chose to focus primarily on the impact elements of the interviews. Figure 1, below, illustrates the basic organization of the material according to the organizing statement. The 'extremes of human nature' are represented by the ends of Figure 1, labeled Into the Fire and Into the Light. The circle in the middle of Figure 1 represents the effects of trauma work on counsellor spirituality. This organization gave rise to the two broad groupings of categories, described in the next section. Although I've represented the two groupings, Into the Light and Into the Fire, as distinct from one another, almost as polarities, the interviews seemed to me to suggest that the relationship 68 between them is more complex than simple opposites. One story would often encompass effects from both Into the Light and Into the Fire. Sometimes the two extremes seemed integrated, sometimes separated. This relationship, this connection, between the two groupings is represented by their connection within the circle of counsellor spirituality. 69 Figure 1 Illustration of the Organizing Statement Into the Light Into the Fire 70 I had hoped initially to identify a process or development of spirituality, perhaps linear, perhaps cyclical; this was not the case for any of the participants. Everything about the participants' experiences overall, over time, challenged definition or reduction. Counsellors at the beginning of their career and those ten or more years into their careers described similar experiences, similar challenges and rewards. As one participant put it, as I finished a very neat summary of how her spirituality had changed, the process had not seemed quite so "tidy" to her (Naomi, Paragraph 74). The sense of 'untidy-ness' was apparent in all of the interviews. Few of the participants chose to recount incidents in chronological order, and even those that chose chronological order initially tended to move back and forth in time during the interview. It was apparent to me that the participants' experience did not fit within the linear organization which I had originally envisaged, and which is typical of critical incident studies (Borgen, 2000). Although invited to do so, participants did not recount incidents beginning with the first significant incident in their career, followed by the next significant incident which occured and ending with the most recent significant incident. Such order was simply not reflective of how participants experienced the relationship between their spirituality and their work. The fact that none of the interviews followed the neat chronological order that I had envisaged was telling. By the end of my third review of the interviews, it seemed apparent to me that there was no clear development of spirituality; there was change, certainly, but the nature of that change could not be easily boxed or categorized. I asked counsellors for feedback on this idea during the follow up interviews, using the following statement: 71 ...there did not appear to be a clearly linear development or process of spiritual change; more a constantly adapting, constantly evolving, ongoing change (growth?). How does that fit for you? (Excerpt from Protocol for Follow-up Interviews, Appendix J) Participants all agreed that the process was not linear; the word "growth" which I asked about did not seem a good fit for any of the participants either. The words "constantly adapting" and "ongoing change" fit for all the participants, as well as the idea that spirituality in this context seems to be something which exists almost outside of time, influenced by past, present and future experiences all at once. The image that I believe comes closest to describing participants' experience is a passage from Kahlil Gibran's The Prophet: For the soul walks upon all paths. The soul walks not upon a line, neither does it grow like a reed. The soul unfolds itself, like a lotus of countless petals. (p.73) One of the central findings of this study was that the assumption that trauma work has an impact on counsellor spirituality appears to be inaccurate, much to my surprise. I had assumed, based on my own experience and based on the literature, that the word 'impact' would most clearly describe the relationship, either positive or negative, between trauma work and counsellor spirituality. During the course of formulating the categories, it became apparent that what participants were describing could not accurately be called 'impacts.' I checked this finding with my research participants in the follow-up interview (Appendix J) by reading the following statement to them and asking for their feedback. 72 Although the question that I asked was about the "impact" that trauma work had on participants' spirituality, the answers given seemed to me to be more about how they "integrated" or "coped" (framing, managing, self-care, etc.) with trauma work. I think what I assumed in asking about impact was a sort of passive, automatic reaction to exposure to stories of trauma. What I think participants were telling me about was more an active, often conscious response to their work - more an active interaction between their sense of spirituality and their work, rather than their work acting on their sense of spirituality. What do you think about this idea? All seven participants agreed with this finding. When I asked them to suggest a word or words which would more accurately described the relationship, participants answers included "influence, creative process, effect, in/forms, incorporate, interact, touch, connection, experience" (Appendix I). All of these words seemed applicable to me, and I have used them throughout the following sections. I chose the word "effect" as being particularly useful for the purposes of this thesis. The dictionary definition of effect includes: effect n 1: result 2: meaning, intent... 6: influence ... syn consequence, outcome, upshot (The Mirriam-Webster Dictionary, 1974, p.232) The word 'effect' includes the idea of intent, which is fitting for a conscious, active process. Also, 'outcome, upshot' and 'result' suggests the possibility of a longer term process, potentially mediated by other factors, whereas 'impact' sounds more immediate, direct, and forceful. Generally speaking, counsellors talked about the changes in spirituality that occurred and that they created over time to integrate and manage exposure to the extremes of human nature and experience. 73 I invited participants at the beginning of the first interview to describe how their work had effected their sense of spirituality, either positively or negatively. What seemed to emerge over the course of the interviews was that the polarities 'positive' and 'negative' were too simplistic. Again, the relationship between polarities was more complex; as one participant put it, there was more "fusion" (Meg, Paragraph 142) in it than that. Although I've divided the categories into the two broad divisions, Into the Light and Into the Fire, these do not represent clearly or obviously positive and negative effects; they are more like two halves of a whole picture. The categories which summarize the effects are divided into the two broad groupings and are described in the following section. Categories As discussed in the overview of findings, above, the organizing statement (participants described being exposed to the extremes of human nature and experience through their work, and described the effect that that exposure had on their sense of spirituality) guided the organization of the categories. The two broad groupings, and the categories which comprise them, are listed on Table 3 and are described below. For each category, I have included an excerpt from the protocol for follow-up interviews (Appendix K) which defines the category and gives examples of the kinds of words and phrases that participants used. It was challenging devising the wording for the categories as counsellors used highly varied wording, reflective of the wide variety of belief systems. I showed these descriptions to participants during the follow-up interviews and asked for comments on the categories in general and on the wording of each category in particular, 74 as I wanted to be sure that each category was sufficiently inclusive and did not conflict with any participant's belief system. 75 Into the Light The broad division Into the Light includes the more inspiring and validating aspects of trauma work, such as witnessing human goodness and strength and witnessing the capacity of people to choose growth and healing. Participants used words like 'inspiring,' 'empowering,' and 'affirming' in describing this part of their work. The following categories describe the effect that exposure to this aspect of trauma work had on counsellors' sense of spirituality. 1. BELIEVING IN THE GOOD IN PEOPLE - believing in "that of god in all of us." Including: seeing and believing in the strength, determination, dignity in people; seeing good and beauty in all of us; seeing beauty in unlikely places; seeing strength and dignity against tremendous odds. Counsellors described how their work provided them with many experiences of the goodness and strength in people, often in situations where clients were facing tremendous odds, such as extreme poverty, neglect and abuse. These experiences affirmed and strengthened a belief in the basic goodness of humanity which, for most participants, pre-dated their careers in trauma work. As one counsellor put it, regardless of how damaged or angry a client is, "[she] always know[s] that the truth is they're much greater than that" (Anne, Paragraph 50); no matter what clients have been through and how they present initially, they are also beautiful and strong. This belief in the goodness of humanity is related to the following category, believing in the capacity for growth. 2. BELIEVING IN THE CAPACITY FOR GROWTH - believing in the power of people to choose to create change in themselves and in their lives. 76 Including: seeing and believing in people's ability to heal and transcend; seeing and believing in people's ability to choose growth and healing regardless of how damaged they may have been; to create growth and healing even in the face of tremendous odds. Participants talked about how they watched people change and how inspiring it is to see people transform themselves. One participant stated: ' [ I witness the] healing process you know and I stand in awe of it, I really do" (Grandpa, Paragraph 92). This was one of the categories that several of the participants described as providing them with hope. All of the counsellors stated that after watching so many people heal, they are able to stay with clients for long periods of time, even when the therapeutic process is challenging, because they know that the possibility of change is there. For example, Meg explained that witnessing healing with one particularly challenging client had the following effect; "it made me see that no matter what a person brought with them there was always this potential... that something good could happen, or something meaningful, maybe that's a better word for it, rather than good or bad, something meaningful could happen" (Paragraph 98). Anne said that, after working with one child with a very challenging home life: "I never turn a kid down now however sick they are, because I know they'll do it [they'll heal], if I can do my bit they'll do theirs" (Paragraph 66). 3. APPLYING SPIRITUALITY - spirituality as an intrinsic part of trauma work. Including: to be effective, need to keep ego out of it, remain humble, stay grounded, offer openness, respect, hope, genuineness, spirit; effectiveness as a counsellor more to do with being than doing; can never loose touch with spiritual self, because need that self, those beliefs to work well, to create connection and healing; sense of mystery, of the magic of connection with people; connection as an almost tangible manifestation of spirituality. 77 Participants talked about how their work kept them constantly in touch with their spirituality, because it was this aspect of themselves which they used in connecting with clients and facilitating healing. One participant put it this way: "[trauma work has been] enhancing of my spirituality, because its not just a job, it's being able to, you know, offer myself and to be, and to work at genuinely being me ... I have to be genuine, and I have to be hopeful [in order to be effective with clients]" (Sharon, Paragraph 54). The connection that is created in the therapeutic relationship was often mentioned as having a spiritual flavor about it. One counsellor described this as an almost tangible atmosphere in the room: "[there is] this kind of glow in the room like we'd tapped into something together" (Sally, paragraph 60). 4. DEVELOPING OR AFFIRMING A SENSE OF PURPOSE -participating in healing provides a powerful sense of purpose Including: helping people heal creates a sense of meaning; feeling honored; seeing healing affirming of purpose of work; powerfully rewarding; contribution to society, humanity, on an individual level. Participants talked about the meaning that trauma work has for them, the sense of purpose and value that it has for them. Watching people heal and having a part in facilitating that healing can be profoundly rewarding. One participant said that what felt significant in terms of spirituality for her in one story of healing was that it "really reinforced for [her] that what [she] do[es] is worthwhile" (Babs, Paragraph 105). Another participant described the effect on spirituality of witnessing an abusive parent break the cycle of violence: " it gave me a sort of a sense of purpose or connectedness to humanity you know, making a difference, so that, I think, reinforced a lot of my beliefs somehow, gave me a sense of hope" (Grandpa, Paragraph 14). Some participants talked 78 about there being a sense of divine as well as personal purpose in the work that they do. For example, Naomi said that she sometimes feels that her role in facilitating healing, being a catalyst or guide, is something that "comes through me, it's not from me" (Paragraph 84). Similarly, Meg said that she often feels she is a "conduit" (Paragraph 136) for healing, which she finds both humbling and inspiring. 5. RECOGNIZING AND/OR PARTICIPATING IN GLOBAL CONNECTEDNESS - believing that we are all connected. Including: contributing to, participating in, global network; spiritual sense to that network; helping to create social change; advocacy work; individual healing contributing to societal healing; the individual and the universal or eternal are connected, they influence and reinforce one another. Many of the counsellors talked about having a sense that the work that they do has an impact on more than just an individual level. For example, Meg said that she feels that: "the effect [of helping people heal] goes beyond that particular individual, it's as if it goes into the atmosphere" (Paragraph 106). Several participants said that taking part in helping break the cycle of violence seemed to them to be contributing on a societal as well as individual level. One participant said that watching healing from violence "gives [him] a lot of hope for humanity" (Grandpa, Paragraph 92). Some participants talked about the value for them of doing advocacy work and trying to change social systems to make them more responsive to individual needs. In describing the general effect of her work on her sense of spirituality, Sharon said that, "I feel connected to other people [through] doing things that can help them, and sort of globally help, and so the advocacy work, I feel very... filled up by that" (Paragraph 8). Into the Fire Into the Fire represents the challenges of trauma work, such as encountering or hearing about the capacity of people to do harm to one another, working with clients who are not ready or not willing to change and the frustrations of working with larger systems. Participants talked about this side of trauma work as challenging them, pushing them to become stronger, tempering or polishing their beliefs and values. 1. DEFINING AND ACCEPTING LIMITATIONS - defining where you can be effective, accepting where you cannot be effective. Including: defining what you can and cannot work with (clients, systems, contexts); recognizing and accepting your own and/or client limitations; finding ways to understand and let go of what is outside of your limitations; choosing what you expose yourself to, letting go of the rest; finding ways to understand and let go when clients are not ready to change. Participants said that they found that when they came up against a limit or boundary in their work it both challenged their sense of hope or connection (the wording depending on their definition of spirituality), and that their sense of spirituality helped them to frame those limits in ways that made sense to them. For example, Anne said, in letting go of a client who was not ready to give up drug and alcohol use: "I had to give it to God, so the impact on my spirituality basically is always these cases are cause for me to read more, understand more, I think it's clearer actually, that's what it is ... as I go along [my views get] polished" (Paragraph 176). Participants also talked about choosing the kind of work that they do based on protecting their sense of spirituality. For example, Sharon said that, at this point in her career, she doesn't work with offenders because if she did she feels it would be difficult for her to "maintain a positive outlook on the world" (Paragraph 106). Similarly, Grandpa said that working in areas other than trauma helps him to stay hopeful and balanced (Paragraph 98). 2. DEVELOPING CREATIVE SEPARATION STRATEGIES WITH CLIENTS - developing ways to separate yourself somewhat from aspects of the client or the client's story. Including: things you do within the work that you do, both to protect yourself and to maintain your effectiveness with clients; protection rituals to shield yourself from potential toxicity; seeing the client as separate from their story or their acts, to allow connection with strength or goodness in the client. Participants talked about developing creative separation strategies with clients, for self protection as well as for effectiveness with clients. For example, Anne said that before sessions with some clients she would "say a silent little prayer for myself, around protection for myself... I do my visualization of something, some kind of material, some kind of cloth that will that will protect me from the things I'm hearing" (Paragraph 108). Creative separation was also used to help therapists' connect with clients. Grandpa stated that: "I guess I compartmentalize you could say, you know, it's like I know that other stuff [what the client has done] is there but it's, I just think it makes sense to connect with people, try to understand them, but then still get back to, you know, this is the reality" (Grandpa, Paragraph 54). Meg said that, in describing her work with a particularly challenging client, she imagined "an invisible shield ... that would just you know create a little bit of a distance" both for self-protection and to allow her to work more effectively with the client (Paragraph 88). 3. ADJUSTING WORLD VIEW - to include new understandings of humanity and systems Including: integrating, understanding, and finding meaning for pain and violence; expanding and adjusting world view, view of humanity, 81 human nature, to encompass new understanding of the capacity of people and systems to do harm; refining or polishing views; finding balance in view of world and of humanity, of people. Participants described coming to terms with the knowledge of the frequency and degree of violence that occurs in the world. Sally said that, "it's like I have some new knowledge that I didn't have before" that needed to be integrated into her belief system and understanding of the world (Paragraph 60). Witnessing and hearing about violence in its many forms challenged participants to stretch their understanding of the world and of humanity. Meg said, of working with a particularly challenging client: "it was a bit of a reality check for me that you know some of this work is dealing with, maybe a lot of this work is dealing with the dark side in people, that we all have ... this stuff in ourselves ... [now I'm working] not just [with] the part where people are recovering from violence and moving on, but [with] the whole story." (Paragraph 100). Many participants talked about struggling to find ways to understand the "immensity of the capacity of, of humans to do evil to one another" (Meg, Paragraph 140) referring, for some participants, not only to offenders but also to co-workers, other professionals and social systems. 4. UTILIZING FAITH - to sustain you in this work. Including: the necessity of lived spirituality (as opposed to theoretical beliefs) for strength, support, endurance and guidance; spirituality necessary for self-preservation, to stay strong and well; need beliefs for stamina, strength, to maintain perspective and balance, hope and joy. Most of the participants talked about the necessity of faith in being able to survive in trauma work. Naomi put it in the following way: "I don't know how anybody could do trauma work and not have some sense of, of something that was supporting them ... otherwise it would be so dry and bitter" (Paragraph 86). Many participants talked about using prayer for guidance and strength in their work. Babs, for example, in describing her work with abused children said: "I did a lot of praying for, I need something, I need to help these kids, you know, in whatever that may be, I really was looking for strength in dealing with the kids, and I found it and I loved it" (Paragraph 36). Others participants talked about consciously and deliberately hanging onto their beliefs in the fundamental goodness of humanity and of life to balance out the pain that they witness in their work. 5. IMPLEMENTING SELF-CARE STRATEGIES IN PERSONAL LIFE - things you do outside of work to counteract or prevent the potentially wearing effects of work on body, mind and soul. Including: outside passions to balance work; need things that you do outside of work, away from work to help stay strong and balanced; spiritual or grounding practices; hobbies, activities or time away; personal relationships or connections that are healthy and balancing. All seven participants talked about the importance of having things in their lives outside of work to help counteract or prevent the potentially wearing effects of work on mind, body and spirit. As Naomi put it, "in order to be able to do the work I have to look after myself (Paragraph 88). In order to stay balanced and well, "you have to have things outside your work where you um where you're totally absorbed in it and its refreshing and its satisfying" (Anne, Paragraph 130). Participants talked about many kinds of activities that they used to help them stay connected and spiritually grounded, such as time with friends and family, time in churches or spiritual places, time spent in nature. Although the types of self-care that counsellors talked about varied, the importance of those activities in remaining healthy in all ways, as well as spiritually healthy, was emphasized by all seven participants. 83 6. ACCESSING PROFESSIONAL SUPPORTS - to help maintain wellness and perspective Including: finding ways to process traumatic material; accessing support from co-workers, peers, supervisors; artwork; developing networks; accessing counselling. As noted in the section on demographic information, not all of the participants had ready access to professional support systems in their place of work. Of those that did not, many found ways of accessing support from colleagues or supervisors outside of their workplace. Participants talked about the value of being able to connect with and utilize professional support systems to prevent feelings of isolation, to help maintain hope and perspective and connection. Both this and the category above, Self-Care, helped participants to prevent harm to their sense of spirituality and helped them to renew that sense, in whatever terms they defined it. For example, Grandpa said that, after working in a community devastated by a molester who had victimized many, many children, that he tried "not to let it impact [his] spirituality" (Paragraph 78). "I had to come back and talk to people about it and just... kind of look at it... and talk about it afterwards and spend some time to recover" (Grandpa, Paragraph 84). The eleven categories which emerged from this study were subjected to four validation procedures to confirm thier validity. The results of these measures are described below. 84 Table 3 List of Categories Into the Light This process was one of affirming beliefs and strengthening spirituality through actions. 1 . Believing in the good in people 2 . Believing in the capacity for growth 3. Applying spirituality 4. Developing or affirming a sense of purpose 5. Recognizing and/or participating in global connectedness Into the Fire This process was one of feeling spiritually challenged yet finding a response which helped participants to protect or reconnect with spirituality. 1 . Define and accept limitations 2 . Develop creative separation strategies with clients 3. Adjust world view 4. Utilize faith 5. Implement self-care strategies in personal life 6. Access professional supports 85 Validation Procedures The four validation procedures used in this study - confirming exhaustiveness, checking results with participants, tabulating participation rates and independently categorizing effects - each contributed to and confirmed the validity of the present study. The results of these four procedures are described below. Exhaustiveness By continuing the initial interviews until participants reported that a complete account of their experience had been achieved, it appears that saturation in each of the interviews was reached. This was confirmed in the follow-up interviews, when the participants were invited to add any additional incidents and/or effects to complete the picture of how trauma work effects counsellor spirituality. All of the participants stated that the categories represented a comprehensive summary of their experiences and had no further effects and/or incidents to add. Retaining 10% of the summaries from the initial formulation of the categories also confirmed the exhaustiveness of the categories. After the categories were finalized, the group of summaries that had been withheld were sorted into the categories. I was able to sort most of the summaries in the final group into the categories. The only summaries which remained after the final sorting were those which were outside of the focus of this study. These remaining summaries all referred to events outside of the work place which had an impact on participants' spirituality and were therefore not applicable to the present research question. 8 6 Follow Up Interviews Checking the results of the study with participants proved a useful validity check. Participants were invited to comment on the overview of the findings and the categories, and were asked to review and revise how the summaries of their interview had been categorized. Participants confirmed the general findings and the applicability of the categories to their experience. Categorizations were reviewed and discussed and revisions were made as needed. If there were any categories which the participant had not addressed in the initial interview, these were discussed during the follow-up interview. In some instances, participants confirmed the applicability of the category to their experience and gave an example of the pertinent effects of their work on their sense of spirituality. In other instances, the participant and researcher jointly concluded that the category was not applicable to the participant's experience; this was noted and included in the analysis of participation rates, discussed below. In addition to confirming the findings of this study, the follow-up interviews provided the opportunity for this researcher to clarify questions which were outstanding after the initial interviews and analysis. For example, in the general findings, participants' language guided the choice of words to supplant the word 'impact' in describing the relationship between trauma work and spirituality. The follow-up interviews afforded the opportunity to ask for clarification and guidance in the categorizations. In some instances, I made assumptions about effects which I felt were implied but not specified in the dialogue, which I was then able to check with participants during the follow-up interview. The follow-up interviews provided an invaluable opportunity to clarify and 87 deepen this researcher's understanding of the participants individual experiences and their experiences as a group. Participation Rates In order to assess the rate of participation in each of the categories, the categorization of the summaries was tabulated to demonstrate the number of summaries that were placed in each of the categories (Table 4, below). The column headings represent the pseudonym initial of each participant; the rows identify the effect categories, divided into the two broad groupings, Into the Fire and Into the Light. The numbers identify the summaries that were placed in each category. Instances where the participant did not describe the category in the initial interviews, and then endorsed the category in the follow-up interview are indicated by the initial F. In some cases, effects had been addressed during the initial interviews when the demographic questions were asked. As the demographic questions were not included in the numbering system, these summaries are represented by the initial D. Blank cells indicate that the category was not applicable to the participants' experience. Participation rates were calculated based on material from the initial interview and calculated again including material from the follow-up interviews. The initial interview (represented on Table 4 by numbers and the letter D) yielded 86% participation rates for five of the categories and 100% participation rates for six of the eleven categories. After the follow-up interviews, participation rates were calculated again including material from the follow-up interviews (represented on Table 4 by the letter F). Only two blank cells remained after the follow-up interviews. Therefore, nine of the categories 8 8 yielded a 100% participation rate and two of the categories, Category 5 of Into the Light and Category 4 of Into the Fire, each yielded an 86 % participation rate; these percentages are well above required 25% participation rate (Alfonso, 1996). The high participation rates offer strong confirmation of the validity of the categories. In addition to using Table 4 to demonstrate participation rates, I was interested to see whether a pattern of primacy might emerge among the categories. Many of the summaries were categorized into two or more of the categories. During the follow-up interviews, I invited participants to choose which category was most salient for them for each summary. The most salient category for each summary is indicated in bold on Table 4. Once the categorization of all of the summaries had been reviewed, I invited participants to choose one or more categories which they felt most clearly articulated their experience overall of the effect of trauma work on their sense of spirituality. I was curious to discover if a pattern might emerge, or if some of the categories might consistently be of particular importance to counsellors. There was no pattern that I could discern. Participants choice of most important category or categories overall (choices ranged across the eleven categories) appeared to bear no consistent relationship to the categories that the were most salient during the initial interviews. I expect that factor analysis based on a much, much larger sample size would be needed to extract such a pattern, should one exist. 8 9 Table 4 Participation rates I CATEGORY | S | M | A | H | G | N | B | INTO THE LIGHT 1. Believing in the good in people 101 52, 14, 3, 28, 82 173, 38, 34, 81 36, 47,91 32 52, 65, 56 12, 53, 77 2. Believing in the capacity for growth 55, 107, 60 3, 112, 82 173, 56, 34, 38, 81, 170, 111, 69 36, 20, 91, 67, 12 92,8, 94, 70 52, 56, 65, 84 99, 16, 79 3. Applying spirituality 101, 55, 107, 60, 46 52, 14, 112, 28, 82 34, 38, 56, 147, 170, 69, 76, 6 20, 91, 47, 36 60, 105, 32 65, 84, 41 26, 12, 16, 88, 118, 53 4. Developing or affirming a sense of purpose 123 82, 28, 108 6, 170, 38 36, 20, 7, 3, 47, 91 8, 105, 94 41, 84, 52 99, 79 5. Recognizing and/or participating in global connectedness 46, 123 14, 28, 82, 3 38, F 7, 3 92, 8, 105 41, 12, 5, 77, 84 INTO THE FIRE 1. Defining and accept ing limitations 103 140, 108, 112 164, 128, 173, 16 101, 61, 12, 67, 20, 7 105, 98, 70,76, 8/27 F 94, 99 2. Developing creative separation strategies with cl ients 101, 103, 72 82, 126 38, 100, 111 3, 101 40/51, 46 F 77, 26, 14/8, 62 3. Adjusting world view 72, 67, 81, 105, 82, 103 140, 82 85 67, 79, 12, 55, 3 98, 76, 74, 6, 8/27, 46, 60, 70, 32 38, 26, 20, 12 34, 26, 62, 12 4. Utilizing faith 82, 126, 108 173, 16, 85 67, 79, 36 40/51, 60, 46 20, 88 16, 94, 14, 34, 14/8, 26 5. Implementing self-care strategies in personal life 81, 82 140 142, 129, 128 20, 128, 55 76, 98 5, 38, 88, 77 115, 12/16, F 6. Accessing professional supports D, F 140, 126, F 164, 142, 173, 69, 128 128, 67, 6, 12, 3 76 F D Note: F: follow-up interview D: demographic interview numbers: transcript paragraph numbers Independent Raters 90 Finally, the categorizations of the two independent raters were compared to the categorizations depicted in Table 3, above. The two raters were provided, through e-mail, with one third of the summaries to categorize. Once the raters had independently categorized the summaries, they reported their categorizations (one over the telephone, one through e-mail). Their categorizations were compared to mine and a percentage of agreement was calculated. The first independent rater categorized 53 of the 69 effects in the same way that I did, yielding an agreement rate of 77%. 60 of the second rater's categorizations were consistent with this researcher's, yielding an agreement rate of 87%. Agreement rates with both independent raters are within an acceptable range (75 - 85 %), as defined by Andersson and Nilsson (1964). These agreement rates support the validity of the categories. 91 Chapter V: Discussion The current chapter discusses the findings of this study relative to the literature and research on the effect of trauma work on the spirituality of the counsellor. Areas of discussion include examining the possible impact of demographic variables on the results of this study, comparing the general findings and categories resulting from this study to the literature and research, identifying the limitations of this study and considering possible implications of the current study for counselling research and practice. Demographic Variables One of the interesting observations for me in doing this thesis was the degree to which participants, who were very different from one another in many ways, shared common experiences in the effect that their work has had on their sense of spirituality. Variables of interest in the literature, such as age of clients (working with adults or children), definitions of spirituality, experience, education, caseload, gender, etc., did not seem to have much bearing in terms of effect of trauma work on spirituality, at least in the stories of these seven participants. It was beyond the scope of this study to examine any of these variables in detail and, of course, given the very small sample size in this study, the results cannot be generalized to other counsellors. In terms of gender, for example, since the study included only one male participant, this study can not address the question of what role these variables might play in the influence of trauma work on spirituality. 92 There is general agreement in the literature and research on vicarious trauma that symptoms of vicarious trauma are more likely to occur among counsellors with higher caseloads of survivors of violence. Although the participants in this study all had high percentages of victims of violence in their caseloads, their exposure to trauma material in terms of numbers of clients per week varied. Interestingly, there did not appear to be any difference in terms of effect on spirituality between the three people who worked in trauma part-time and the four that worked in trauma full-time. The explanation for this may be contained in Category 1, Into the Fire, Defining and Accepting Limitations. Many participants talked about the kind of work that they felt comfortable doing and what they did not feel comfortable doing. Some participants felt able to work full-time in trauma, others said that they needed more of a mix in their work. What seemed critical in this was simply being aware of and respecting their own limitations. One of the participants raised the question of whether there might be a difference in effect among counsellors who work with adults and counsellors who work with children and their families. Brady (1997) also examined this variable, comparing therapist with high caseloads of children to therapists who worked primarily with adults and therapists with mixed caseloads. She found no significant differences in vicarious trauma symptamology among the three groups. Similarly, in this study, participants described very similar experiences, similar rewards and challenges, whether they worked with primarily children, primarily adults or both. 93 Another interesting and unexpected twist in the research was the inclusion of the potential influence of working with perpetrators of violence (who were usually also victims). When I realized that several, but not all, of the participants worked with offenders (some convicted offenders, others not), while other participants worked only with survivors of violence, I began to pay attention to the potential effect of that difference. Interestingly, this variable also did not appear to have a significant influence on the effect of trauma work on counsellor spirituality. Those participants that worked with offenders described the same effects as participants that worked exclusively with survivors of violence. Similarly to percentage of caseload, what appeared to be most important was recognizing the kind of work that is most appropriate for the individual. For example, some participants felt that working with offenders, or for some participants, working with sex offenders, was not an aspect of trauma work that they felt able to do. Limitations were individually defined and expressed; what seemed to be important was that those limits were drawn and respected, rather than where they were drawn. One of the variables which was not directly addressed in this study is that of whether or not a personal history of violence influences the relationship between counsellor spirituality and trauma work. All of the participants mentioned their family and/or friends at some point during the interview as being significant in the effect of their work on their sense of spirituality. Two mentioned a personal history of trauma; two others specifically mentioned not having a personal history of trauma. These four discussed personal history in various ways; as providing stability, meaning, challenge, 94 balance. As discussed in Category 5, Into the Fire, many participants talked about the grounding, balancing influence of having strong, healthy relationships in their personal lives. It was beyond the scope of this thesis, however, to examine the effect of personal trauma (or lack thereof) on the relationship between spirituality and trauma work. Although participants varied greatly in their responses to demographic questions, there was sufficient similarity in their experiences that they all confirmed the general findings of this study during the follow-up interviews. This commonality may be due, in part, to a bias which may have been introduced by one of the inclusion criteria of this study. The general findings of this study and the possible influence of this criterion on those findings are discussed below. General Findings In this study, the question asked of participants was what impact their work had on their sense of spirituality. The central finding of this thesis was a re-framing of the idea that trauma work has an impact on spirituality; rather, it would appear that a more active, or interactive relationship exists between counsellor's sense of spirituality and trauma work. Jon Kabat-Zinn (1990), in his book Full Catastrophe Living, draws a distinction between reaction to stress and response to stress; reaction is an automatic, often sub-conscious process, whereas response is a more conscious, deliberate, chosen process. In my opinion, this distinction is applicable to the relationship between spirituality and trauma work. This group of seven counsellors described their response in terms of their sense of spirituality rather than a reaction to their work. 95 Participants in this study agreed that the interaction between trauma work and spirituality could not be neatly divided into positive and negative effects. At the same time, none of the participants in this study reported the profound disruption to spirituality that the literature on vicarious trauma and spirituality suggests is possible (Charney & Pearlman, 1996; Figley, 1995; Pearlman, 1994; Pearlman & Saakvitne, 1995; Pearlman & Saakvitne, 1995b; Saakvitne, 1996) and that I experienced as a volunteer at the Casa Guatemala orphanage. There are a few possible explanations for this contrast. Jon Kabat-Zinn (1990) describes learning to respond rather than react to stressors as the key to preventing and managing the potentially harmful effects of stress. Perhaps the most damaging effects of trauma work on spirituality happen when counsellors find themselves reacting rather than responding to their work. If counsellors are in a supportive environment, if they are aware of the potentially harmful effects of trauma work and aware of their own triggers and challenges, they are then equipped to respond to their work in ways that feel healthy to them. The theoretical literature and the research into vicarious trauma may already be having an effect in this regard. All of the participants that I interviewed knew about vicarious trauma and were aware of the potential hazards of their work. The need for self-care and support is being validated and normalized by the burgeoning literature on vicarious trauma. Perhaps the shift towards recognizing the essential role of spirituality in people's lives and in counselling is also playing a role here; there is now more permission to talk about spiritual issues and more validation of spiritual self-care. 96 The inclusion criterion in this study of soliciting counsellors who were comfortable talking about spirituality may also have influenced this study's findings by systematically excluding participants who were likely to have experienced the most damaging effects of trauma work on spirituality. It is logical that people who are willing to talk about the effect of their work on their spirituality are aware of and observant of that aspect of their experience. Kabat-Zinn (1990) describes awareness as the first and essential step towards learning to respond rather than react to stressors. By soliciting counsellors who are comfortable discussing spirituality, I may have excluded counsellors who are not as aware of this aspect of experience and therefore excluded counsellors who are more likely to have experienced the more devastating effects of trauma work on spirituality, as I did. The research may suggest an additional explanation for the lack of extreme effects on spirituality among these participants; spirituality may be important in enabling counsellors to cope with exposure to traumatic material and therefore in preventing significant vicarious trauma symptoms. In Maria Arvay's (1998) narrative study, spirituality was included in the discussion regarding self-care strategies that were useful to the participants in managing secondary traumatic stress. Joan Brady (1997) found that a strong sense of spirituality was negatively correlated with vicarious trauma symptoms. Specifically, Brady found that scores on the Wrathfulness, Deisticness and Irrelevance factors of the Gorsuch Adjective List correlated positively with scores on the Impact of Events Scale and with scores on the TSI Belief Scale. In addition, scores on the TSI Belief 97 Scale correlated negatively with scores on the Spiritual Well-Being Scale, implying that "increased distortion in cognitive beliefs was related to reduced spiritual well-being" (Brady, 1997, p.72). The causal relationship between these dependent variables, if any, can, of course, only be hypothesized. One of the explanations suggested by Brady is that a strong sense of spirituality may prevent the development of significant vicarious trauma symptoms. One of the questions Brady (1997) cited in her discussion section was whether or not trauma counsellors who did not experience vicarious trauma symptoms had a strong sense of spirituality before beginning the work or whether spiritual well-being developed through or during their careers in trauma work. The seven participants in this study talked about having a fairly solid sense of values and beliefs on entering the trauma field; several said that they had a strong faith or sense of spirituality before beginning this work. They also talked about the effect of this work of tempering, polishing, and clarifying their sense of spirituality. My impression overall is that, generally speaking for these seven people, the challenges and rewards of trauma work tempered and refined what was already strong. Given the possibility that a strong sense of spirituality might act as a protective buffer, it is unlikely that the participants in this study would experience the more devastating effects of working in trauma. It is possible that the inclusion criterion of comfort discussing spirituality may have had the result of soliciting counsellors with a 98 strong sense of spirituality, thereby excluding trauma counsellors who may have experienced the spiritual disruption described in the literature. The question that then arises is whether or not trauma counsellors generally are interested in and aware of spirituality. Perhaps many of the people that are drawn to trauma work are attracted to the uniquely spiritual challenges and rewards that exposure to the extremes of human nature and behaviour offers. Alternatively, perhaps the people that survive and continue in trauma work are the ones with a strong sense of spirituality. Unfortunately, given the very small sample size of this study, the experiences of the seven participants in this study can not be generalized to other counsellors working with victims of violence. Clearly, more study is needed to clarify this question. The Categories I have borrowed Ingersoll's (1994) dimensions of spirituality again to organize the integration of the categories which arose in this study with the research and literature on vicarious trauma and spirituality: meaning, relationship, play, mystery, experience and conception of divinity. While I have focused on only two or three categories in each of the dimensions listed below, elements of each of the dimensions are woven throughout the categories which emerged in this study. Like Ingersoll's spiritual dimensions, the categories that emerged in the current study were also interrelated, as illustrated in the number of effects that participants described for many of the incidents that they recounted. Meaning 99 Both of the possibilities for the dimension of meaning, as described by Elliot Ingersoll (1994), beauty and a feeling of purpose, were relevant to the results of this study. Category 1 in Into the Light referred to recognizing and believing in beauty, strength and goodness in people. The element of purpose is identified in Category 4 in Into the Light, Developing or Affirming a Sense of Purpose. These categories resonate with the voices of the participants, in part, in both Maria Arvay's (1998) narrative study and Cynthia Bettcher's (1997) focus group. In both of these studies, participants discussed the potential for trauma counsellors to develop a profound sense of purpose and meaning through their work. Generally speaking, Category 1 and 4 of this study also support Joan Brady's (1997) results, which highlight the potential benefits of trauma work in terms of the spiritual well-being of trauma counsellors. The literature on vicarious trauma and spirituality and aspects of Bettcher's (1996) results also point out the possibility of disruption to sense of meaning (Charney, & Pearlman, 1996; Pearlman & Saakvitne, 1995b; Saakvitne, 1996). In this study, participants talked, not about disruption to sense of meaning, but about consciously working on preventing disruption. Category 1 and 2 in Into the Fire, Defining Limitations and Developing Creative Separation Strategies with Clients both refer to creating and framing boundaries and limitations in ways that help them to understand, accept and find meaning in their own and their clients limitations. Setting and respecting limits and utilizing boundaries enabled participants to maintain a sense of meaning, as well as protecting other aspects of spirituality. 100 Relationship Aspects of the dimension of relationship were included in many of the categories, particularly in Category 5 in Into the Light, Global Connectedness. Participants described this connection in varying ways, including their sense of connection to humanity and their sense of connection to the divine. Category 3 of Into the Light, Applying Spirituality, also referred to connection, in the context of the therapeutic relationship. The possibility of a heightened sense of connection which emerged in this study did not appear in the literature that I found on the relationship between trauma work and counsellor spirituality. Rather, theorists tended to focus on the possibility of disruptions to the sense of connection and the necessity of working on maintaining relationships with others, self and the divine. Counsellors in this study echoed the need to remain mindful and active in maintaining connections. Counsellors in this study detailed a variety of strategies in maintaining connection in the face of the traumatic material to which they are daily exposed. This was most evident in two categories in Into the Fire, Category 6, Accessing Professional Supports and Category 3 Adjusting World View. Counsellors talked about using the supports available to them professionally to help them stay connected both with their sense of self, through processing traumatic material, and their sense of connection with colleagues facing similar challenges. This finding supports Pearlman and Saakvitne's (1995) assertion that professional supports are important in maintaining a sense of connection. Counsellors in this study described consciously striving to balance their view of humanity, recognizing 101 and integrating the potential of people to do harm to one another, without loosing their fundamental connection to, and belief in, the beauty and goodness of humanity. Plav It really struck me, when I was transcribing the audiotapes, how often we laughed during the interviews. The quality of that laughter was not cynical or sarcastic (or, at least, not often), it was joyful. Participants talked about the wonder and magic of watching people create change in their lives, the amazement and joy that they experienced witnessing and participating in that change. Anne, for example, said that she knows when children she works with are getting better, because they start to sing. She laughed as she told me about one little girl in particular who, when she was getting better, "could really sing" (Paragraph 64). Other participants talked about change manifesting in clients' stories and artwork, illustrating a return to strength, joy, and laughter. Although the literature regarding spirituality and vicarious trauma referred to the possibility that witnessing change can help to create a sense of meaning and purpose for counsellors, I did not find references to the joyfulness and awe that the participants in this study expressed. Participants also talked about the necessity of maintaining personal outlets for joy and fun, the necessity of having other things in their lives that they are passionate about and that absorb their interest. Consistent use of self care strategies (Category 5, Into the Fire), according to the counsellors in this study, helps to maintain the capacity for joy and play in counsellors' lives, both in and outside of the work place. This finding is consistent with the many references in the literature and research on vicarious trauma on 102 the importance of effective self-care strategies in helping counsellors to cope with exposure to traumatic material. Mystery. Conception of Divinity, and Experience The third category in Into the Light describes how counsellors apply their sense of spirituality in their work with survivor clients. Many of the participants described the therapeutic relationship and the healing that can occur in that context as having an element of mystery, of magic. Participants described how their sense of spirituality enhances the work that they do, and how the work that they do can have the effect of enhancing their sense of spirituality. This finding is consistent with Joan Brady's (1997) results regarding a positive correlation between exposure to trauma material and scores on the Spiritual Well-Being Scale. It is challenging to compare the results of this study with Joan Brady's (1997) results using the Gorsuch Adjective List, as not all (or even most) of the participants in this study hold an anthropomorphized view of divinity. While the seven participants talked very little about questioning or loosing touch with their sense of spirituality, they did discuss consciously and deliberately using their belief systems to sustain them in confronting the reality of violence in their work (Into the Fire, Category 4, Utilizing Faith). Spirituality appears both to enhance counsellor's ability to work effectively in trauma, and to protect counsellors from the potentially damaging aspects of trauma work. The participants in this study described the necessity of their living their beliefs, of keeping their sense of spirituality close and vivid and real, to help them stay healthy and balanced in their work and in their lives. In my opinion, this finding supports Brady's 103 results that trauma counsellors tended to view God or a Higher Power as benevolent and potent. The results of this study are evocative, addressing a few of the gaps and calling into question some of the assertions posited in the literature regarding the effect of trauma work on the spirituality of trauma counsellors. However, the results of this study are limited in several ways; both limitations and implications are discussed in the following sections. Limitations of the Study The design of this study introduced several limitations. First among these limitations in terms of importance is the very small sample size of this study. As referred to in several sections of this chapter, the experiences of seven people simply cannot be safely generalized to other counsellors. The use of the four validation measures confirming the validity of the results of this study suggest, in my opinion, that this study accurately and comprehensively describes the effect of trauma work on the spirituality of the seven participants involved in this study. Regardless of how accurately this study describes the experiences of these participants, however, it cannot be said to describe the experiences of trauma counsellors in general. The methodology chosen for this study, the critical incident technique, was useful in examining how trauma work effected the spirituality of the participants. By asking participants for their view of how their spirituality has changed due to their work, and by linking that change to specific work related incidents over time, a detailed description of 104 the effect of trauma work on counsellor's spirituality emerged. As I had hoped, the link to specific incidents provided concrete details exemplifying change. In my opinion, using work-related incidents to exemplify impact helped participants to isolate the influence of work from other influences in their lives, as well as helping participants to be detailed and specific about how their spirituality has changed in response to their work. In this study, the analysis focused primarily on the experience or outcome of the incidents (the effect on spirituality) rather than on the incidents themselves. Due to the time (and energy) constraints of the researcher, this study was limited to examining effects; the incidents could not be examined in detail and categorized separately from the effects. This limitation of the current study was unfortunate; an examination of significant incidents would have been a useful addition to the research on vicarious trauma as well as the research on vicarious trauma and spirituality. As discussed in the section examining the general findings of this study, a bias may have been introduced by the inclusion criterion of soliciting participants who are comfortable talking about spirituality. In addition to the small sample size of this study, this possible bias may further reduce the generalizability of the results of this study. Finally, the role of demographic variables in the relationship between trauma work and counsellor spirituality, although observed, could not be examined or analyzed directly or in detail. The potential role of gender and the possible influence of a personal history of trauma particularly received little attention in the current study. 105 Although limited in several ways, the present study offers unique and original information which is relevant to counselling research and practice. The implications of this study are discussed in the following section. Implications for Research and Clinical Practice Generally speaking, the results of this study are consistent with Brady's (1997) findings that trauma work may be positively correlated with the spiritual well being of counsellors. The present study augments Brady's findings by suggesting ways in which trauma counsellors may consciously and deliberately interact, in spiritual terms, with their work. These findings offer a challenging and hopeful view to offset the concerns raised in the literature regarding the potentially devastating effect of trauma work on counsellor spirituality. It would appear that there is at least a subset of counsellors who are thriving, in spiritual terms, in trauma work. The general findings of this research suggest that the relationship between trauma work and counsellor spirituality is complex and reciprocal; this has been a challenging shift in thinking for this researcher, as I originally expected to discover impact categories which could be clearly defined as positive or negative. This shift in thinking from polarities to ambiguities has been reflected in my work as a counsellor. I used to say that there were 'good' and 'bad' aspects of my work. For example, I would define working with a parent who was verbally abusive towards her child in my presence as being difficult for me, an aspect of my work that I did not like. I would define witnessing healing and growth as being the 'good' aspects of my work, the 106 part of my work that I liked. I now view the rewards and the challenges of my work as being equally useful to me, if I remain mindful of my responses, if I use all aspects of my work and my responses to my work as opportunities for personal and professional growth. For example, I worked with a client recently who was highly distrustful and tended to verbally attack the professionals working with him. Previously, before I began this research, I would have labeled the days that I worked with him as 'hard' or even 'bad' days. Using what I have learned through this research, I found ways to both connect with the client and protect myself from the anger and fear that he projected towards me. I reminded myself of my belief in the client's fundamental goodness, of his potential to change and, in sessions with the client, I visualized his anger flowing around and past me, without touching me. In this way, I was better able to genuinely express empathy and caring for the client and found sessions with him less exhausting and disheartening than I would have, previous to this research. I was also better able to maintain my own sense of groundedness and mindfulness and felt satisfied with the work that I was doing with him, even on days when the client reverted to expressions of anger and mistrust. The categories developed in this study have informed my work as a counsellor, suggesting specific ways in which I can interact, spiritually speaking, with my work, reminding me of how I can respond to the more challenging aspects of my work in ways which feel healthy to me, reminding me to celebrate the joy my work can offer me. In the example that I used above, I applied Categories 1 and 2 of Into the Light (Believing in the 107 Good in People and Believing in the Capacity for Growth) and Category 2 of Into the Fire (Developing Creative Separation Strategies with Clients) to improve my connection with the client and to protect myself from potential toxicity. I hope that other counsellors might find this research as useful as I have, as comforting, as confirming. In my opinion, the categories which emerged in this research are specific enough to offer practical, useable guidelines and open enough to be relevant for most counsellors, regardless of their spiritual orientation. This study also lends support to the current trend in counselling psychology to acknowledge the importance of spirituality in peoples' lives, and to integrate spirituality more explicitly and openly in counselling research and practice. This study suggests that spirituality may in fact form a crucial and integral part of how trauma counsellors remain grounded, balanced, effective and inspired in their work. As such, more openness regarding spirituality, and more support and guidance for that openness in practice, training, and research, may be useful for counsellors, assisting them in avoiding the more painful effects of exposure to traumatic material. Clearly, much remains to be done in examining the relationship between trauma work and counsellor spirituality. This study, in combination with Brady's (1997) findings, suggest many questions for future research. For example, it appears that a strong sense of spirituality may help counsellors to cope with trauma work; this finding begs several questions. Are counsellors with a strong sense of spirituality attracted to trauma work, or is it possible to develop a strong sense of spirituality through working 108 with victims of violence? If a strong sense of spirituality protects counsellors from vicarious traumatization, does that imply that counsellors who experience vicarious trauma are less spiritually grounded or aware? If so, would spiritually oriented support be useful in coping with vicarious traumatization? It would also be useful to examine specific aspects of trauma work that are significant for counsellors in terms of effect on spirituality. If significant work-related incidents can be identified, counsellors can be better prepared, through training and supervision, to cope with those incidents. Research in these areas may be very useful in both preventing and treating vicarious traumatization. Conclusion It seems clear to me that ambiguity must be embraced in attempting to understand the interaction between counsellor spirituality and trauma work. As the character of Dr. Feldman in Maria Arvay's (1998) dissertation states: I have come to realize through [the participants'] stories and my own that it seems to be about living in the paradox, living with ambiguity. At some point, we arrive at an acceptance that it just is. Life goes on. (P.216) It has been a useful challenge for me to resist simplicity, to respect and reflect the complexity of the participants' experiences, and my own, to accept and even revel in the shades of gray. I end, as I began, with my own experience. When I started this research project, I was a student of counselling psychology. Now, at the end, I have been working as a 109 counsellor for a year and a half. In the conclusion of my research proposal, written two years ago, I stated: I hope that participants will be able to offer insight regarding both the potential harm and the possibility of healing in working with victims of violence. Buoyed with such expertise and experience, I hope to enter the field of trauma work far more prepared for its spiritual impact than I might otherwise have been. For me, and for other prospective counsellors who share my concerns, this study may provide a sense of knowledge and of shared experience and an awareness which in themselves may be crucial in becoming and in remaining successful trauma counsellors. Those personal goals, those hopes which started this project were realized. Not only have I benefited from the experience and insight of the participants regarding the rewards and challenges of trauma work, indeed, of counselling work in general, I have gained insight into my own experience, past and present, through this project. I chose to begin my career in counselling working with a mixed caseload, including a fairly small percentage of victims of violence, in part because of the insights into my own needs and limits that I gained in doing this research. This research project and, most importantly, the intense self-scrutiny and honesty that it has required of me, this process has formed a part of my soul's "unfolding." Although at times grueling, frustrating, and utterly exhausting, I am profoundly grateful for this experience. I too, through this study, have been tempered by fire, inspired by light. Laurie Anne Pearlman and Paula Mclan (1995) suggest that connecting with other counsellors is essential in managing and preventing the symptoms of vicarious trauma. 110 Communication, education and support are necessary in illuminating and guiding the processes of working in trauma and of surviving in trauma work. They state that: Trauma therapies are sensitive relationships requiring the best of both parties; we can do our part only with an adequate map and colleagues to help us hold the flashlight (p.564). I thank you, Anne, Grandpa, Meg, Naomi, Babs, Sharon and Sally, for the flashlight. 111 Reference List Alfonso, V. (1996). 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Dissociative identity disorder: Theoretical and treatment controversies, (pp.467 - 492). Northvale, NJ: Jason Aronson, Inc. Saakvitne, K. W. (1996). Countertransference and vicarious traumatization: the therapist at the eye of the storm. Paper presented in the symposium entitled In the Trenches of Trauma: Three Contemporary Issues in Psychoanalytic Work with Trauma Survivors at the Sixteenth Annual Spring Meeting of Division of Psychoanalysts (39), New York, NY. Schauben, L. J., & Frazier, P. A. (1995). Vicarious trauma: The effects on female counselors of working with sexual violence survivors. Psychology of Women Quarterly. 19. 49 - 64. Schoenrade, P. (1995). Review of the Spiritual Well-Being Scale. In J.C. Connelly & J.J. Kramer (Eds.). Mental Measurement Handbook. Twelfth Edition (pp. 983 - 984). Lincoln, NB: University of Nebraska Press. Seaward, B. L. (1991). Spiritual wellbeing: A health education model. Journal of Health Education. 22. (3), 166 - 169. Walton, D. T. (1997). Vicarious traumatization of therapists working with trauma survivors: An investigation of the traumatization process including therapists' empathy style, cognitive schemas and the role of protective factors. Unpublished doctoral dissertation, Philidelphia, PA: Temple University. Woolsey, L. K. (1986). The critical incident technique: An innovative qualitative method of research. Canadian Journal of Counselling. 20 (4), 242 - 254. 118 APPENDIX B: Basic Information for Initial Contact by Telephone This information would be presented in the initial contact in staff meetings or over the phone. There are five areas of information that I would like to discuss with you: 1.1 am doing a master's thesis about counsellors doing trauma work. I would like to talk to trauma counsellors who have been working with survivors of violence for two or more years about how their work has effected them. By trauma counsellors I mean counsellors who spend over half their time in one-on-one or group work with survivors of violence. 2.1 am especially interested in finding out how your work has effected your sense of meaning and spirituality. I am using a very broad, individualistic definition of spirituality. It could mean sense of purpose or meaning, connection with people, nature or life, practicing a religion, or simple joy and play. It's a part of human experience that is only beginning to be discussed in counselling psychology and there is almost no research on it. If you feel that your work has had an impact on your spirituality, either positive or negative, and you are comfortable talking about this experience I would be very interested in talking to you. 3.1 would like to conduct two interviews with you. The first will be longer, about an hour or an hour and a half, the second will be only about half an hour. The first interview will be for learning about your experience of how your work has effected your spirituality and what situations related to your work were particularly significant in their impact on your spirituality. The second interview will be a follow-up interview for you to give me feedback about how I have interpreted and categorized the first interview, to make sure that my interpretations were accurate. 4.1 would like to audiotape the interviews. The audiotapes will be transcribed and marked with your pseudonym to ensure confidentiality. All of the information in the interviews will be kept strictly confidential and the audiotapes will be erased as soon as the thesis is finished. 5. The purpose of this study is to collect information about the effect that trauma work can have on the spirituality of therapists. Research in this area is just beginning, and I hope that this study can provide information both to inform future research and new counsellors beginning work with survivors. (Staff meetings only - not necessary for people contacting me by phone) 5. If you would like more information, please contact me at the number listed on the flyer. Many thanks, Sandy 123 APPENDIX E: Explanation of Demographic Information I have a list of basic demographic information which I would like to ask you about. The research in this area suggests that these variables might have an effect on how you experience your work. All of this information, like the rest of the interview, will be kept confidential. No identifying information will be used in the final copy of the thesis. I would like to have a name other than your own that I can use to refer to you. Would you like to choose a pseudonym? What is your age? What are your qualifications? Education? How long have you been working with survivors of violence? How much supervision do you receive? How much peer support do you receive? What percentage of your caseload is comprised of survivors of violence? 124 APPENDIX F: Opening Statement and Potentially Relevant Questions As I mentioned before [over the phone or in the staff meeting], I am interested in learning how your work has effected your sense of meaning and spirituality. I am using a very broad definition of spirituality, working from the assumption that spirituality is a varied and very individual experience. It could mean sense of purpose or meaning, connection with people, nature or life, belonging to a religion, or simple joy and play. During this interview, we will use the words and concepts that are relevant to your experience of spirituality. What I am particularly interested in is how that aspect of your experience, however you define it, has been effected by your work. The emphasis, then, is on the impact rather than on the description of spirituality. While describing events or situations related to work, I will be careful not to ask questions that might elicit identifying information about your clients. Were there any situations related to your trauma work that had a particularly strong effect on your spirituality? Let's start with the earliest significant event that you remember. Thinking back to a time previous to that earliest significant event, how would you describe your individual experience of spirituality before the occurrence of that first significant event? What was the event? What actually happened when this event took place? What was meaningful about this incident? How important was this incident at the time? How important was this incident in retrospect? What did you learn about yourself from it? How did you feel after the event? What was different? How did you recognize the difference? What are some examples of how your spirituality changed? Were there particular experiences that illustrated that change for you? What is your experience/definition of spirituality now? How do you feel about that definition? 125 APPENDIX G: Additional Interview Questions 1. Briefly, how would you describe your sense of spirituality? 2. Briefly, what impact, either positive or negative, has your work had on your sense of spirituality? 3. The interviews so far have moved between describing specific events that occured at work that have a significant impact on spirituality, and then examining that impact in detail. Some participants preferred to recount events in chronological order, beginning with events from early in their career and then moving forward in time to the present, while other participants have preferred to jump around in time. What would you prefer? 126 APPENDIX H: Resources Vancouver Crisis Line: 872-3311 Articles: Pearlman, L.A. (1995). Self-care for trauma therapists: Ameliorating vicarious traumatization. In B. Hudnall Stamm (Ed.), Secondary Traumatic Stress: Self-Care Issues for Clinicians. Researcher, and Educators, (pp.51 - 64). Lutherville, MD: Sidran Press. Pearlman, L. A. & Saakvitne, K. W. (1995). Treating therapists with vicarious traumatization and secondary traumatic stress disorders. In Charles R. Figley (Ed.) Compassion fatigue: Coping with secondary traumatic stress disorder. New York, NY: Brunner/Mazel, Inc. Videos: Vicarious Traumatization I: The Cost of Empathy Vicarious Traumatization II: Transforming the Pain 127 APPENDIX I: Figure 8 Used in the Follow-Up Interviews 128 APPENDIX J: Protocol for Follow-up Interviews OPENING STATEMENT AND OVERVIEW I thought I would start with an overview of my findings first and get your reactions to that, and then we can look at how I summarized and organized your interview in particular. This visual (figure 8) illustrates the basic organization of the material. The organizing statement which emerged during the analysis was as follows: Participants described being exposed to the extremes of human nature and experience through their work, and described how they integrated or coped with that exposure. I divided the extremes of human nature - the stories that participants described from their work - into two basic categories: Into the Fire and Into the Light. Unfortunately it was beyond the scope of this study to analyze the stories in detail; each category will be represented only by a brief summary of the kinds of stories counsellors discussed. Into the Fire represents the challenges of trauma work, such as encountering or hearing about the capacity of people to do harm to one another, working with clients who are not ready or not willing to change and the frustrations of working with larger systems. Into the Light represents the inspiring aspects of trauma work, such as witnessing human goodness and strength and the capacity for growth and healing. Although I've represented these two broad categories, light and fire, as distinct from one another, almost as polarities, the interviews seemed to me to suggest that the relationship between them is more complex than simple opposites. One story would often encompass both polarities. Sometimes the polarities seemed integrated, sometimes separated. What do think of that? The circle in the middle of the figure 8 represents participant experience; how counsellor's integrated or managed exposure to the light or the fire. This was the focus of the analysis. Although the question that I asked was about the "impact" that trauma work had on participants' spirituality, the answers given seemed to me to be more about how they "integrated" or "coped" (framing, managing, self-care, etc.) with trauma work. I think what I assumed in asking about impact was a sort of passive, automatic reaction to exposure to stories of trauma. What I think participants were telling me about was more an active, often concious response to their work - more an active interaction between their sense of spirituality and their work, rather than their work acting on their sense of spirituality. What do you think about this idea? (I would then want to have some discussion around the idea of "impact"- was this the right question to be asking? Is there in fact an impact that somehow didn't come out in the interviews, or is the word impact not really a good fit with participants experience? What word would fit? Etc.) I invited participants at the beginning of the interview to describe how their work had effected their sense of spirituality, either positively or negatively. What seemed to emerge over the course of the interviews was that the polarities "positive" and "negative" were too simplistic. Again, the relationship between polarities was more complex than 129 that, as one participant put it, there was more "fusion" in it than that. How does that fit for you? Also, there did not appear to be a clearly linear development or process of spiritual change; more a constantly adapting, constantly evolving, ongoing change (growth?). How does that fit for you? CATEGORIES: Let's look now at the categories that I used to describe the interviews, and then we can look at how I categorized your interview. INTO THE FIRE: 1. DEFINING AND ACCEPTING LIMITATIONS - defining where you can be effective, accepting where you cannot be effective. Including: defining what you can and cannot work with (clients, systems, contexts); recognizing and accepting your own and/or client limitations; finding ways to understand and let go of what is outside of your limitations; choosing what you expose yourself to, letting go of the rest; finding ways to understand and let go when clients are not ready to change. 2. DEVELOPING CREATIVE SEPARATION STRATEGIES WITH CLIENTS - ' developing ways to separate yourself somewhat from aspects of the client or the client's story. Including: things you do within the work that you do, both to protect yourself and to maintain your effectiveness with clients; protection rituals to shield yourself from potential toxicity; seeing the client as separate from their story or their acts, both to allow connection with strength or goodness in the client. 3. ADJUSTING WORLD VIEW - to include new understandings of humanity and systems Including: integrating, understanding, and finding meaning for pain and violence; expanding and adjusting world view, view of humanity, human nature, to encompass new understanding of the capacity of people and systems to do harm; refining or polishing views; finding balance in view of world and of humanity, of people. 4. UTILIZING FAITH - to sustain you in this work. Including: the necessity of lived spirituality (as opposed to theoretical beliefs) for strength, support, endurance and guidance; spirituality necessary for self-preservation, to stay strong and well; need beliefs for stamina, strength, to maintain perspective and balance, hope and joy. 5. IMPLEMENTING SELF-CARE STRATEGIES IN PERSONAL LIFE - things you do outside of work to counteract or prevent the potentially wearing effects of work on body, mind and soul. Including: outside passions to balance work; need things that you do outside of work, away from work to help stay strong and balanced; spiritual or grounding practices; hobbies, activities or time away; personal relationships or connections that are healthy and balancing. 130 6. ACCESSING PROFESSIONAL SUPPORTS - to help maintain wellness and perspective Including: finding ways to process traumatic material; accessing support from co-workers, peers, supervisors; artwork; developing networks; accessing counselling. INTO THE LIGHT 1. BELIEVING IN THE GOOD IN PEOPLE - believing in "that of god in all of us" Including: seeing and believing in the strength, determination, dignity in people; seeing goodand beauty in all of us; seeing beauty in unlikely places; seeing strength and dignity against tremendous odds. 2. BELIEVING IN THE CAPACITY FOR GROWTH - believing in the power of people to choose to create change in themselves and in their lives. Including: seeing and believing in people's ability to heal and transcend; seeing and believing in people's ability to choose growth and healing regardless of how damaged they may have been; to create growth and healing even in the face of tremendous odds. 3. APPLYING SPIRITUALITY - spirituality as an intrinsic part of trauma work. Including: to be effective, need to keep ego out of it, remain humble, stay grounded, offer openness, respect, hope, genuineness, spirit; effectiveness as a counsellor more to do with being than doing; can never loose touch with spiritual self, because need that self, those beliefs to work well, to create connection and healing; sense of mystery, of the magic of connection with people; connection as an almost tangible manifestation of spirituality. 4. DEVELOPING OR AFFIRMING A SENSE OF PURPOSE - participating in healing provides a powerful sense of purpose Including: helping people heal creates a sense of meaning; feeling honored; seeing healing affirming of purpose of work; powerfully rewarding; contribution to society, humanity, on an individual level. 5. RECOGNIZING AND/OR PARTICIPATING IN GLOBAL CONNECTEDNESS -believing that we are all connected. Including: contributing to, participating in, global network; spiritual sense to that network; helping to create social change; advocacy work; individual healing contributing to societal healing; the individual and the universal or eternal are connected, they influence and reinforce one another. CATEGORIZATION OF E A C H INTERVIEW: I'd then show participants how I divided up their interview into chunks of dialogue (each discussing a particular story and the participant's response to that story) and how I summarized each chunk. I will ask for their feedback on the summaries. I could also ask for clarification if I had any questions about the interview. I would then show them the categories that I thought each chunk fitted into and which category I thought most salient for each chunk, asking for feedback on my interpretations. 131 I'd then show them the chart showing which categories each participant endorsed and how often, pointing out particularly the column pertaining to thier interview. I would invite their observations or comments on the chart. I would then ask participants if they had any further questions or comments, or if there was anything else that needed to be added (such as further ideas or stories which had not already been included). I would also offer to mail/deliver them a copy of the thesis, or just the chapters that interest them if they would prefer. 132 Appendix K: Information for Independent Raters Hi Llyn and Gita! Thank you sooo much for agreeing to do this for me! This reliability check will make my study a lot stronger. I did seven interviews with trauma counsellors. I asked each counsellor how their sense of spirituality has been effected by the work that they do. Here is how I analyzed the interviews that I did: • I divided each interview into 'chunks' of dialogue that describe the effect that that trauma work has had on the counsellors sense of spirituality • I summarized each of the chunks • I came up with categories that I thought described the summaries • I then sorted the summaries into the categories • Each summary includes one or more EFFECTS. For each EFFECT, choose one category which best describes the effect. The basic idea, as we talked about, is to check whether or not the categories are clear and coherent enough for someone else to be able to sort the EFFECTS into the categories themselves. I've given you about a third of the EFFECTS to categorize. The categories are divided into two groups - Into the Fire and Into the Light. The categories within each group are numbered. Into the Light has 5 categories, Into the Fire has 6. After the following descriptions of the categories, I've given you an example of how I categorized several EFFECTS and why, followed by the EFFECTS that I'd like you to sort. INTO THE LIGHT 1. BELIEVING IN THE GOOD IN PEOPLE - believing in "that of god in all of us" Including: seeing and believing in the strength, determination, dignity in people; seeing good and beauty in all of us; seeing beauty in unlikely places; seeing strength and dignity against tremendous odds. 2. BELIEVING IN THE CAPACITY FOR GROWTH - believing in the power of people to choose to create change in themselves and in their lives. Including: seeing and believing in people's ability to heal and transcend; seeing and believing in people's ability to choose growth and healing regardless of how damaged they may have been; to create growth and healing even in the face of tremendous odds. 3. APPLYING SPIRITUALITY - spirituality as an intrinsic part of trauma work. Including: to be effective, need to keep ego out of it, remain humble, stay grounded, offer openness, respect, hope, genuineness, spirit; effectiveness as a counsellor more to do with being than doing; can never loose touch with spiritual self, because need that self, those beliefs to work well, to create connection and healing; sense of mystery, of the magic of connection with people; connection as an almost tangible manifestation of spirituality. 133 4. DEVELOPING OR AFFIRMING A SENSE OF PURPOSE - participating in healing provides a powerful sense of purpose Including: helping people heal creates a sense of meaning; feeling honored; seeing healing affirming of purpose of work; powerfully rewarding; contribution to society, humanity, on an individual level. 5. RECOGNIZING AND/OR PARTICIPATING IN GLOBAL CONNECTEDNESS -believing that we are all connected. Including: contributing to, participating in, global network; spiritual sense to that network; helping to create social change; advocacy work; individual healing contributing to societal healing; the individual and the universal or eternal are connected, they influence and reinforce one another. INTO THE FIRE: 1. DEFINING AND ACCEPTING LIMITATIONS - defining where you can be effective, accepting where you cannot be effective. Including: defining what you can and cannot work with (clients, systems, contexts); recognizing and accepting your own and/or client limitations; finding ways to understand and let go of what is outside of your limitations; choosing what you expose yourself to, letting go of the rest; finding ways to understand and let go when clients are not ready to change. 2. DEVELOPING CREATIVE SEPARATION STRATEGIES WITH CLIENTS -developing ways to separate yourself somewhat from aspects of the client or the client's story. Including: things you do within the work that you do, both to protect yourself and to maintain your effectiveness with clients; protection rituals to shield yourself from potential toxicity; seeing the client as separate from their story or their acts, both to allow connection with strength or goodness in the client. 3. ADJUSTING WORLD VIEW - to include new understandings of humanity and systems Including: integrating, understanding, and finding meaning for pain and violence; expanding and adjusting world view, view of humanity, human nature, to encompass new understanding of the capacity of people and systems to do harm; refining or polishing views; finding balance in view of world and of humanity, of people. 4. UTILIZING FAITH - to sustain you in this work. Including: the necessity of lived spirituality (as opposed to theoretical beliefs) for strength, support, endurance and guidance; spirituality necessary for self-preservation, to stay strong and well; need beliefs for stamina, strength, to maintain perspective and balance, hope and joy. 5. IMPLEMENTING SELF-CARE STRATEGIES IN PERSONAL LIFE - things you do outside of work to counteract or prevent the potentially wearing effects of work on body, mind and soul. Including: outside passions to balance work; need things that you do outside of work, away from work to help stay strong and balanced; spiritual or grounding practices; 134 hobbies, activities or time away; personal relationships or connections that are healthy and balancing. 6. ACCESSING PROFESSIONAL SUPPORTS - to help maintain wellness and perspective Including: finding ways to process traumatic material; accessing support from co-workers, peers, supervisors; artwork; developing networks; accessing counselling. Here's a couple of examples of how I arrived at the sortings. The code 'B12' identifies the participant and the paragraph in the interview. The first line, marked STORY, if there was one, gives you the context (no need to categorize this), the following lines marked EFFECT are descriptions of the effect of that story on the participant's sense of spirituality. For each effect, mark the category that you feel best describes the effect. LI identifies the category for EFFECT 1 and L3 identifies the category for EFFECT 2 (the first and third categories of Into the Light). B12 : STORY: the participant was working with a client, a young man, who had horrendous seizures and was very violent and was verbally abusive/foul EFFECT 1- LI - participant thought that the client was 'not throw away', there's something good there, in spite of all the behaviour. She went looking for that good, and found it, was able to connect with the client. Her faith in the belief in the client's essential goodness was validated through that experience. EFFECT 2- L3 - participant believes in treating all people with respect for good that's there, that's in them. Part of how she works with clients is applying this belief, treating all people with respect, openness, and kindness, regardless of their behaviour. I sorted EFFECT 1 into category LI because the participant's belief in and witnessing of, the good in people, and EFFECT 2 into category L3 because of the importance for her of applying her belief that people should be treated with respect, kindness and openness, regardless of their behaviour. M140 EFFECT 1- F3 - participant found it very challenging becoming aware of the "immensity of the capacity of humans to do evil to one another". She said she felt ashamed to be a human being at times, seeing what people can do to one another. It's been challenging for her to work this into her worldview, to accept and integrate the knowledge of violence in the world. EFFECT 2 - Fl - participant picks the part she can work with - i.e.- this participant chooses not to work with sexual offenders. Also, this participant does not feel that working with trauma survivors full-time is a great idea for her. EFFECT 3 - F5 135 - participant finds she gets physically run down, vulnerable to illness if she's not careful, because she is around a lot of toxicity, hearing so much traumatic material. She finds she has to work hard to maintain her own wholeness, self-care strategies are really important for her. I coded EFFECT 1 as category F3 because she had to integrate the reality of violence that she was confronted with in her work into her understanding of humanity. I coded EFFECT 2 as category Fl because the participant had to set limits for herself in her work (not working with offenders, not working full-time with survivors). I coded EFFECT 3 as category F5 because the participant talked about having to work hard at taking care of herself; self-care strategies are important to her. I've listed about sixty EFFECTS below. I hope there is enough detail in them for you to make a determination. If you need more info, or if you have any questions about the categories and needs clarification, let me know. And thank you very very very much!! 

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