Limitations of this study and opportunities for future research

Reflecting back on the process of carrying out this research study, I also became aware of the many choice points that occurred and decisions I took, which could have been made differently by another researcher. As a single researcher carrying out this study, certain limitations arise in the use of IPA, particularly the interpretative elements. I have attempted therefore to bracket likely assumptions and biases as far as I am aware of them and to document the process as fully as I can, following Moustakas’ (1994) recommendations, although I have now come to understand how impossible it is to succeed in this process completely (Kvale, 1996). Accordingly, I also decided to extend the framework of Yardley’s (2000) four evaluative principles to include her three subsequent recommendations (Yardley, 2008) in order to improve the validity of my analysis. Triangulation was carried out firstly by my research supervisor, who audited the analysis of one interview by reading the transcript and evaluating the documented evidence for the themes and sub-themes which emerged from it. One participant also evaluated my themes in detail and gave feedback confirming the

faithfulness of my description and interpretation of her data. Secondly, member checking was carried out when I was recently invited back to the TSC to present my findings to a meeting comprised of seven of the nine participants; feedback from this session also helped to confirm whether they felt my data was an authentic reflection of their experiences. Thirdly, in common with Smith et al. (2009), Yardley (2008) also recommends leaving a comprehensive ‘paper trail’ of the research process. Therefore rigorous and systematic documentation of the particular

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details of each stage of the research process was carried out so that the reader might also be able to fully understand and evaluate how the research process was followed.

There are, nonetheless, several limitations of this study which it is important to discuss. A first limitation is the cross-sectional nature of this study which meant that I was unable to quantify trauma exposure with any great measure of accuracy. There are few longitudinal studies in the literature, a significant weakness, given that both negative and positive impacts of trauma work appear to develop cumulatively over time; more longitudinal studies might

therefore be able to address these limitations in future. A further related limitation is that of sample selection. Through careful selection of participants I aimed to achieve a homogenous sample whose accounts may be more relevant to counselling psychologists than most previous research. However, I recognise that despite this, participants’ experiences of and exposure to trauma work varied significantly, and that, as clinicians, their accounts might afford a different perspective to that of, for example, social workers, psychotherapists and other trauma workers. However, Hefferon & Gil-Rodriguez (2011) recommend that with IPA the appropriate focus should rather be on transferability of findings from one group to another, therefore, it may be worthwhile for future investigations to extend the applicability of my findings to other groups of trauma care workers, as well as those treating specific types of trauma clients.

I recognise that a further limitation of this study is that I am reliant on the reports of clinicians, which necessarily provide only one viewpoint of the therapeutic relationship.

Appreciating the inter-subjectivity inherent in my research question requires recognition that it is necessary to fully explore the “reciprocal and dynamic interplay of subjectivities of [both]

therapist and client …” (Rasmussen, 2005, p.27). Unfortunately, ethical and logistical issues precluded gathering clients’ accounts for this study. However, I recognise that clients may have different views and future research would be much strengthened by including both perspectives in the discourses surrounding effective trauma treatment (Rasmussen, 2005).

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The tendency of clinicians to focus on their clients’ experiences rather than their own meant I had to decide to exclude some interview data from analysis. Principally, I chose not to include my participants’ considerations rationalising which modality worked best for which client. These responses did not directly answer my research question, which was aimed specifically at clinicians’ own subjective experiences of delivering the two recommended modalities, and therefore did not meet my criteria for inclusion. However, future research might also investigate whether there are certain trauma client characteristics which would indicate that one treatment modality might be more effective and helpful to them than another.

In terms of opportunities for further investigation, several research areas seem promising. Firstly, more clarification is needed of the constructs, such as CF, VT and STSD, used to define and describe negative impacts of trauma work on the professionals who deliver it, and of the prevalence of clinically significant levels amongst clinicians; a greater use of control groups, and a better understanding of the relationship between exposure to trauma and development of negative impacts is also recommended (Elwood et al., 2011). There is scope too for clarifying constructs around PTG and VPTG: Manning-Jones et al. (2015) identify subtle but important differences between them and note there is a lack of accurate measurement for VPTG; neither is there sufficient understanding of the relationship of VPTG with either resilience or STSD.

Secondly, there is a similar necessity to improve the sensitivity of patient outcome measures. As Sara observed, most current clinical measures of PTSD (such as the IES-R and PCL-5) are verbally-based cognitive measures which do not seem able to pick up this extra dimension that participants in this study felt results in such a profound and miraculous recovery following EMDR treatment. It may be worthwhile therefore to investigate, clarify and confirm these client experiences first: Kvale & Brinkman (2009) recommend a mixed methods approach for this kind of enquiry, with a cross-over design where clients experience TF-CBT first then

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EMDR Therapy, or vice versa, and complete IES-R and PCL-5 measures pre- and post- both treatments. In addition, semi-structured interviews could employ thematic analysis to explore those experiences of recovery which may not currently be being picked up by standard clinical measures. Subsequent research might then be able to explore more accurately the relationship between the effectiveness and efficacy of different trauma treatments and, in addition, the effects of these outcomes on clinicians’ likelihood of experiencing burnout, CF or STSD, as well as increased CS and VPTG. Perhaps, in this way, it may be possible to challenge the

“dominant discourse” (Mattie: 07:29), that is, the hegemony currently surrounding TF-CBT, and

open up research to explore in more depth and detail the mechanisms of transformation in EMDR Therapy that currently appear so “miraculous” (Sara: 22:49) and which seem to have such potential for enhancing both client and clinician well-being,

A third area of research which could be pursued involves an exploration of to what extent a good therapeutic connection provides meaning and a protective factor to therapists engaged in trauma work, and whether this would vary according to whether TF-CBT or EMDR Therapy is used. As an adjunct study, it might be interesting to compare the use of various EMDR methods for BLS in terms of their effects on the therapeutic alliance as these seem to be experienced differently from clinician to clinician; this may shed further light too on what is already known from previous research regarding client preferences and abilities for different BLS techniques (Herbert et al., 2000; Lee & Cuijpers, 2013; Rothbaum, 1997). I have been unable to find any reference to RSI in the current EMDR research literature, so from the point of view of clinician well-being, this issue might also be important to explore further. A final

suggestion for a research study would be an investigation into the idea that bilateral types of exercise might be more effective at helping both clients and clinicians alike to engage in self- regulation as part of self-care. Beginning to build an evidence base of the most effective self- care strategies for clinicians engaged in trauma work would go some way towards meeting our

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individual and professional, if not organisational, responsibility to mitigate negative effects of trauma work, as Iqbal (2015) recommended.

In sum, despite the limitations of this study, I believe the use of IPA methodology has allowed a more fine-grained exploration of some important and previously neglected aspects of trauma work (Moustakas, 1994). In so doing it has opened up a range of fresh avenues for future research, and my hope is this will also offer practical relevance for both client and clinician well-being when engaged in trauma work.