Negative psychological, physiological and behavioural

All participants discussed various negative changes to cognitive schemas and imagery systems, experienced at times during the duration of their trauma work. Whilst the changes do not necessarily fit exclusively in one category or another, these have been broken down into four categories to aid the reader and best represent the changes discussed. The categories of change are cognitive, emotional, physical and behavioural.

Cognitive change. Many examples of participant cognitive changes connected

directly with hearing trauma narrative during clinical work have previously been discussed throughout this chapter (eg: pages 92, 95, 101). Other cognitive changes identified were connected to matters of practical application of the recommended treatment models and participant expectations or feelings of responsibility for others.

Claire feels helpless when working with clients who becomes stuck in the therapeutic process.

(Claire) 79-85 … they need to believe in getting better in order to

stay engaged. So if things are difficult, if they are still getting nightmares, if they are still very avoidant, if they are still jumpy, then sometimes they have to hang on through all of that to stay engaged in order to get the benefits they want. So that’s difficult for them. Difficult for myself as a therapist because sometimes we think it’s not going anywhere and then you begin to wonder what else you can do…

Claire acknowledges the precarious position trauma clients find themselves in when they doubt the therapeutic process, question their capability of recovery and find it difficult to move forward. From her extract, there is a clear sense of Claire’s experience as a therapist, sometimes mirroring that of her stuck clients.

Not only had Paul a clear expectation on himself as a therapist borne out of his strive for perfection and his difficulty in dealing with failure, he also has an unconscious expectation on his clients to recover within his expected timeframe.

(Paul) 164-5 … I do have a massive perfectionist schema and I

don’t like it if people don’t get better…

175-8 … I almost have an expectation that people will walk into my clinic and within eight, twelve, sixteen sessions they will be walking out feeling better…

Similar to Paul, Julie’s expectation was also placed on her client. (Julie) 116-9 … I mean I’m seeing a lady at the moment

[………] who was abused as a child and [……….] she’d never cried in the session. I’ve seen her now twenty something times and she’s never actually cried…

David has a clear expectation on himself as a therapist.

(David) 135-7 … I think my focus is solely on the patient and

their affect and I, sometimes it’s easier than other times but I think as a clinician you have to mirror something that’s really cool, calm and composed whilst conveying compassion…

Whilst David’s perception of what a therapist ‘should be’ is perhaps ideal and something which he strives for, his extract highlights occasions when his sense of identity as a trauma therapist has been challenged as he struggles to live up to his own expectations.

Expectations of others on the whole related to other professionals, employers or clients. When Jenny spoke about making a difficult decision to delay treatment with one of her client’s because of personal triggers, her difficulty arose from her sense of guilt in putting her own needs before the needs of others and the heavy responsibility she felt in letting down her employers and clients awaiting treatment.

(Jenny) 177-9 … it would have been a lot easier to make that

decision based on the way I was feeling, rather than the repercussions of what making that decision would mean to the company and to other people on the waiting list…

Adrian and Helen both reported changes to the way they think about their trauma work, which has been influenced by the expectations of others.

(Adrian) 64-9 ... I think I could do it, I think my colleagues could

do it but we can’t because of the restraints. Let’s say that happens once a fortnight but then that would trigger, I don’t know 24hrs to three days, particularly if it falls over a weekend if it’s

come up on a Friday say, just very frustrated [laughs] and fed up with it and erm, [exhale of breath] having to redirect my thoughts to the benefits of working…

Without doubt, Adrian feels constrained and disillusioned by the restraints placed upon himself, his colleagues and his identity as a trauma therapist. Using a coping strategy of laughter, Adrian’s disruptions to power are evident and clearly shown with his frustration and frequent feeling of disillusionment impacting on his personal life away from work when he has the time to reflect. Furthermore, Adrian’s sigh and purposeful effort in questioning of the advantages of working, gives a sense of his feeling of despair.

(Helen) 221-3 ... well am I not doing the job effectively enough

in the time that I’m told I should be able to do it in? So it’s made me sort of think about my practice and think can I sort of speed it up a little bit..?

Helen has felt inadequate by the expectations placed on her and questioned her competency, effectiveness and sense of self as a skilled trauma therapist. Furthermore she now feels compelled to work at a faster pace with trauma clients to compensate for her perceived ineffectiveness and her employers reduced therapeutic session times.

Emotional change. All participants reported experiencing a range of negative

and positive emotional changes. However, within this section of the thesis, only an example of the impact of negative emotional changes will be presented. Without doubt the therapeutic relationship is extremely important (Lambert &

Barley, 2001; Paul & Charura, 2015) but even more so when working with

trauma clients. In order to engage in trauma work, clients have to completely trust their therapist to be able to offer a safe, supportive and compassionate working environment whilst they relive their traumatic experiences. All participants talked about the therapeutic relationship they have with their clients and the importance they place upon it and all gave examples where they have been emotionally touched by their client’s story.

Helen’s sadness resulted from her identification and empathy for her emotionally overwhelmed clients dealing with family trauma.

(Helen) 32-41 ... it’s when they actually got to the hot spots, to

the sort of key areas that brought about strong emotional responses in the client and they tended to be because there were family members involved [………] their emotional responses were really strong and hearing what had happened it brought out the emotional response in me being also a mother and a sister and a daughter, so that I think came out stronger in the CBT than the EMDR…

From her extract, there is a sense that when Helen accurately senses the feelings and personal meanings for her clients after hearing the full trauma narrative, the impact on her sense of self is profound.

Like Helen, Julie has literally felt engulfed by her overwhelming sadness. (Julie) 119-22 ... I just felt this enormous wave coming over me

[bracelets jingle] of what I can only describe as sadness and it sort of almost came over us both and it almost, and we both, I mean, I started crying but she just lost it...

From Justin and David’s extracts, there is a sense of the resilience needed to work with trauma clients and the emotional changes that can bring. Justin’s client had very complex historical trauma presentation which felt different to other cases he had worked with. Justin’s client had PTSD and in his opinion was “neurologically shut off to some degree”, when a further traumatic incident took place. Because of this, Justin believed the client only started to comprehend the enormity of the additional trauma during their therapeutic work. His extract gives a sense of the prolonged mental effort it took for him to sit alongside his client and support her through a rollercoaster of emotions, whilst dealing with his own.

(Justin) 139-43 … that’s quite hard to deal with. So it’s just, it

takes quite a lot of, I find quite a lot of stamina for me to sit with her and hold her, psychologically hold her not physically, but be with her in a holding place as she goes through this, seemingly on some levels for the first time. That, that’s very, very tough...

We already know David believes his resilience for trauma work has declined since becoming a father (page 106). In this extract, he struggles to make meaning of this further.

(David) 88-91 ... I’m less sort of resilient to y’know, car injury

fatalities. I was going to say before children but x amount of years ago, so I don’t know if it’s a combination of more of them over many years or whether its y’know, something about having children as well or maybe it’s a combination of both. So I would call it a cumulative effect really…

David’s self-questioning and recognition of the rise in trauma presentations he has worked with over the course of his career, may help give him a meaningful frame of reference and an alternative, justifiable explanation for his emotional change.

Another emotional change identified was when participants judged other professionals capabilities. Judgement was generally aimed at other professionals and based out of concern for client safety or in defence of a particular treatment model and the participant’s sense of self. Paul and Justin felt aggrieved on behalf of their client’s, who they perceived to have been formally misdiagnosed or received an inadequate service from other professionals.

(Paul) 59-60 … twelve sessions of CBT with another therapist

and I mean it’s been absolutely appalling. They had not done any proper psycho-education stuff with her...

Jenny’s frustration was aimed at the professionals who commission work within her primary care system, whom she believed had little or no understanding of it. From her extract her feelings of disgust, insignificance and injustice shine through.

(Jenny) 290-1 … but obviously we’re governed by people who

have no training in mental health or treatment in it and they seem to outrank us and it stinks at times I must admit…

Claire felt passionate about the level of experience therapists should have before undertaking specific trauma training.

(Claire) 283-88 … So I feel quite strongly about people who take

themselves off to something like EMDR training and have only been qualified a year or two as perhaps a counsellor or something; and they don’t have that professional depth of experience that I think you need before you go into these cases; and I think that’s

dangerous because these techniques are very powerful and people are very vulnerable. So I suppose that would be my soapbox [laughing]…

Although laughing in recognition of her political statement, Claire’s metaphor of her ‘soapbox’ clearly reinforces her strong belief that professionals with limited clinical experience from other therapeutic backgrounds to that of her own, do not have the capability to deliver EMDR safely and by doing so, put their clients at risk of re-traumatisation or themselves at risk from EMDR’s formidable effects.

Paul, like Claire, also compares his clinical skills and experience to that of a counsellor.

(Paul) 64-7 … I’m quite precious about CBT and I think if y’know,

I’ve done all this training to be a cognitive behavioural psychotherapist but if anybody can, whose just got a bit of a background in counselling, can come along and do EMDR, then I almost feel it devalues my skills if I don’t try CBT first…

Paul remains loyal to his core therapeutic model before considering delivering EMDR. His use of language suggests how much value and importance he places on the CBT model and his professional identity as a cognitive behavioural psychotherapist. It is clear from his extract that Paul believes should he initially offer EMDR which he believes can be delivered by a professional less qualified or experienced than himself, his hard work in gaining his qualification may go unrecognised and thereby threaten his sense of self.

Physiological change. Many of the physiological changes reported by

participants such as sleep disturbance, nausea, lack of concentration and hypervigilance resulting from increased arousal, were symptoms of participant anxiety and reflected those changes commonly experienced by trauma clients. Paul’s extract reinforces this and clearly points towards his heightened anxiety and feelings of vulnerability on the road as a result of frequently working with repeated trauma presentations involving road traffic accidents.

(Paul) 92-4 … when I’d been hearing so many people talk about being rear-ended in cars I became quite hypervigilant for threat myself when I was driving...

Like David, another four participants reported feeling upset or tearful, either during or after a therapeutic session as a result of having heard a client’s trauma narrative.

(David) 38-9 ... going into detail with some of the intrusive situations I think afterwards, I have found myself, y’know, you become a little upset...

Seven participants experienced replaying their clients haunting trauma images for up to several months. Like Julie, these powerful images impinged upon their professional and personal life, interrupted their concentration levels and normal daily functioning and for some, went on to disturb their patterns of sleep.

(Julie) 19-22 ... I used to be left with some of the images that they described. I’d keep those with me during my day, my working day and then in, from a personal prospective, sometimes at night I would have dreams about some of the things that were going on..

Behavioural change. Seven participants reported changes in their behaviour.

Angela gave two examples of when she has experienced disruptions to her safety, trust and power and felt violated by harrowing trauma details.

(Angela) 136-9 … there have been a couple of people that I’ve

worked with where they’ve experienced sexual trauma and the kind of circumstances around that has kinda affected my own [pause] my own sex-life for a short period of time…

144-8 … I remember going home and feeling so grubby and kind of polluted by some of the things that I’d heard, that I’d get in the door and I’d just take off my clothes and put them straight into the washing machine and then get into the shower; and y’know it was like cleansing away the nastiness of the things I’d been exposed to…

Angela’s change in behaviour gives a powerful insight as to the impact of hearing trauma narrative during forensic work and provides clear evidence of the disruptions to her sense of self. Her feelings of contamination synonymous with sexual trauma clients, give a sense of her clients trauma seeping through her clothes and tainting her skin like some sort of insidious bacteria.

The shock and disbelief experienced by Laura after hearing one client’s trauma narrative, led to short-term prejudice and fear towards those members of the public she appraised as having a particular cultural background.

(Laura) 130-1 ... it did alter my behaviour only like I say, I had a

different image for a while of the people involved…

Like Paul, another two participants reported changes to their driving habits after becoming fearful and hypervigilant as a result of trauma work with victims of road traffic accidents.

(Paul) 228-9 … I go past that motorway most days [pause] but I make sure I drive carefully past there! ...