Treating Shame in Survivors of Complex Trauma by Deanna West B.A., University of British Columbia 2015 THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF EDUCATION IN COUNSELLING UNIVERSITY OF NORTHERN BRITISH COLUMBIA August 2022 © Deanna West, 2022 ii Abstract While research continues to establish a connection between shame and complex trauma, there is a lack of understanding on how this is addressed in therapeutic practice. The current research employed a qualitative exploratory research methodology to answer the question, how do counsellors perceive and treat shame in adult survivors of complex trauma? Seven counsellors were recruited to engage in a virtual semi-structured. The data was analyzed using thematic analysis resulting in three main themes, each containing various sub-themes. The three themes are emotional landscape, which pertains to the emotional effects of shame and how they can be treated in therapy; self-concept, which explores the negative beliefs and thinking patterns clients develop and suggests techniques for diffusing shame; and attachment and the therapeutic relationship, which highlights interpersonal difficulties faced by clients and the impact of the therapeutic alliance, along with exploring the personal experience of counsellors in the therapeutic relationship. iii Table of Contents Abstract .............................................................................................................................. ii List of Tables ..................................................................................................................... v Acknowledgements .......................................................................................................... vi Chapter 1: Introduction ................................................................................................... 1 Significance of the Research ........................................................................................... 2 Purpose of the Study and Research Questions ................................................................ 4 Researcher Context ......................................................................................................... 5 Conceptual Lens .............................................................................................................. 6 Terminology .................................................................................................................... 6 Overview of the Thesis ................................................................................................... 8 Chapter 2: Review of the Literature ............................................................................... 9 Causes of Complex Trauma ...................................................................................... 10 Complex Posttraumatic Reactions ............................................................................. 12 Shame ............................................................................................................................ 16 The Experience of Shame .......................................................................................... 17 Shame Coping Styles ................................................................................................. 19 Theories of Shame ..................................................................................................... 20 Intersection Between Shame and Complex Trauma.................................................. 22 The Treatment of Complex Trauma and Shame ........................................................... 24 Staged Treatment ....................................................................................................... 25 Foci of Treatment ...................................................................................................... 27 Theories of Treatment ............................................................................................... 29 Shame Oriented Interventions ................................................................................... 33 Chapter 3: Methodology................................................................................................. 35 Exploratory Research .................................................................................................... 36 Thematic Analysis ......................................................................................................... 37 Ethical Considerations................................................................................................... 37 Research Procedures ..................................................................................................... 39 Evaluation of the Study ................................................................................................. 47 iv Chapter 4: Findings ........................................................................................................ 52 The Emotional Landscape ............................................................................................. 52 An intolerable Experience ......................................................................................... 52 Building Capacity ...................................................................................................... 54 Self-Concept .................................................................................................................. 57 Defective Self ............................................................................................................ 57 Self Blame ..................................................................................................................... 58 Disguise and Conceal ................................................................................................ 60 Disrupting the Shame Cycle ...................................................................................... 61 Attachment and the Therapeutic Relationship .............................................................. 64 Interpersonal Difficulties ........................................................................................... 65 The Therapeutic Alliance .......................................................................................... 66 The Person in the Professional .................................................................................. 69 Chapter 5: Discussion ..................................................................................................... 74 Discussion ..................................................................................................................... 74 Existing Literature ..................................................................................................... 78 Limitations .................................................................................................................... 80 Future Research ............................................................................................................. 81 Implications for Practice ............................................................................................... 82 Knowledge Mobilization………………………………………………………………82 Conclusion .................................................................................................................... 83 References ........................................................................................................................ 85 Appendix A: Information Letter and Consent Form ................................................ 104 Appendix B: Resources................................................................................................. 109 Appendix C: Recruitment Letter ................................................................................ 110 Appendix D: Recruitment Poster ................................................................................ 111 Appendix E: Interview Questions................................................................................ 112 v List of Tables Table 1 Overview of Analysis 46 vi Acknowledgements I would like to express my utmost appreciation to the people who made this research possible. I am grateful to the participants who volunteered to share their time and experience with me. Their dedication to their clients and passion for their work is inspiring, and I am so thankful for their honesty, insightfulness, and openness. Thanks to my amazing supervisory committee Dr. John Sherry, Dr. Davina Banner-Lukaris, and my supervisor Dr. Linda O’Neill for their continued support and guidance throughout this whole process. I would also like to thank my family for always being a source of support and encouragement. Thank you to my partner, who always believed in me and kept me going on difficult days. To my friends and community in Prince George, who welcomed me, thank you for helping me grow as a person and a therapist. Finally, my sincere gratitude goes to the clients who inspired this research for their courage and vulnerability, 1 Chapter 1: Introduction One of the primary functions of the human brain is to change and adapt based on lived experience. Novel events are interpreted as potential life lessons that can teach us about ourselves and the world after integrating them into our existing body of knowledge. New experiences are particularly salient for children as they grow and learn how to exist in the world. Significant events during the beginning stages of life can guide a child to develop beliefs like they are valued and safe, or that most people are dangerous and will hurt you if given a chance. For children who experience trauma, the lessons they are taught and the beliefs they develop can have enduring adverse effects (Lawson & Quinn, 2013). As the understanding of the brain, development, and the impact of trauma has increased over the past several years, the definition of trauma expanded. A broader array of adverse experiences are being recognized for their impact on children’s wellbeing and development. Events such as emotional and verbal abuse, early medical procedures, and parental separation are now included in the framework of trauma (van der Kolk, 2005). The developing brain understands and interprets events differently than more mature minds, and therefore the meaning of trauma cannot be consistent among children and adults (D’Andrea et al., 2012). Many foundational beliefs are developed during these formative years, such as conceptions of their sense of worth, safety, and expectations for interpersonal relationships (Shorey & Snyder, 2006). Due to their development capacity, children tend to internalize negative events and believe they somehow caused or were deserving of what happened to them (Courtois & Ford, 2013). The result can be a child devaluing or degrading themselves to compensate for the events they experienced, often leading to shame. 2 Nearly a century ago, one of the founders of modern psychology, Sigmund Freud, theorized that shame originated from a fear of withdrawal of love (1923/1959). An experience shared by most when we feel unlovable or inadequate, shame is an uncomfortable feeling that affects thoughts, emotions, and body sensations. Upon the dissipation of shame, there is a felt sense of emotional and physical relief. However, for some, the experience of shame is much more frequent and enduring. This type of shame bonds to an individual’s sense of self, relaying messages of unworthiness, unlovability, and aloneness. It is more than an emotion; it is a state of being that may attach itself to an individual’s identity. The susceptibility to this form of shame is particularly prevalent in individuals who have endured complex trauma (Feiring et al., 2002). As counsellors work with adult survivors of complex trauma, they have the opportunity to support them in improving their mental health and wellbeing. This may involve treating the effects of complex trauma, including shame. Despite the frequency of this situation, there is a lack of direction within the field of counselling regarding effective ways to support complex trauma survivors in healing from shame. Significance of the Research In recent years there has been a burst in the understanding of trauma in academia and the general public. Through greater understanding of the precipitating events and outcomes of trauma, it has become evident that a standard definition of trauma cannot apply to all ages and populations. This is especially evident in children who have been through adverse events or trauma. Post Traumatic Stress Disorder (PTSD) is defined in the DSM-5 as symptoms following direct or indirect exposure to violence, real or threatened death, or serious injury (American Psychiatric Association, 2013). Symptom domains include intrusion, avoidance, and alterations in mood, cognition, or arousal. By comparing the trauma responses of children and adults, 3 D’Andrea et al. (2012) highlight the need for developmentally appropriate criteria for PTSD as children have different posttraumatic reactions than adults that go beyond the scope of a PTSD diagnosis. One specific type of such trauma, known as complex trauma, is characterized by repetitive and ongoing stressors perpetrated by a guardian or other significant person in the child’s life (Lawson & Quinn, 2013). Though a caregiver may not be the origin of the traumatic event, a single incident can be compounded by a lack of safety and protection by the person supposed to act as their protector (Pynoos et al., 1999). Children integrate these novel experiences and begin to behave in a manner consistent with their new beliefs. These behaviours, patterns, and ways of surviving may become engrained over time and continue into adulthood. Some of these maladaptive ways of coping with their environment can have physical and psychological consequences. One’s conception of self often acts as the foundation for which other skills, beliefs, and experiences are built. Advancements in therapy may be blunted if new ways of being are incongruent with personal beliefs. Therefore, many counsellors posit that working with shame is one of the critical components of overcoming abuse (Chouliara et al., 2014). More could be known about the accompanying shame that often results from complex trauma, as posttraumatic shame has been understudied in research (Blum, 2008). Shame should be understood not as an inevitable and enduring by-product of trauma but as a symptom that merits attention and understanding (Blum, 2008). There are several barriers to studying how complex trauma manifests in adulthood and the subsequent shame. One such difficulty is that complex trauma is not a formal diagnosis. While professionals have a common understanding regarding the causes and sequelae of complex trauma, the absence of a formal diagnosis is a barrier to research. The lack of empirical 4 information inhibits the development of treatment and training for those at the frontlines working with clients who have complex trauma. An additional barrier arises from clients not recognizing that their current functioning may be related to childhood trauma. The presence of adverse childhood events may not be uncovered until later sessions, if at all, as often the adverse events are not recognized as traumatic to the individual (Courtois, 2004). Though many presenting issues may be related to complex trauma, there is no certainty that this will be uncovered during the therapeutic process. In many instances, research facilitates the creation of new knowledge and innovation, while at other times, research has to catch up with what is already being put into practice. Although much of existing trauma research has focused on studying the effects of complex trauma, there is a lack of research regarding specific therapeutic frameworks or practices to support clients in healing from shame. Counsellors have been working with clients with complex trauma for decades and have seen and felt the effects of shame before it was recognized by research. Treatment is widely practiced but in the early phases of scientific and clinical validation (Cloitre et al., 2009). Researchers have the opportunity to collect information from counsellors practicing in the field, learn from their experience and propel the research to a point where treatment methods and best practices can be established and empirically validated. It is time for research to catch up to practice. Purpose of the Study and Research Questions The present study draws upon the experience and knowledge of professionals currently working in the field of counselling. The purpose of the study is to learn about the beliefs and best practices of counsellors working with shame in adult survivors of complex trauma. The primary research question is, how do counsellors perceive and treat shame in adult survivors of complex 5 trauma? This includes their beliefs about shame and wisdom gained from experience in working with this population. The goal is to understand how counsellors are currently working with shame to uncover effective methods of treatment and highlight areas that may require more research. These findings will open the door for future research to build upon current practices to develop, research, and distribute the most effective treatments to support clients healing from shame. Researcher Context My interest in researching adults with complex trauma stems from two different standpoints; the personal and the professional. It was after learning about complex trauma that I could label my own experiences as such, which sparked a healing process. I began working through these experiences and uncovering how the adverse events from my childhood have carried into my adult life and how that impacts me today. In my professional life, I have worked at an alternative school and volunteered as a youth mentor. I have also worked as a counsellor with children and youth who have experienced adverse events. Through these experiences, I learned how children are impacted by events that are often not considered traumatic by adults. Given minimal attention, the children were left to work through their trauma on their own accord without professional help. During my practicum experience counselling adults, I bore witness to the range of effects of complex trauma. I have observed how shame can affect therapy and bring unique challenges to the clients’ healing. I am continually inspired by clients’ resiliency and seek to improve myself as a counsellor and contribute to the body of knowledge on how counsellors can best support these individuals on their journey to heal shame. 6 Conceptual Lens I am guided by the social constructionism theoretical lens, which holds that no one objective reality exists but that multiple realities co-exist as meaning is constructed between individuals (Hansen, 2004; Schwandt,1994). As truth is relative, researchers have the opportunity to explore how people create meaning based on experiences and shared discourse (Finlay, 2002). This includes perceiving difficult events, such as trauma, and how the individual construes it. Constructs will have many interpretations depending on the individual's perceptions and the context in which it is discussed. The terms “trauma” and “shame” have differing meanings for each participant and bring up unique ideas and experiences. The goal is not for a uniform meaning among all participants but rather to seek understanding and capture the essence of meaning (Creswell & Poth, 2018). Data collected from participants is accepted not as objective truth but as a representation of the truth to them at that point in time. As meaning is coconstructed between individuals, my involvement with the research will inevitably influence the data collection and analysis. This is not a detriment within the constructivist paradigm but an opportunity for reflection on how researchers and participants function collaboratively to uncover meaning (Finlay, 2002). Terminology As the research on shame and complex trauma continues to expand and develop, the field is in the midst of change. Therefore, the terminology used to describe various concepts is in flux and not universally agreed upon by practitioners and researchers. The lack of formal classification and diagnosis of complex trauma also inhibits the creation of widely recognized causes and symptoms. The terms and definitions used in the present study are a collection of the most commonly used and accepted definitions of the following constructs. 7 Shame Shame is a basic human emotion experienced by most people. The shame referred to in the present research, and experienced by many survivors of complex trauma, differs from the more common experience of shame. It surpasses an emotion and is experienced as a belief and state of being. In the research, it is referred to as complex shame, traumatic shame, toxic shame, pathogenic shame, shame-based identity, or state shame. The present research will refer to this experience simply as shame and define the construct as a negative and disturbing experience involving feelings and beliefs of self-condemnation and the desire to hide the damaged self from others (Lewis, 1992; Tangney, 1995). Shame is more than an emotion involving affect, cognition, and feeling (Blum, 2008). The internal sense of shame is experienced as feelings of inadequacy, incompetence, helplessness, and powerlessness (Andrews et al., 2002; Ferguson et al., 1999) and maintains a global view of the self as unworthy (Blum, 2008). For those that have experienced complex trauma, the experience of shame is often intensified and enduring. The result is that the whole self feels defective, often resulting from a perceived failure to meet selfimposed standards (Feiring et al., 2002). Complex Trauma Complex trauma has evolved in title and concept over the last several decades. The construct of complex trauma has been referred to as complex PTSD, development trauma, and type II trauma. This proposal will refer to the term as complex trauma. It will be defined as prolonged traumatic events perpetrated or exacerbated by significant adults in the individual’s life and occurring during times of developmental vulnerability (Courtois & Ford, 2013). Traumatic events, also known as adverse childhood events, are wide-ranging and may include incidents such as the death or prolonged separation from a caregiver, witnessing domestic 8 violence, emotional, sexual, physical abuse, or neglect. The impacts of complex trauma on the individual shall be referred to as complex posttraumatic reactions or complex posttraumatic sequalae. Overview of the Thesis The first chapter introduces the topic of shame in adult survivors of complex trauma and outlines the current research and defines pertinent terms. The second chapter begins by reviewing the literature on complex trauma, shame, and the ways in which these topics are correlated. I will then provide an overview of some commonly used methods in treating complex trauma and their application to shame. Chapter three explores the qualitative approaches and methodology employed in this research to collect and analyze participant data. It will also outline the measures taken to ensure the research standards of ethics, validity, and reflexivity were met. The fourth chapter, research findings, describes the results of participant interviews which were analyzed and grouped into significant themes and sub-themes. The fifth and final chapter provides a discussion of the research findings and situates it within the existing literature, includes a discussion of limitations, and proses ideas for future research and practice. 9 Chapter 2: Review of the Literature Introduction The topics of shame and complex trauma are complicated and constantly evolving with research and the experience of individuals and counsellors. The following will provide a summary of the above concepts as they pertain to the current research. I will also give an overview of the interaction between shame and complex trauma and the implications for treatment. Working with an adult survivor of complex trauma is an individualized process; therefore, the final section will outline commonly used methodologies but is not an exhaustive list of all treatment methods. This literature review will provide an introduction to complex trauma, shame, and their therapeutic treatment in adult survivors of complex trauma. Complex Trauma Complex trauma is a relatively recent term that describes multiple or prolonged traumatic events occurring during developmentally significant stages (van der Kolk, 2005). Other important factors include the frequency and severity of trauma, the extent to which their caregiver contributed to the impact of trauma, and the level of support upon disclosure and discovery of the trauma (Courtois, 2004; van der Kolk, 2003). These experiences create opportunities for psychological harm in many areas, such as self-regulation, relational attachment, dissociation, identity, and attention (van der Kolk & Najavits, 2013). Entrapping their mind and body in a state of uncertainty and perceived danger, the child’s ability to deal with stressors and to assess their ability to protect themselves amidst the threat of external danger is disrupted. 10 Causes of Complex Trauma Through millions of years of evolution, the human brain has developed a series of survival mechanisms designed to keep us safe from the threat of danger. These evolutionary responses anticipate, protect, and prevent real or imagined hazards by identifying potential threats and preserving bodily resources in case of need for mobilization (Courtois & Ford, 2009). Threatening events ignite the brain’s survival mechanisms and fight, flight, or freeze responses. Throughout the lifespan, the brain and body continue to amend the conceptions of threats and danger. For a young child, it is especially distressing when the caregivers who are their source of security and support are also the source of their trauma. This can cause chaos and confusion in a child's mind as survival takes precedent over normal growth and development (Courtois & Ford, 2013). For individuals with multiple adverse events or prolonged trauma, their survival brain may be active most of the time. This can result in difficulties in the current functioning of the mind and body, along with prolonged consequences. The brain may have a difficult time in the future differentiating between a dangerous situation and a safe situation due to prior experiences. The definition of traumatic events as perceived by children expand beyond the criterion for a PTSD diagnosis (D’Andrea et al., 2012). Complex trauma results from exposure to severe stressors that are repetitive and prolonged, involve harm, abandonment, or lack of protection by caregivers or other adults, and occur at critical developmental times (Courtois et al., 2009). Physiological evidence has demonstrated that more subtle traumatic events show similar consequences in infancy as more salient events occurring in adolescence or adulthood (LyonsRuth et al., 2006). The inciting events that may cause complex trauma are numerous and continue to expand with further research. Complex trauma may occur from variations of attachment trauma, including witnessed or experienced abuse, often occurring where the 11 individual is trapped or conditioned (Courtois, 2008). Repetitive and complex trauma can include events such as sexual or emotional abuse, neglect, witnessing familial violence, community danger, oppression, terrorism, or war (Courtois & Ford, 2013). Previous studies on complex trauma often focused on physical and sexual abuse; however, more recent research has demonstrated that other forms of trauma, such as verbal or emotional abuse or neglect, may have an equal or more significant impact. Teicher et al. (2006) found that emotional maltreatment was more closely associated with psychiatric symptoms than physical abuse. Childhood exposure to parental verbal aggression was associated, by itself, with moderate to large effects on measures of dissociation, limbic irritability, depression, and anger-hostility (Teicher et al., 2006). Children may also experience complex trauma from witnessing a caregiver being harmed. Jaffe et al. (1986) found evidence of this in their research, demonstrating that school-age children from homes where their mothers are abused show similar symptom profiles to children identified as physically maltreated. It is an unfortunate commonality that people who experience complex trauma in childhood and adolescence often experience multiple adverse events, such as emotional abuse, witnessing domestic violence, or a caregiver’s substance use. Experiencing multiple forms of trauma can have a compounding effect and lead to greater psychological distress. Teicher et al. (2006) found that combined exposure to verbal abuse and witnessing domestic violence was associated with large adverse effects, particularly in the presentation of dissociation. It has also been found that combined exposure to different categories of abusive experiences often equalled or exceeded the impact of exposure to familial sexual abuse (Teicher et al., 2006). 12 Complex Posttraumatic Reactions As the criterion for inciting events differs in complex trauma from a traditional PTSD diagnosis, so too do the psychological impacts. For example, Ford et al. (2006) conducted a study with educated women and found that those who experienced trauma in childhood or adolescence may suffer from complex forms of posttraumatic biopsychosocial dysregulation independent of either PTSD or other psychiatric disorders. Complex posttraumatic reactions differ from PTSD symptoms in that they are more complex and enduring. They often result in personality changes and identity disturbances and increase the individual’s vulnerability to repeated harm to self or others (Herman, 1992). There is an established association between early childhood trauma and the development of a multitude of disorders and symptom complexity later in life (Briere et al., 2008; Cloitre et al., 2009; van der Kolk, 2005). The core domains affected by complex trauma are relational attachment, self-regulation, cognition, self-concept, and biology (Cook et al., 2005). Interpersonal Relationships. Based on Bowlby’s attachment theory (1973), an individual’s attachment style serves as a model for how they view others, the world, and their place and value within it. An individual’s attachment style is formed through interactions with significant adults early in life. Those who have experienced complex trauma by caregivers integrate the experiences into their understandings of themselves and the world (Talbot, 1996). This frequently leads to enduring feelings of lack of safety which impacts the child’s relationship with themselves and other people (Toth & Cicchetti, 1996). Common complex posttraumatic reactions include difficulty trusting others and forming stable relationships (Herman 1992). They may learn from experience that interpersonal relationships are unstable and chaotic, characterized by loss and victimization (Pearlman & Courtois, 2005). Seeking what is familiar, 13 they often form relationships with others who have unresolved loss or trauma, who may be abusive or re-enact trauma from the past, reinforcing distrust in others and cementing feelings of being unloveable (Basham & Miehls, 2004; Johnson, 2002). Physical Impacts. As the biological fear response involves the central nervous system and flooding of adrenaline and cortisol throughout the body, it is no surprise that the effects of complex trauma are not confined to the mind. As the brain goes through tremendous changes during childhood, prolonged stress and trauma impact normal brain development. The prefrontal cortex is particularly affected by chronic stress, which affects the ability to focus, reason, and make decisions, among other executive functions (van der Kolk, 2014). A component of brain development is amending neural pathways, strengthening commonly used paths, and pruning underutilized paths. Repeated trauma changes the brain's structure, resulting in the facilitation of stress responses, paving the way for difficulties in emotional and behavioural regulation and information processing (Lewis, 2005). The body-brain connection is frequently disrupted, causing individuals to have trouble connecting with their body states and may experience stress somatically as pain throughout the body (Herman, 1992). As adults, they are at greater risk for physiological illnesses like obesity, heart disease, and cancer (van der Kolk, 2005). There is also a strong relationship between complex trauma and the presence of risk factors for the leading causes of death in adults, such as an increased likelihood of smoking and developing smokingrelated diseases, cancer, obesity, and diabetes (Kuhlman et al., 2018). Psychological Impacts. Complex trauma can have short- and long-term impacts on an individual’s mental health. Herrenkohl et al. (2013) conducted a 30-year long-term study on adults who experienced childhood abuse and neglect between 18 months and six years of age. They found that adults with a history of complex trauma had higher levels of anxiety, twice the 14 rate of moderate to severe depression, higher levels of substance use, increased levels of bodily pain, and poorer overall health, controlling for socioeconomic status and gender. While complex trauma does not correspond to a DSM diagnosis, over 50% of children who experienced complex trauma met the criteria for a DSM diagnosis later in childhood (Carlson et al., 1989). Even decades later, they have an increased risk of depressive disorders (Chapman et al.,2004; van der Kolk, 2005). Related to the development of mental health issues is difficulty understanding, processing, and expressing emotions. This can lead to difficulties in regulating arousal, attention, cognition, and behaviours (Courtois & Ford, 2009; Herman, 1992). Rather than being equipped with adequate emotional and behavioural regulation skills typically learned in childhood, complex trauma survivors learn other ways of coping through necessity. One such method of self-modulation is using substances as a means of coping, as demonstrated by the fact that complex trauma survivors have higher rates of smoking and substance misuse (Herrenkohl et al., 2013; van der Kolk, 2005). Another way of coping with overwhelming states or emotions common to trauma survivors is dissociation, where one often uncontrollably disconnects from their thoughts, feelings, or identity, sometimes causing memory gaps. With increased incidents of complex trauma comes an increase in the likelihood and readiness of dissociation (Liotti, 1992). This is a means of protection for complex trauma survivors at times when being present is overwhelming (Dorahy & Clearwater, 2012; Herman, 1992). Those with complex trauma are also more likely to engage in self-harm, as well as attempt and complete suicide (Huhlman et al., 2018; van der Kolk et al., 1991; van der Kolk. 2005). Cognition. Cognition is a broad term referring to mental processing around understanding, interpreting, and implementing information. Many factors influence cognition, 15 including biological predisposition, experiences, and ingrained beliefs. As trauma impacts the prefrontal cortex, the capacity to reason and engage in future planning is disrupted. The ability to learn and be successful in school is also diminished, as an activated stress response is a detriment to learning new information. Through a child’s brain, integrating adverse events in a cohesive way to maintain a sense of safety in the world is a difficult task and can have lasting repercussions on cognition. Impacts can include the development of major distortions about themselves, their worth in relationships, and the motivations of others (Pearlman, 2003). Broad areas affected by distortions identified by Kubany and Manke (1995) are the ability to predict and prevent certain events, distortions around the causality of events, misplaced responsibility for causing trauma-related outcomes, and responsibility for other wrongdoings. Issues in cognition influence how trauma survivors will think about themselves and their perpetrators relative to their trauma, and associated beliefs will become a filter through which new information is interpreted. Self-Concept. One of the first researchers in childhood trauma, Herman (1992), explained that while trauma in adulthood can be damaging, trauma in childhood shapes the individual's personality. There are many mechanisms at play influencing a person’s ability to develop a complete and well-rounded sense of self, making it one of the key areas affected by complex trauma. Left with the unanswered questions as to why the adverse events occurred, the developing brain reorganizes itself to adopt the core belief that they are bad or flawed and deserving of what happened to them (Courtois & Ford, 2013). Paving the way for alterations in self-perception, they may internalize their experiences into lessons about themselves and the world, believing that they are shameful and somehow damaged (Courtois, 1979; Pearlman, 2001). Although these beliefs may not be within their conscious awareness, they can have 16 detrimental psychological impacts. If significant others do not respond appropriately, beliefs that they are undeserving of protection may be solidified (Courtois & Ford, 2013). The negative beliefs can expand through development into feeling worthlessness, shameful, and damaged, leading to low self-esteem and negative identity development (Courtois & Ford, 2013). They may lack positive self-concept and suffer from chronic feelings of ineffectiveness in many areas (van der Kolk, 2003). In adolescence, complex trauma survivors may engage in high-risk behaviours in an attempt to cope with their difficult emotions and circumstances (Courtois & Ford, 2013). For example, Glassman et al. (2007) found that adolescents with a history of complex trauma were more likely to internalize criticism, engage in self-harm, and adopt a selfcritical cognitive style. Shame The emotions shame and guilt are on the continuum of disgust that ideally function to increase healthy social behaviour (Gilbert, 1997). Guilt incites feelings and cognition that coincide with wrong behaviour and leads to reparative actions, while shame incites thoughts and feelings of the self as wrong or bad and can lead to withdrawal or avoidance (Dorahy, 2010). Erikson (1950) suggested that experiencing shame is a normal part of development and can be beneficial in increasing prosocial behaviour. While most authors agree that shame itself is not harmful in small doses, an overabundance of shame can have detrimental effects (Blum 2008). There is a range of circumstances that hold the potential to incite shame. Shame often occurs from the belief that one is not meeting expectations and that others are aware of the person’s failure (Feiring et al., 2002; Tangney et al., 1998). Lewis (1992, 2000) posits that individuals internalize cultural standards, and shame occurs when people believe their inability to meet the standards is due to enduring personal shortcomings. The perception of “others” to not have to 17 represent actual people or opinions and can be symbolic (Blum, 2008). Shame can arise from the perception of negative evaluation by others (Gilbert et al., 1994) and predicting rejection (Claesson & Sohlberg, 2002). Although their perceptions may not be accurate, the resulting state of shame is real (Lewis 1992, 2000). Shame can also be an unfortunate by-product of situations causing a loss of dignity, power, and helplessness or a threat to one’s self-concept (Wilson & Droždek, 2004). The Experience of Shame Words people have used to describe the feeling of shame include negative, disturbing, and painful. Shame incites thoughts and feelings of self-condemnation, being defective (Feiring et al., 2002), helpless, incompetent, inferior, and powerless (Andrews et al., 2002; Ferguson et al., 1999). Shame can also incite anger towards oneself or reflect onto others, referred to by some researchers as shame rage (Lewis, 1971; Tangney et al., 1992). Common physical reactions to shame are similar to the common fear response and can include blushing, sweating, feeling weak or fainting, or a burning sensation (Lazare, 1987). The uncomfortable experience of shame motivates the self to hide from others in an effort to end the pain and discomfort of shame (Ferguson et al., 1999). Symptoms of Shame Chronic shame can have detrimental and far-reaching consequences. Lewis and Ramsay (2002) found that after feeling shame, 4-year-olds had an increased cortisol response, affecting immune functioning in the short and long term. Shame has been connected with a myriad of mental health issues, especially if it is repressed or left unprocessed (Blum 2008). It has been found that feeling shame is connected to a diagnosis of major depressive disorder (Andrews & Hunter, 1997), predicts the presence and severity of PTSD and depression (Robinaugh & 18 McNally, 2010), and can manifest as other psychopathologies such as depression, rage, narcissism, and dissociative identity disorder (Lewis, 1971). A connection has also been found between chronic shame, dissociation, and difficulties in interpersonal relationships (Dorahy, 2010). Social anxiety is often concurrently experienced with shame, as they are concerned with negative appraisals by others (Gilbert & Miles, 2000; Lutwak & Ferrari, 1997). Finally, chronic shame has been found to impact suicidality (Wilson et al., 2006). Shame proneness was a term first coined by Lewis (1971) to describe someone who frequently feels worthless and inadequate, regularly experiences difficulties due to emotional distress, has difficulty in interpersonal relationships and social interactions, and desires to hide from others. Shame proneness is also a means to describe why certain events elicit shame in some but not in others. Those who are shame prone are also more likely to experience depression and dissociation (Feiring et al., 1996). A strong shame proneness can cause shame to be internalized, affecting the individual to their core (Adams, 2008). Researchers and practitioners have identified a common cycle for which shame is internalized and exacerbated. Those who are shame-prone are often highly self-critical and hold beliefs about being defective in their own eyes and the eyes of others (Bradshaw 1998, 1995). Therefore, they are more likely to have difficulty in interpersonal interactions and perceive others as disappointing or judgemental. This, in turn, ignites a feeling of shame. In attempts to avoid feeling shame, they conceal parts of themselves from others. This reinforces their personal beliefs that they are inherently bad (Adams, 2008). As shame is internalized and continues to deepen, related experiences also begin to elicit shame, which then perpetuates increased shameful thoughts, which then become internalized, and the shame cycle continues (Kaufman, 1985, 1989). The crucial elements of this cycle are distortions in conceptions of themselves and others. 19 Internalizing shame can cause splitting, where the undesirable parts of the self are hidden or disowned (Kauffman, 1992). This can lead to perfectionism, hyper-independence, or appearing authoritative (Bradshaw 1998, 1995). There is often a lack of warmth towards the self, which is replaced with hostility and contempt (Gilbert, 2000; Whelton & Greenberg, 2005). As shame is a self-conscious emotion characterized by fear of judgement, a consistent finding is that shame motivates individuals to conceal parts of themselves from real and imagined others (Barrett et al., 1993; Tangney, 1995; Tangney & Dearing, 2002). This pushes the individual to engage in safety behaviours involving patterns of concealing, submission (Andrews et al., 2002; Gilbert, 2000) or avoiding interpersonal interactions (Dorahy & Clearwater, 2012; Ferguson et al., 1999). The individual is motivated to reduce their experience of shame, and therefore minimize engaging in potentially shame-producing experiences or thinking about similar events (Wilson et al., 2006). Shame Coping Styles The way that shame is manifested within an individual varies greatly depending on many unique circumstances and characteristics. One identified contributor is whether the shame has been felt or bypassed (Lewis 1971). Felt shame is recognized and acknowledged by the individual and dissipates through means such as connection, time, and empathy (Lewis, 1971, 1992). Bypassed or repressed shame occurs when the individual is defended from fully experiencing the shame (Lewis, 1971). This happens when there is recognition of a shameinducing event followed by minimizing the emotional response or ignoring any incited shame. The feeling of shame can be so intense that it may only be tolerable in small doses for the individual, pushing them to take means to avoid the overwhelming wave of feeling. Bypassed shame is more closely connected with psychopathology, as it impacts the individual in unconscious ways (Lewis, 1971). These shame-coping styles include withdrawal (removal from 20 the situation or anxiety), avoidance (ignoring the situation or distracting the self), attacking self (inward rage or conformity), and attacking others (outwardly directed anger) (Elison et al., 2006). Attacking the self and attacking others has also been called inwards or outwards expression of shame, respectively and can be experienced concurrently (Gilbert, 1997). “Shame rage” occurs when shame caused by rejection from others is projected outwards in an attempt to regain some control or as misdirected retaliation against a rejecting “other” (Lewis, 1971; Tangney et al., 1992). Theories of Shame Researchers and practitioners have several different viewpoints on the development and internalization of shame. One of the primary categories is the cognitive-attributional theories, which posit that certain cognitive processes lead to shame. In one study, Feiring et al. (2002) found that an individual’s attribution style accounted for more variation in adjustment than the severity of the abuse. The specific patterns of cognition are known as attribution styles, which there are many types. Lewis (1971) identified one style as global versus specific. When an individual experiences a failure, a specific attribution style would perceive an error in this situation, while a global attribution style would perceive an error in the entire self (Lewis, 1992). Similarly, Janoff-Bulman (1979) highlighted the differences between characterological selfblame, which perceives failures as personal faults, versus behavioural self-blame, where incorrect behaviour causes failure. Lewis (1992) identified several additional sets of attribution styles. The first is internal versus external attribution styles, relating to whether an event is caused by an individual’s agency (internal) or outside circumstances (external). The second is stable versus unstable, whether something is engrained and permanent (stable) or changeable (unstable). The attribution styles that lead to shame are internal, stable, global appraisals that 21 follow a negative event and become increasingly engrained over time (Feiring et al., 1996; Lewis, 1971; Tangney et al., 1992). Another common perspective relates to object relations/ attachment theories. Lewis (1971) suggested that shame is rooted in attachment and that rejection from a caregiver is interpreted as a rejection of the self. One of the pioneers of attachment, Bowlby (1973), stated that children’s internal working models of themselves and the world complement that of their caregiver. Children feeling unwanted or having disruptions in their attachment lays the groundwork for shame to develop. Lewis (1971) believed that there were three cognitive prerequisites to shame; self-awareness, the ability to anticipate others’ reactions, and a degree of socialization. While there is some evidence to support the development of shame during infancy, it is widely accepted that shame emerges during toddlerhood (Draghi-Lorenz et al., 2011). As caregiving relationships are a basic biological need (Greenberg & Mitchell, 1983), children will distort negative experiences and direct blame inward. Caregivers regulate their infant’s states and emotions through attunement; however, when caregivers are missattuned or use missattunements as a means of control, it results in shame for the child (Schore, 1994). Children from abusive homes or those lacking warmth and support may experience strong shame and engage in shameavoidant behaviours (Talbot, 1996). Shame becomes ingrained over time, and new experiences are integrated based on this adapted working model of shame (Schore, 1994). Finally, the functionalist perspective conceptualizes shame through the lens of evolution and adaptation. Those who ascribe to this viewpoint believe that shame has an adaptive function that increases the chances of survival. According to Barrett (1995), the function of shame is to create and maintain cohesive relationships with others through self-regulation in adherence to social norms. Shame was developed as a means to manage social threats and challenges, wherein 22 a shame response would result in de-escalation in tumultuous social situations and facilitates cohesion (Erikson, 1950; Gilbert, 1997; Gilbert & McGuire, 1998;). Modern-day shame may also protect from marginalization and rejection and motivate correction through self-criticism (Gilberts et al., 2004; Nathanson, 1987). Research has provided some evidence that humans are wired to feel shame as an evolutionary function. Lee et al. (2001) posit that shame is an innate primary response as a means for social cohesion, but that through evolution and increased selfconsciousness, humans have developed the ability to internally shame themselves. It has been suggested that individuals can engage in self-to-self-dialogue and have relationships with themselves, which leads to the self judging the self and acts as a mechanism for shame (Gilbert et al., 2004). The negative consequences of internalized shame are generated through increased self-consciousness and the ability to self-shame. Intersection Between Shame and Complex Trauma As demonstrated by the literature, the circumstances conducive to internalizing shame overlap with the events and circumstances of complex trauma. It is not surprising that shame and complex trauma have a symbiotic relationship. Harman and Lee (2010) found that individuals with PTSD had more shame and self-criticism than nonclinical populations. They suggest that shame may play a crucial role in the maintenance and severity of complex posttraumatic symptoms. Complex trauma promotes the development of beliefs like no one is trustworthy, feeling disconnected from others, and feeling inherently bad and deserving to be treated badly by others (Lyons-Ruth & Jacobvit, 1999). Children have difficulty processing their trauma due to their cognitive development and are more likely to internalize blame, leading to shame, isolation, and concealment (Buckley, 2014). Talbot (1996) outlines the process of trauma facilitating the development of shame. Following the abuse, a child loses their sense of power and control. The 23 negative experience is distorted and directed inward to maintain the relationship with their caregiver. The message of being bad and unworthy of protection intensifies, love and care turn into frighting and shameful concepts, and others become a source of danger. Children may resist sharing their experiences believing that people are untrustworthy, and they lose the hope that they will ever truly feel safe (Courtois & Ford, 2009). Greater incidents of trauma were correlated with increased shame, and shame proneness has been correlated with the severity of posttraumatic symptoms (Leskela et al., 2002; Stotz et al., 2015). These early formed beliefs and experiences become the template for adult relationships with themselves and others (Shorey & Snyder, 2006). Dorahy and Clearwater (2012) identified several factors that led to internalizing shame in sexual abuse victims: the secretiveness of the abuse and pressure for concealment, the belief that others saw them as shameful, and that they saw themselves to be bad and unlovable. Shaming statements and negative comments by parents (Gilbert et al., 1996), along with lacking secure relationships with caregivers and having a damaged sense of self, are conducive to internalizing shame (Talbot, 1996). Other types of caregiver-child interactions that increase shame-proneness include humiliation, being overly critical (Ferguson & Stegge 1995; Kaufman 1985), an overabundance of parental control and treating the child as incapable (Chorpita & Barlow, 1998), parentification (Wells & Jones, 2000), frequently ignoring (Claesson & Sohlberg, 2002), and devaluing the child’s sense of worth and value to themselves and others (Leary et al., 2011). Lewis (1992) also identified that when caregivers are shame-prone, children can develop “empathic shame” in response to their caregivers through learning to be self-critical and developing self-blaming patterns. Wilson et al. (2006) identified the following eight psychological domains affected by posttraumatic shame. Self-evaluation is impacted by a loss of self-worth and self-esteem and 24 doubts of moral virtue. There are increased difficulties and affect regulation, particularly for emotions such as humiliation, sadness, and anger. Judgement of self and others’ actions are affected through an increased propensity for self-blame and perceiving judgement from others. There is the potential to develop defensive patterns as a means of protection from shame, such as repression and avoidance. As posttraumatic shame often involves hiding parts of the self, there is potential for the self to feel fragmented. There may be a psychological revaluation of many parts of the self, including self-respect, autonomy, and vitality. With posttraumatic shame also comes an increased risk of developing PTSD symptoms, as well as an increased risk of suicidality. Adult survivors may become trapped in a cycle of behaviour perpetuated by a fear of rejection, difficulty managing affect and difficult emotions, and feeling powerless (Buckley 2014). Adult survivors of child sexual abuse describe experiencing shame daily (Buckley, 2014) or seeing themselves as shameful people (Dorahy & Clearwater, 2012). One study by Feiring and Taska (2005) found that individuals with high levels of shame reported more intrusive posttraumatic symptoms six years following disclosure of their trauma. It is apparent in the literature that posttraumatic shame is a common symptom of complex trauma that affects many aspects of their life and wellbeing. The Treatment of Complex Trauma and Shame Without a standardized method for working with shame, practitioners have developed best practices based on current research, established theories, experience, and shared knowledge. Treatment modalities can be varied depending on the practitioner’s education and theoretical orientation. Treatment of complex trauma can take anywhere from months to decades (Courtois, 2008). While some theories of treating complex trauma include guidelines for working through shame specifically, others conceptualize shame as a by-product of trauma that is resolved 25 through treatment without direct focus. There are two crucial assumptions of treatment as identified by Courtois (2010); that complex trauma can have enduring negative effects on the client and that posttraumatic symptoms should be conceptualized as once-necessary survival mechanisms that are now impacting an individual’s life. The following overview of best practices will include some basic guidelines for working with complex trauma that are necessary for healing shame, along with highlighting any shame-specific practices. Staged Treatment Working with complex trauma involves three broad stages of treatment. The general stages are relatively consistent throughout the discipline, although treatment methods and modalities do differ based on specific theories. The first stage of treatment focuses on increasing the client’s safety and stabilization. Safety in this context refers to the absence of real danger, the ability to manage survival responses, and the accumulation of resources should the threat of danger arise, while stabilization refers to the tapering of emotional turbulence leading to distress (Courtois et al., 2009). Complex trauma survivors are often accustomed to feeling chronically unsafe; it is through therapy that the feeling of safety may be achieved and ideally spread to other areas in the client’s life (Courtois, 2008). Education regarding the causes and reactions of complex trauma is crucial during this phase, as clients may often hesitate to label their experiences as traumatic. Providing information about typical trauma responses and their effects can provide the client with understanding and decrease self-blame for their trauma response and shed light on how past trauma may affect current functioning (Courtois et al., 2009). Normalizing the client’s experience through validation and education is one way to reduce shame during this phase (Buckley, 2014; Jackson et al., 2009). Other significant tasks are building the therapeutic alliance and skill-building in affect and emotion regulation. While some 26 clients may not transition to the second stage, progress in the first stage can greatly improve the client’s life and well-being (Courtois, 2008). The second stage of treatment consists of exposure to the trauma in varying degrees depending on the philosophy of the counsellor and client. Following the guidelines of Courtois & Ford (2009), exposure is not to the traumatic memories themselves but the emotions triggered by the memory. Treatment involves practicing control over emotional reactions to the trauma memories and increased control over the ability to recall specific memories voluntarily rather than intrusively. Other researchers and clinicians hold the belief that trauma memories need to be actively remembered and processed for the purpose of exposure and for healing to occur. The primary importance is the desires and readiness of the client, and any degree of processing the trauma should be done with caution with a primary focus on safety (Courtois, 2008). Premature trauma processing can overwhelm and has the potential to retraumatize and exhaust the client and should be done with caution to ensure readiness of the client (Chu, 1992). Cloitre et al. (2002) found that exposure to the trauma memory was beneficial for clients in the treatment of complex trauma, but that due to the difficulty of treatment, clients were more likely to drop out at this stage. Using narrative techniques in combination with grounding can facilitate gradually processing the trauma while maintaining safety for the client (Courtois, 2008). Sensorimotor activities that encourage movement, nonverbals, and body states can also be beneficial for processing (Follette et al., 2009). It is common for novel emotions to arise during this phase, such as grief, shame, and rage (Courtois, 2008). Although feeling shame can be a barrier to the effectiveness of exposure (Lee et al., 2001), verbally processing the events can play a major impact in healing from shame. Tangney and Dearing (2002) observed that verbally recounting the experience can alleviate negative feelings associated with the trauma, including 27 shame, through inspiring a different method of thinking that alleviates the client from blame and responsibility. Imagery rehearsal/scripting with trauma memories can provide the opportunity to re-examine and modify trauma memories to decrease shame and self-blame (Courtois & Ford, 2013). Following a narrative approach to treatment, processing trauma can allow clients to see the situation through the lens of their adult selves rather than that of a child (Chu, 1992), increase self-efficacy, and help develop a coherent life story (Courtois et al., 2009). The third phase of treatment aims to support the client in integrating the therapeutic work completed in the prior phases into their life. The clinicians can help clients find a “new normal” where they are less affected by the original trauma and accompanying posttraumatic reactions (Courtois, 2008). Grief and sadness may arise during this phase as clients gain perspective on how trauma adversely impacted various aspects of their lives (Courtois & Ford, 2009) and feel loss over what could have been (Buckley, 2014). In this phase, clinicians act as a secure base for self-exploration as they begin to establish new patterns and continue skill-building (Courtois et al., 2009). The three stages of treatment are not necessarily linear, and clients may move back and forth between phases. Foci of Treatment In conjunction with the three stages, core domains are affected by complex trauma that are common areas of focus in treatment. One such area is emotion dysregulation, where emotions are perceived as unmanageable and overwhelming (Courtois & Ford, 2013). After being invalidated for expressing emotions such as anger, anxiety, or sadness, experiencing them in adulthood may cause shame (Courtois et al., 2013). Emotion regulation can be improved through therapeutic validation of emotions, along with teaching targeted skills. 28 A second area of focus in therapy is difficulties with self-concept and self-integration (Courtois & Ford, 2013). This domain is particularly relevant to working with posttraumatic shame as it concerns identity and core beliefs, both of which can lead to the belief that one is inherently “bad” (Courtois et al., 2013). A survivor of complex trauma may experience a degree of fragmentation of the self as they conceal memories, sensations, knowledge, or emotions that may be triggering (Putnam, 1989); this concealment or denial can easily lead to shame (Lewis, 1971). Part of the therapeutic process is to expose and understand these aspects of the self concerning their trauma and shift any blame for the trauma away from the self (Buckley, 2014). The counsellor can also serve to make sense of the confusing messages and subsequent core beliefs developed in childhood relative to the trauma (Buckley, 2014). Harman and Lee (2010) suggest that survivors need to be taught techniques for self-compassion as part of treatment. Increasing the sense of agency and self-control is also an important task, as it is common for survivors to feel as though they lack control over themselves and their lives (Buckley, 2014; Talbot, 1996). The therapist can help clients identify and build on existing areas of strength and control (Courtois & Ford, 2013). As trauma impacts an individual’s relationship with their body, reconnecting the mind and the body is an additional aspect of treatment (Courtois, 2008). Attachment styles are often affected by complex trauma but can be repaired in therapy (Courtois, 2008). While the therapeutic relationship is critical for healing in most therapeutic work, it is especially essential with survivors of complex trauma. Although past relationships are often the cause of trauma, they can also be the key to healing (Kinsler et al., 2009). While a therapeutic relationship can be more challenging to build with survivors of complex trauma (Courtois, 2008), a strong alliance near the beginning of therapy is related to a reduction of symptoms after treatment (Cloitre et al., 2004). Valory (2007) suggests that through a healthy 29 therapeutic relationship, a client can shift attachment patterns to be more securely attached, which can then extend to relationships outside of therapy. Kinsler et al. (2009) state that the therapeutic relationship is the main agent of change in therapy. It may be the first time the client has engaged in a secure relationship and is valued and validated. The counsellor has the task of modelling healthy attachment, creating boundaries (Chu, 1992), co-regulating, and supporting the client in maintaining safety (Courtois, 2008). Creating a safe and empathic connection will provide an environment where the client may feel open to discussing their shame, and receive empathy and understanding in return (Talbot, 1996). Special care must also be taken when ending the therapeutic relationship, as this can bring up feelings of abandonment or a loss of safety (Courtois, 2008). Herman (1992) recommends giving the client the option to return for check-ins or to continue therapy as necessary. Theories of Treatment Although there are common patterns to treatment practiced by most counsellors, there are specific theories that some therapists practice in the treatment of complex trauma. As a widely practiced method of therapy, cognitive behaviour therapy (CBT) has been used to treat complex trauma and subsequent shame. Under the larger umbrella of CBT are specific treatments and practices that clinicians have found beneficial in working with complex trauma. One of the foundational components of CBT is examining and shifting maladaptive cognitions, which over time, can diminish the experience of shame (Van Vliet, 2009). Re-attribution training supports clients in shifting thoughts and beliefs about behaviour outcomes and environmental events (Metalsky et al., 1995). Similarly, social fitness training developed by Henderson and Zimbardo (2001) is a strategy that targets maladaptive attributions to reduce self-blame and shame. 30 Cognitive processing therapy (CPT) has been practiced with survivors of complex trauma since Resick and Schnicke first wrote the manual in 1993. CPT practices are similar to CBT, with additional steps to support the client in processing the trauma. Resick et al. (2008) found that clients had improvements with PTSD symptoms, including anger, guilt, and shame, using this model. Their study supports the finding that altering the meaning of the traumatic event may be a critical mechanism of change to reduce posttraumatic symptoms (Resick et al., 2008). With similar foundations in behavioural theories, contextual behaviour trauma therapy (CBTT) is based on the concept that trauma symptoms are maintained due to avoidance of negative memories and emotions (Follette et al., 2009). Following this approach, the client and therapist analyze behaviours based on their function and the sequences that led to these behaviours, including examining the function of negative coping strategies. Interventions include skills training, radical acceptance, and supporting the client in analyzing and shifting behaviour patterns. The overarching goal of CBTT is for the client to create a cohesive self through various environments, experiences, and emotions. Another phased-based approach first developed by Cloitre et al. (2002), skills training for affective and interpersonal regulation (STAIR), teaches clients skills to understand and manage their emotions and reactions. STAIR employs skills training, behavioural approaches, and gradual exposure, and has been found to be effective in minimizing PTSD symptoms (Cloitre et al., 2002). Adams (2008) described the benefits of transactional analysis theory, which focuses on identifying and shifting clients’ negative internal scripts and empowering them to make different life choices. This is done through imagery, grounding, skill-building positive self-talk, and bringing awareness to pain. This theory characterizes posttraumatic symptoms as maladaptive 31 methods of meeting needs and postulates that individuals will meet their needs in positive ways if they have the skills and ability to do so. As the primary component of compassion-focused therapy, compassionate mind training (CMT) focuses on increasing the client’s self-acceptance and self-compassion to decrease shame and self-criticism (Gilbert & Irons, 2005; Gilbert & Procter, 2006). This approach conceptualizes self-criticism as a necessary safety behaviour often developed in childhood that is perpetuated through time, as well as the lack of ability to self-soothe or tolerate distress (Gilbert & Procter, 2006). The goal of therapy is to help the client recognize their self-critical automatic thoughts and replace them with compassionate thoughts through self-exploration and acceptance, employing methods like psychoeducation and imagery. Emotion-focused therapy (Greenberg, 2002) is another commonly used approach for individuals with complex trauma. Under the belief that emotions are the key to processing trauma, the client learns to understand and manage their emotions and bodily states to eventually replace negative emotions with more positive ones (Follette et al., 2009). Emotion-focused trauma therapy can also include activities that encourage the client to deal with feelings about the perpetrator through exercises such as speaking to an empty chair, which can reduce shame and self-blame (Courtois & Ford, 2013). Courtois and Ford (2013) have developed an approach to treating complex trauma that includes treatments that specifically target shame. It is based on five identified areas of treatment: posttraumatic adaptations, relational working models, self-Identity, healthy development, and emotion regulation (PRIDE) (Ford, 2012). This acronym was chosen as the emotion pride is the opposite of shame, and experiencing pride may be a challenging but important task for trauma survivors (Courtois et al., 2013). Therapeutic interventions specified in 32 this model include increasing the client’s ability to manage difficult emotions, known as the window of tolerance, through means such as exposure and coregulation with the therapist. Other techniques used are imagery rehearsal, memory rescripting, and exploring personal and relational patterns to increase self-acceptance. Stemming from attachment and developmental theories, constructivist self-development theory has been practiced and expanded upon for decades (McCann & Pearlman, 1992). The theory posits that children who lack secure attachment have disruptions in development in core self-capacities: affect tolerance, self-worth, and connection to others (Pearlman, 1998). Without the necessary skills, individuals may engage in risky behaviours to regulate and meet their needs. The development of new healthy relationships can serve to repair these deficits, and therefore great importance is put on the therapeutic relationship. In this paradigm, there are five focus areas in relationships with self and others: safety, trust, esteem, intimacy, and control (McCann & Pearlman, 1992). Saakvitne et al. (2000) expanded upon this theory by creating the risking connection attachment-based model for treatment. They identified four critical elements for building a secure therapeutic relationship: respect, information, connection, and hope (RICH). Attachment difficulties are reworked in the therapeutic relationship, providing an opportunity for the client for self-exploration, building skills, and recreating secure and healthy relationships outside of therapy. Expressive therapies serve as an alternative to traditional talk therapy for working with complex trauma. The following are examples of the wide variety of modalities for expressive therapy. Art therapy has been used as a way for clients to process their trauma nonverbally (Bailey, 2007). This can serve to facilitate exposure to the trauma memories while minimizing flooding or overwhelming the nervous system (Avrahami, 2005). The creative expression of art 33 therapy can occur via various visual mediums such as sculpture, drawing, painting, or collage. Other art therapy methods include photography (Glover-Graf, 2007) and therapeutic doll making (Stace, 2014). Sand tray therapy also uses creative and expressive means to facilitate posttraumatic growth (Lennihan, 2013). Often employed in a group setting, psychodrama uses theatre and drama techniques to facilitate exposure and reduce trauma symptoms (Glass, 2006). In addition to creative approaches, somatic techniques have been growing in popularity for their ability to address the body’s role in trauma therapy. Modalities such as Somatic Experiencing utilize kinesthetic techniques and attention to body states to resolve symptoms and decrease chronic stress (Levine, 1997). Many studies have also captured the effectiveness of dance and movement therapy in treating trauma (Ho, 2015; Koch et al., 2019; Pierce, 2014). Shame-Oriented Interventions As shame can affect all stages of treatment (Kubany & Watson, 2003), researchers and counsellors have highlighted certain effective practices. Clients may not disclose their trauma or shame at the onset of therapy, or at all, as experiencing shame has been linked to non-disclosure in therapy (MacDonald & Morley, 2001). Clients may refrain from revealing their shame for a myriad of reasons, such as lack of awareness or fear of rejection. Lewis (1971) suggests that when working with trauma survivors, a therapist should suspect the client is experiencing shame and interpret any expression of guilt as a sign of concealed shame. One approach to decreasing shame is to shift blame away from the client by reframing any current life challenges and maladaptive behaviour as resulting from their trauma and survival strategies (Kinsler et al., 2009). Through a greater understanding of external factors that contributed to their current life circumstances, the goal is to shift attribution styles from internal blame to external blame (Van Vliet, 2009). Ideally, this would help the client decrease negative 34 global-self judgements and create a more positive self-concept. As perfectionism is a common coping strategy to avoid shame, it is helpful to reframe mistakes and imperfections as normal behaviour and to work to lower self-expectations (Van Vliet, 2009). Finally, there is a critical role for empowerment as clients gain an increased sense of agency, creating the opportunity to experience hope for creating meaningful change in their lives (Van Vliet, 2009). Summary Through growth in research on the causes and effects of complex trauma, there is an increased understanding of the effects of complex posttraumatic reactions within short and longterm contexts. An internalized sense of shame often accompanies complex trauma, and there are various theories and explanations as to why this is the case. Internalized shame can be an intense and uncomfortable experience that influences an individual’s treatment in therapy. While there are several treatment methodologies and practices for complex trauma, few target shame specifically, and those that do often lack scientific validation. Although this area has had minimal research, many counsellors have firsthand experience working with the issue. This raises the question of the methods that practicing counsellors are currently using in supporting adult survivors of complex trauma to heal from shame. 35 Chapter 3: Methodology Qualitative Methods The essence of qualitative inquiry is to seek a deeper understanding of an aspect of the human experience through collaboration between the researcher and the participant (Mayan, 2016). Qualitative research seeks to uncover the meaning individuals ascribe to a particular phenomenon in a robust way that cannot be contained by numbers or statistics. Qualitative inquiry typically consists of smaller sample sizes in order to focus on a more in-depth understanding of the phenomenon in question (Mayan, 2016). The smaller sample size facilitates the mandate of a rich understanding that is not concerned with generalizability. The constructivist view of qualitative inquiry holds that there is no absolute truth but that multiple realities exist and can be co-constructed through participant and researcher. It is an inductive inquiry as it seeks to create common themes and a broader understanding from multiple perspectives through an exploration of the data (Mayan, 2016). Qualitative inductive inquiry peers into existing phenomena to interpret subjective data and find patterns of meaning. Data often comes in the form of stories, memories, recollections of experiences, or observations (Mayan, 2016). A cornerstone of qualitative inquiry is a collaboration between researcher and participant, wherein mutual respect and minimizing power differentials are emphasized. Instead of creating knowledge, qualitative inquiry employs respectful and collaborative methods to observe and describe knowledge that exists in participants' minds, hearts, and stories. The goal of the current research parallels the nature of qualitative inquiry, as it seeks to understand and create meaning from the unique experience and perspectives of counsellors working in the field. As shame affects all stages of treatment, from the decision to seek mental health support to the intricacies of ending a therapeutic relationship, 36 it is beneficial for all parties that the counsellor is equipped with as much research and understanding regarding the nature and treatment of shame. Exploratory Research The current research employed an exploratory research methodology. This type of research is applicable when little is known about a topic or area of interest that merits exploration (Stebbins, 2011). As the name suggests, exploratory research functions to collect data on a relatively understudied area to better understand the phenomenon. Through induction, exploratory methodology uses the data to create generalizations, or themes, pertaining to the topic. The purpose of the exploration is to discover new information or build theories (Jupp, 2006). While most qualitative research involves exploration, exploratory research is distinguished by focusing on building theory and creating generalizations (Stebbins, 2001). Any discoveries made can then serve as a base upon which other researchers can build. Stebbins (2001) highlights the need for flexibility and open-mindedness in all phases of research to minimize researcher bias and the possible effects of preconceptions. The aim is to approach the data without expectations to allow generalizations to emerge through an inductive process (Schutt, 2019). This contributes to increasing validity as generated themes require researcher creativity but are led by the data. While there is a range of research on complex trauma and shame, there is minimal research on how they intersect in therapeutic treatment. My research is exploratory as it aims to create generalizations about counsellors’ treatment of shame in adult survivors of complex trauma, an area where little information exists that may serve as a base for other studies to build upon and continue exploring. 37 Thematic Analysis Thematic analysis was used to analyze the collected data. This method was selected as it allows each participant to share their unique perspectives and understanding while also investigating patterns and themes across participants to find common themes (Braun & Clarke, 2006). This allows the research to honour the experiences of the research participants while also uncovering meaning about the topic. Braun and Clarke (2006) discuss the merits of thematic analysis to understand or uncover an important aspect of a group or phenomenon. Through thematic analysis, the researcher moves beyond codes to extract and interpret the meaning behind and within the data to construct significance within the broader research topic (Creswell & Poth, 2018). In the constructivist nature of thematic analysis, researchers seek to find patterns in how participants assign meaning to their reality, which then goes through another level of coconstruction as it is conveyed to the researcher (Braun & Clarke, 2006). As everyone’s experience of shame is unique, so too is the relationship with their counsellor, who is then conveying the information to the researcher. While so much can be learned from individual experiences, conducting thematic analysis draws from multiple perspectives to facilitate greater understanding. Ethical Considerations This research was conducted in accordance with UNBC’s research guidelines after receiving approval from the UNBC Research Ethics Board (REB). The process for REB approval included completing the CORE (course on research ethics) training and detailing the research procedures to confirm that the study adhered to ethical standards. These standards included ensuring that the participants were well-informed about what was involved with participating in the study, which I facilitated through providing an information sheet and consent 38 form, and requiring participants to provide informed consent before the interview. Data management principles were also strictly upheld. Participants’ interview recordings and transcripts were stored on a secure UNBC server that only I could access and were filed in a separate location from the participants’ consent forms after removing any identifying information. I also sent participants their transcripts for member checking through the secure online platform Sync to protect their data. Confidentiality and Consent The importance of confidentiality is especially salient for constructionist qualitative research. As reality is co-constructed between researcher and participant, external circumstances hold the potential to affect the research and the data. If the participant does not believe that their identity will be concealed and their stories treated respectfully, this will affect the information they choose to share and, therefore, the constructed meaning. A variety of measures were taken to retain confidentiality and increase the privacy and protection of the participants. Participants were provided with a consent form that outlines the research procedures as well as the limitations to confidentiality (Appendix A). These limitations include the suspected harm to self or a named other, concerns of harm or neglect to a child or vulnerable adult, or under court order (Canadian Counselling and Psychotherapy Association, 2020), and were reviewed at the beginning of the interview. Participants’ consent forms and identities were kept in a secure folder on my personal computer that is protected by a password known only by me and permanently deleted two years following the completion of the research. Participants were given an identification number known only to me and are used for identification in data analysis and reporting phases to protect their identity. Any potentially identifying information for participants or their clients, such as 39 named community organizations or places of education, were redacted in the transcript and omitted from further data analysis. After conveying their interest, participants received an informational letter via email along with a consent form outlining items such as the research purpose, how confidentiality will be addressed, and where to contact with more questions (Appendix A). Participants returned the completed form to me by email. Interviews were conducted via video call on Zoom. Conducting virtual interviews ensured that the participant could choose a location for the interview they felt was safe and secure to maximize confidentiality. At the beginning of the interviews, I reviewed the steps taken to ensure anonymity along with the limits of confidentiality, and reminded participants of their right to withdraw consent at any time up until the data analysis phase. Participants also had the opportunity to ask questions and voice concerns. I verbally requested permission from participants before starting to record the interview and gave participants the opportunity to change their screen names on Zoom to increase their comfort level. Knowing that shame and complex trauma can be difficult conversation topics, I used my skills as a counsellor to help the participant remain in a regulated emotional state. Participants were also reminded of their freedom to decide when and how much to share, to not answer a particular question, and to quit the research study at any time (Mayan, 2016). Additionally, I provided participants with a list of virtual counselling resources they could access if necessary (Appendix B). Research Procedures Recruitment of Participants As is common in qualitative research, I used purposive sampling methods to recruit participants, wherein participants are selected based on their ability to provide information to the researcher on the research topic (Creswell & Poth, 2018). Criterion sampling was also used as 40 individuals were selected based on meeting certain educational and vocational qualifications, along with having experience working with a specific population (Creswell & Poth, 2018). Using these sampling methods facilitated the selection of participants that will best be able to inform the research. Participant criteria included having a master’s level education in counselling or counselling psychology and having experience working with shame in adult survivors of complex trauma in a therapeutic setting. Requiring a master’s degree in counselling ensured that participants had met a minimum educational requirement and had completed standardized counselling coursework on topics such as counselling theories and ethics. There were two channels of participant recruitment: an informational letter was sent to 45 private counselling firms and community mental health services (Appendix C), and a recruitment poster was shared on social media (Appendix D). Interested persons contacted me via email to arrange interviews. As each participant has a unique experience to contribute to research, the number of participants was determined not by saturation but by information power. In adherence to information power, the size of the study is dependent on several factors, including the amount of data provided by each participant and the scope of the research question (Malterud et al., 2016). Seven participants were recruited, which is an appropriate size for qualitative research as it permits a range of unique perspectives while ensuring that each interview was given sufficient attention and analysis (Mayan, 2016). The recruited participants were located across BC and in various cities across Canada as far east as Ontario. The group consisted of two men and five women and had varying levels of counselling experience. At the time of the interview, each one was working as a counsellor in private practice. 41 Interviewing Data collection was conducted through semi-structured interviews. This method was chosen as it encourages dialogue and conversation but also allows for continuity between participants (Creswell & Poth, 2018). Semi-structured interviews are particularly applicable when enough is known about a topic to develop thoughtful questions, but knowledge gaps exist wherein the answers could not be predicted (Richards & Morse, 2007). A list of questions can be found in Appendix E. Interviews were approximately one hour in duration. I took minimal notes during the interview, consisting of follow-up questions to ask participants and any big ideas they mentioned. I made entries in a journal before and after interviews, reflecting on the process and noting any significant themes from interviews. Within a qualitative constructionist methodology, it is through the interview process that data is not simply observed but created between the participant and researcher (Mayan, 2016). As the instrument of research, I strived to maintain awareness of how my presence affected the interviews. I spent the first few minutes of each interview building rapport with participants and expressing my appreciation for their participation in an effort to help them feel comfortable during the interview and minimize any potential power imbalance. This is a reflexive process, which is inherent to the constructivist approach. During the interviews, I was very conscious of how I conducted myself. I recognized that the way I may reflect a participant’s statement or the follow-up questions I asked could shift the interview and change the data. For example, when one participant spoke about having emotions towards others instead of deflecting them inwards, I summarized her answer and used the term “redirecting” to reflect her idea. She responded with, “Yeah it’s great you say redirecting because…” and used that term several times throughout the interview. While it was good that the participant felt she was being understood, I couldn’t help 42 but think that I had affected the data by introducing this term. The following exert was taken from my reflective journal from an entry written after the aforementioned interview: I was trying to be super neutral about everything so I did not influence things, but it is impossible to have no effect. Even as I reflected her idea, [the participant] said, great word yes that’s exactly it, and then used it. Did I just create my own data? But at this point it’s inevitable to me that the researcher influences the data because just engaging in the conversation has an effect. Throughout all interviews, I aimed to minimize any preconceived biases regarding the answers that I was expecting. I did this by writing any thoughts or ideas I had before the interview in my reflexive journal. This allowed me to bring awareness to my thoughts and bring any unconscious bias to the surface. During interviews, I attempted to stay present with the participant and follow their lead. In another instance, a pattern emerged between the first and second interviews, and I was excited about the results. I knew my feelings would influence the following interview, so I engaged in reflexivity by using the reflective journal and staying grounded in the interview to not steer the results in any direction. The pattern never emerged again, and the journal helped me process my disappointment and not carry it with me through the interviews. On a personal level, I thoroughly enjoyed speaking with other counsellors about their work. Hearing others' passion and experiences made me reflect on my own practice and the type of counsellor that I wanted to be. I felt so much gratitude that the participants chose to share their time and wisdom with me. At the end of the interview, participants were given a choice between a $20 Starbucks or Tim Hortons E-gift card, which was sent to them via email. 43 Data Analysis The data was analyzed using the six-phase method of thematic analysis outlined by Braun & Clarke (2006). The first phase involves transcribing the interview and becoming familiarised with the data. Using the video recordings, I transcribed each interview verbatim, including aspects of speech such as pauses, word repetition, utterances, etc. This was done to retain data for analysis purposes, as well as support the accuracy and validity of the research. After transcribing the data, I read each interview again to check for accuracy and began noting significant points. I then sent each participant a copy of their transcript as part of member checking. This was undertaken to provide participants with an opportunity to amend or redact anything that was said and to ensure their words were an accurate representation of their beliefs and experience. Of the seven participants, five replied approving the transcript, and two did not respond. I then read through the transcript three additional times while taking notes and highlighting significant quotes. The transcript was coded in the second phase of data analysis. Codes identify reoccurring features of the data that serve as building blocks that will later build into categories and themes (Braun & Clarke, 2006). I employed structural coding methods, which is an elemental form of coding where codes are created based on their content and then collated for further analysis (Saldaña, 2016). I coded data manually by highlighting sections of text, writing codes in page margins, then transferring them to an excel spreadsheet on my computer. In the beginning stages, I struggled with knowing what to code, how specific or broad codes should be, and how to label codes. Coding is often an ambiguous, creative process, requiring the researcher to develop a personal method and style of coding (Saldaña, 2016). Braun and Clarke (2006) echo this statement, explaining that there are no rigid rules for analysis and theming, but that it is a flexible 44 process dependent on the researcher’s discretion. Once I became familiar with the process, I enjoyed coding and thinking about all the possibilities for the data. During this phase, creating an abundance of codes is recommended in anticipation that some may be eliminated and could be contradictory (Braun & Clarke, 2006). After the initial coding, I created 171 codes. The third phase involves analyzing the codes for broader meaning and searching for themes. Codes are organized into categories of similar meaning and collated to form preliminary themes (Creswell & Poth, 2018). To complete this step, I conducted focused coding, which organizes frequent or meaningful codes into categories (Saldaña, 2016). First, I sorted the codes, removing infrequent ones and collating similar codes. Next, I wrote down each code on a post-it note and included which transcripts the code applied to. At this point, I had some loose ideas about potential themes, but it wasn’t until I began putting codes into categories that solid patterns emerged. Mayan (2016) suggests confining the analysis to 1-3 major themes for an optimal exploration and analysis of the data. I turned a blank wall into a thematic map (Braun & Clarke, 2006), grouping codes into categories and grouping categories into sub-themes and sub-themes into themes. Themes were created not only based on their frequency within the data but also based on saliency regarding the research question (Braun & Clarke, 2006). This was a very satisfying process, making connections within the data and seeing how they all come together to form a bigger picture. During the fourth phase, codes are reviewed, and categories are refined. To complete this step, I extracted the coded exerts from transcripts to create an outline of each theme with the raw data. While reviewing the codes and transcripts, some codes were recategorized into a more appropriate category, while others were eliminated for their lack of relevancy. This was done to ensure the patterns created by the raw data corresponded to the larger themes, known as internal 45 homogeneity (Mayan, 2016). I also reviewed the themes for external homogeneity, ensuring the categories and themes were distinct and separate (Mayan, 2016). Some categories were moved under more applicable themes during this phase, and a new sub-theme was created. Phase five entails defining, refining, and naming themes for the final analysis (Braun & Clarke, 2006). I created a detailed analysis of each theme and reflected on their relationship to the larger research question. I found naming the themes to be a difficult task. I wanted to find a name that would convey the importance of the theme while keeping them broad enough to cover all the data within the themes. Each theme was named and renamed several times during this phase until the final names were solidified. Please see Table 1 for a list of themes, sub-themes, and sample codes. Once I had a name and description for each theme, I sent participants a description of the themes and sub-themes their interview contributed to verify that the themes accurately represented their beliefs. I received six participant replies, five approving the themes and one including a note of clarification for one of the categories. The last phase is the creation of the final report with all stages of analysis completed, which constitutes chapters 4 and 5 of this research. When including participant quotes, I removed “ums”, stutters, and false starts to prioritize the meaning conveyed by participants over verbatim speech. To illustrate themes using participants’ words was a satisfying process that brought a sense of completion to the research. 46 Table 1. Theme Sub-Theme An Intolerable Experience Category Feeling shame Shame and the Nervous System Psychoeducation Emotional Landscape Building Capacity Experiential Techniques Building Tolerance Honouring Shame Defective Self Self-Blame Negative Beliefs Disguise and Conceal Challenging Shame Self-Concept Disrupting the Shame Cycle Validation Externalizing Emotions Diffusing SelfBlame Interpersonal Difficulties Attachment and the Therapeutic Relationship The Therapeutic Alliance The Person in the Professional Safety Developing trust Personal Vulnerability Sensing Shame Self-Work Sample Code • Reported as painful • Client unlikely to name shame • Shame is freeze response • Struggle to stay present in session • Teach about shame • Psychoeducation trauma reactions • Most powerful interventions • Use somatic techniques • Use coregulation in session • Teach breathing tools • Can’t argue people out of shame • Validate shame before processing • Blame self for childhood trauma • Angry at self for past trauma • Report low self-esteem • Make self-deprecating statements • Fear of authenticity • Observe hiding behaviour in session • Bring attention to diverting conversation • Ask client if shame is disrupting their life • Normalize trauma reactions • Normalize shame as survival response • Build tolerance to move anger towards source • Practice having emotions towards others • Metabolize shame slowly • May need to provide redemption • Shame inhibits authentic connection • Perceive judgement from others • People start sharing small bits at a time • Need safety before discussing shame • Building trust takes a long time • Alliance takes longer to form than with others • Use more self-disclosure • Client has a sense of who they are as a person • Sensing an energy in the room • Shame resonates in personal nervous system • Need to tolerate discomfort personal shame • Personal therapy important 47 Evaluation of the Study Rigour Traditionally within the academic field, validity is a measure of whether the research methods are accurately measuring the targeted construct (Creswell & Poth, 2018). This refers to accuracy within data collection and analysis, as well as the accuracy of the themes and conclusions, ensuring that they are a result of the data set (Mayan, 2016). As there is no absolute truth or complete accuracy within the qualitative constructionist framework, the concept of accuracy is co-constructed between the participant, researcher, and reader (Creswell & Poth, 2018). Trustworthiness is one of the cornerstones of qualitative validity that pertains to the rigour of a research study and to what degree the research results can be trusted as truthful (Mayan, 2016). Often used synonymously with validity in qualitative research, many of the foundations of trustworthiness pertain to the relationship between the researcher and the participant (Lincoln, 1995). As the researcher’s influence on the study is inevitable, guidelines for trustworthiness serve to minimize the effect of researcher bias (Morrow, 2005). There are a variety of measures of trustworthiness depending on the field of study and research design; therefore, I will be focusing on the measures most pertinent to the current research. Critical for all measures of trustworthiness is a focus on researcher subjectivity and reflexivity (Morrow, 2005) to bring awareness to the ways the researcher will inevitably impact the research study and results (Tracy, 2010). Morrow (2005) highlights the importance of the researcher fully immersing themselves in the data prior to analysis. I submerged myself in the data by watching the recorded interviews, transcribing them, reviewing the notes I had taken during and after each interview, and reading through the completed transcripts three times before beginning to code. 48 Openness refers to the transparency of the researcher in describing their research methods and any decision-making processes during the data collection and analysis phases (DeWitt & Ploeg, 2006). As there are multiple truths, transparency provides the reader with an understanding of the subjective influences in the research and their effect on the research results and analysis. Providing the researcher’s personal background and location also increases trustworthiness as it provides context on how the study is conducted (Lincoln, 1995). In adherence to openness, I have provided a report of my process during the data collection and analysis phases and outlined my thought process for the research results and conclusion. Trustworthiness is vital in exploratory research (Stebbins, 2001), and the reporting of results should adhere to balanced integration, referring to the balance between evidence from the data and interpretations by the researcher (De Witt & Ploeg, 2006). As is found in the results section of the research, I used participant ideas and quotes to illustrate and explain the findings. An issue impacting validity is the restrictiveness of language and whether complicated beliefs and experiences can be conveyed accurately through words. To address this, I used my skills as a researcher and a counsellor to ask clarifying and follow-up questions as necessary to facilitate understanding. To maintain credibility and ensure consistency, that the interviews are conducted uniformly, I conducted semi-structured interviews so that participants had the opportunity to answer the same set of questions and maintain a similar level of detail and interview length between participants (Ponterotto, 2005). Additionally, at the beginning of each interview, I read a definition of the key subject terms, shame and complex trauma. This was done to increase the mutual understanding between myself and the participants and to increase consistency between participants. 49 Validity during the analysis phase is concerned with whether the analysis and findings are an accurate representation of the data (Mayan, 2016). Using the multiphasic thematic analysis procedure outlined by Braun and Clarke (2006) facilitated validity as I immersed myself in the data and went back and forth between the themes and the raw data to ensure that they well represented each other. Additionally, I employed the strategy of member checking to verify with the participants whether I had accurately represented their beliefs and opinions within the research. As described in the procedures section, this was done by sharing a copy of the transcript with the participants and describing the themes and sub-themes derived from their interviews. This gave participants the opportunity to provide feedback on whether the data and analysis captured the essence of their beliefs and experiences. Researcher bias is a potential hindrance to trustworthiness, as it is the task of the researcher to conduct the data collection, analysis, and discussion of findings in an accurate way (Creswell & Poth, 2018). A critical component of ensuring trustworthiness is engaging in reflexivity. Reflexivity Within qualitative methodologies, the researcher plays a critical role in all components of data collection and analysis. This is particularly true of constructivist methodologies, where the interaction between researcher and participant is a critical methodological component (Ponterotto, 2005). As such, the researcher’s beliefs, assumptions, and prior experience will inevitably influence the data and the findings. While it is recognized that bias cannot be eliminated from the research, engaging in reflexive practices can minimize its effects within the research (Finlay, 2002). My role as a researcher is to reflect on how my personal beliefs about the subject matter and the findings influence how I conduct interviews and analyses. Through 50 reflective practice, a researcher can position themselves within the study and increase the trustworthiness of the research (Finlay, 2002). Qualitative methodologies acknowledge the inevitability of researcher influence on the project; however, steps can be undertaken to minimize the effects (Finlay, 2002). Within the constructivist paradigm, where the data is uncovered collaboratively, my reflexive capacities affect the relationship with participants and therefore the interview data (Finlay, 2002). Having professional experience as a counsellor and selecting counsellors as research participants, one of my reflective tasks was to challenge any assumptions that the participants and I share the same meanings for language and concepts that will arise during the interview (Finlay, 2002). I facilitated this by defining key concepts at the start of the interview, using reflective statements, and asking follow-up questions to verify my understanding of the participant’s words. To minimize the power imbalance that is often present between researcher and participant (Finlay, 2002), I used my counselling skills to conduct the interview in a way that enhanced reciprocity and emphasized to the participant their role in research and knowledge creation. I also continuously conveyed my gratitude to participants and sent them a gift card as a thank you. Participants will also receive a summary of the research results to see the outcome of their participation. To help me retain reflexivity throughout the research, I used a journal as a tool to record my beliefs, assumptions, and interpretations throughout the research process (Mayan, 2016). Writing helped me bring awareness to any lingering thoughts that were hidden below the surface of my consciousness, which allowed me to recognize my biases and minimize their effect on the research. Additionally, my supervisor reviewed the themes and analysis during the writing process to check for any areas of bias I may have missed. 51 Summary This research study was conducted through a qualitative social constructionist paradigm. It was designed to uncover an understanding of counsellors’ experience treating shame in adult survivors of complex trauma while acknowledging that it represents a reality created by myself and the participants. As this is a relatively understudied area, I employed an exploratory methodology. This facilitated the inductive creation of generalizations upon immersing myself in the data. To carry out the research, I used purposeful sampling methods to recruit practicing counsellors to participate in semi-structured interviews. Their confidentiality and anonymity were of the utmost importance to ensure they felt comfortable in their participation. The data was then transcribed and analyzed using thematic analysis methodology adhering to the six-step process. I examined and coded the data to create categories and broader themes that became my final results. As an instrument of research, my personal location within the study inevitably affected the data and overall results. Measures were taken to increase the trustworthiness and validity of the results and minimize the effect of researcher bias. Some of these measures include keeping a journal during the research process, being transparent during the analysis phase, and engaging in reflexive practices to be aware of my biases. 52 Chapter 4: Findings The following chapter explores the most salient patterns of meaning arising from the seven interviews. Participants’ knowledge and experience were collected to answer the question, how do counsellors perceive and treat shame in adult survivors of complex trauma? Based on the data, three main themes were identified, each containing several sub-themes: the emotional landscape, self-concept, and attachment and the therapeutic relationship. The Emotional Landscape The first theme pertains to the participants’ perceptions of their client’s experience of emotions and how it can be addressed through therapy. It is composed of two subthemes: an intolerable experience, which explores clients’ discomfort in feeling shame, and building capacity for emotion, which describes how participants support their clients in developing the ability to manage feeling shame and other emotions. An Intolerable Experience Feeling Shame. Many participants have found that their clients seem to struggle with emotions. Participant Five noted that clients with complex trauma might have a tough time with emotional expression and regulation, as strong shame can hinder the development of the self, which can lead to shortcomings in “emotional maturity.” One way this was evident for participants was in their clients’ difficulty with being able to label their emotional experiences as shame. Participant One described, “They won’t say shame or they’ll just kind of explain the feeling, but really what it is- what they’re describing is really shame.” She added that clients identified with shame when she did suggest the emotion. Similarly, participant Three has found that clients are less likely to be able to name shame than other emotions. Several participants 53 found that they identified shame in clients by observing their affect and the emotional description of their experience. Participants described feeling shame as an uncomfortable experience. Participant Three has observed that “A lot of my clients report that it is very distressing, very very upsetting, something that’s hard to tolerate.” Other participants described shame as “intolerable,” “painful,” and an “imploding kind of gunky feeling.” The uncomfortable feeling of shame can lead to negative consequences for clients. Participant Six explained that “A lot of behaviour is driven by the shame, its because it's such an intolerable feeling that they would rather do anything else than feel that shame.” She added that anger is often activated to protect the individual from feeling shame. Participant Seven described shame as a “defence track” to avoid other emotions and impulses, particularly those directed at others. Shame and the Nervous System. Many participants conceptualize shame, at least in part, through a Polyvagal lens and pay particular attention to the nervous system. Participant Two views clients with strong shame as being stuck in their survival brain and that shame is the beginning of a freeze response. She explained that “The more dissociation and freeze there is in their system, the more shame there will be,” and that during moments of dissociation clients will “go hide in the middle of their skull.” In the process of working through shame with clients, participant Two added that “as they work with me, they’re less in freeze and they go into fight or flight, which feels worse because they are feeling emotions that have been avoided.” Participant Four has similarly observed clients will shut down during session, and struggle to stay present due to the difficulty in tolerating their current state. Mentioned by several participants was fawning, which is related to dissociation as it numbs individuals to their own needs to align with their abuser and can result in treating others as perfect. Participant Four observed this in session 54 through clients focusing on people-pleasing rather than being present. Participants also recognized difficulties in their clients’ ability to self-regulate. Participant Six explained that clients often have a dysregulated nervous system and have trouble with grounding and selfsoothing. She added that any established coping mechanisms are often harmful to themselves or those around them. Building Capacity As participants identified that shame is an uncomfortable emotion, it may be difficult to address in therapy as clients lack the ability to tolerate the experience. An important aspect of working with shame is increasing the client’s ability to experience and tolerate the feeling of shame so it can be addressed therapeutically. Participants explored various ways they support clients in improving their ability to tolerate the feeling of shame and better learn to self-regulate. Psychoeducation. With the emotional experience of shame established as a distressing issue for clients, participants described how they supported clients in increasing their capacity to tolerate and process shame. Six of the participants mentioned psychoeducation to help clients normalize and conceptualize shame. Psychoeducation topics included the causes and effects of complex trauma, the evolutionary root of shame and its relation to the nervous system, and education about shame more generally. Many participants made it a point to differentiate guilt versus shame with their clients. As participant Five explained, “the way I sort of look at shame versus guilt is when a person thinks they’ve just done some bad, the action was bad, whereas shame is that they think are bad, inherently bad,” and those without complex trauma backgrounds would tend more towards shame than guilt. A common observation by participants was that shame and complex trauma are commonly found together; clients who demonstrated 55 intense shame have complex trauma histories, and clients who have faced complex trauma have more shame than other clients. Experiential Techniques. Participants leaned towards experiential interventions that could be practiced in sessions. Experiential techniques included immediacy, sitting with emotions in the present moment and describing their experience, encouraging the client to identify in the moment when they are feeling shame and express it, and recalling an emotional memory to practice emotional tolerance. While using experiential techniques were preferred, they were used with caution. Participant Two advised against moving too quickly and “pushing them over a cliff,” while participants Six and Seven also cautioned against overwhelming the nervous systems. Somatic techniques were mentioned by several participants, aimed at helping clients identify, tolerate, and process the physical sensation of emotions. This is done by encouraging clients to pay attention to their body sensations and learn to describe the sensation to identify the emotion. As Participant Two explained about somatic processing, Especially at first, I ask people and what’s the body sensation? They’re going to be like lost and I’m going to ask is it in your chest, is it in your stomach is it in your belly so I really set them up for success. I give them a dropbox menu, then they can say maybe it's in my chest, and then I have a sense of what shame feels like because I felt shame before. Building Tolerance. Along with identifying the emotion, participants discussed the importance of building a tolerance for feeling shame before any further processing occurs. Teaching clients to regulate with tools such as DBT skills, breathing and mindfulness tools, and coregulation with the therapist are done in an effort to increase clients’ ability to sit with their emotions and “take the edge off” their experience. Participant Two teaches clients to pay 56 attention to a part of their body where they feel resourced, such as their seat or back, to feel supported and practice regulation. As several participants noted, developing shame tolerance is a practice and takes time to build. Participant Six described the process of tolerating shame: We share it, then the need to hide or pull away sort of decreases and we increase the tolerance to sit with it. So in my approach that’s very important… to not push away shame, not amplify it, not dismiss it but it’s to work with it in a very real and open way with that safety in place. And it’s to do that a little by a little right, you don’t do it all at once, it's much too overwhelming. Participant Two also described learning to tolerate shame as a gradual process: Usually, even with a first pass, there will have been a shift in how they experience shame in the body. And so, then we explore, so how are you experiencing that you know, what’s the difference. And so I think it is also in a way very resourcing for people to notice that even with just a little pass at noticing the shame, the next go round is already a tiny bit different. It's still yucky but not the same yucky as they’ve lived with for 20-30 years. And so we don’t stay there forever because they’ve got how many years of shame in the nervous system. We work a bit on that, and then we move along. Honouring Shame. Participants also cautioned against shaming people for their shame. While this may seem obvious, participants noted several ways that shame could be reinforced in therapy. Participant One explained the importance of “having a neutral presentation” when clients share their trauma: I have so many of my people tell me when I told people about my sexual trauma I can see the look on their face like they’re just surprised or overwhelmed or even disgusted or 57 whatever, whether it's at them, or the person. Their responses are big and they come off as judgemental even if they’re not intending to. Participant Three also noted how insurance companies or other organizations pressure clients to heal quickly, “which is like the theme of shame right like I should be that way I have this expectation that you’re not meeting to be better.” Participants Two and Four both highlighted the need to honour shame and not tell people they shouldn’t feel shame even if it is done with the best intentions, “arguing with people that they shouldn’t have shame is really unhelpful, and I learned a long time ago that arguing with people out of shame does not work” (Four). Participant Two added that trying to tell someone they shouldn’t feel shame reinforces shame and dissociation by initiating a reaction of “Oh I’m not supposed to feel shame right now; I guess I’m going to keep it down.” Self-Concept The second theme explores participants’ observations of their clients’ beliefs, feelings, and conceptualizations of themselves. It includes the identification and consequences of negative personal beliefs and how these beliefs and patterns can be shifted in therapy. This theme consists of three subthemes: defective self, which looks at clients’ negative self-beliefs including selfblame; disguise and conceal, which examines the ways in which clients hide all or parts of themselves; and disrupting the shame cycle, which explores the ways participants shift shame patterns. Defective Self Participants found it important to identify some of the mechanisms that cause shame to be created and perpetuated as part of treating shame. This is to help identify when there is a strong sense of shame and what areas should be targeted in treatment. 58 Self Blame. Several participants noted that it is common for clients to hold themselves responsible for their past traumatic experiences. As participant Five explained, “Well unfortunately adults who were abused as children, sometimes decades ago, they continue to blame themselves for what happened to them, not always but in most cases. And that is a shameinducing psychological process...”. Participant One has seen clients continue to blame themselves for abuse, even after forgiving the perpetrator. Participants Six and Seven also reported that clients blame themselves for their trauma. When speaking about their experiences, participant Seven has observed clients say things such as, “Well you know, they did that because I wasn’t exactly being the greatest kid sometimes, and you know, well, I could have done better...” or that clients are angry with themselves for what happened to them. An individual believing that they were deserving of trauma or pain was, unfortunately, a common experience. Participant Six described clients’ demeanour as “Like they were waiting to get hurt at any second and they also felt like they deserve it.” Participant Five explained clients’ belief that being treated negatively by others was caused by internal faults. adding “they feel it so strongly, viscerally that they feel there should not be any like need for any effort or even acknowledge the abuse because whatever happened to them in life is just because they were bad themselves.” Participant Three found that it can be a challenge to reframe how clients conceptualize past traumatic events: I find many people seem to struggle with the idea that, like their experience felt normal, but it also wasn’t okay. Which makes sense, you’re trying to tell them about the thing that they thought was normal and their experience for a long time maybe needs to be challenged. 59 Through shame and self-blame, participant Seven noted that emotions that should be directed outwards towards those that hurt them are directed inwards, resulting in being angry at oneself. She labelled the experience of deflective blame, negative emotions, and self-critical thoughts as the self-beating chamber. She described this as a place within the individual marked by low selfesteem, low confidence, being hard on yourself, and self-blame. Negative Beliefs. Internalizing blame and other by-products of shame can have negative effects on identity and an individual’s sense of self. Along with listening to what clients say, participants also observed signs of low self-worth or shame in clients’ body language. Participants list a lack of eye contact, poor posture or crouching inward, skin turning pale, or weepy tears as nonverbal cues that can demonstrate negative views of the self. Additional signs mentioned by participants include hearing statements of hopelessness, such as believing they cannot change and that they will be forever stuck in a state of shame. Participants also reported signs of low self-esteem. Participant Six described the experience as “shame whispers and says, or shouts, at that person, yeah like you’re a piece of crap, basically all the time.” While some clients outright state that they have low self-esteem and lack confidence, others make statements about not being good enough, expressing frequent selfdoubt, self-condemnation, self-hatred, or demonstrating patterns of self-critical thinking. Participant Five described it as believing they are inherently bad, which he labelled the “personal experience of badness” affecting the individual on many levels. Participant Six described the experience as “where our being isn’t right, we’re broken, we’re a shitty person.” Participant Three added, “I think when dealing with shame, one of the biggest ones that come up is the sort of like, I am broken, I am defective, I am not enough or I don’t belong, or I shouldn’t exist.” Among other things, this type of negative thinking and feeling about the self can lead to a 60 perceived lack of agency in one’s life, accompanied by the idea of an “ought self” characterized by ways they should think and act differently. Disguise and Conceal Burdened by beliefs of self-condemnation and critical thinking patterns, it is not surprising that almost all participants discussed clients’ tendencies to hide some or all of themselves from others. This is explained as means of self-protection to avoid being hurt or having their shame ignited. Several participants noted their clients’ uncomfortableness in vulnerability and acting as their authentic selves. Participant Two explained the reasoning as, “They’re not comfortable with being seen and being known, because it’s too dangerous.” The danger, in this case, comes from the ability to be hurt or rejected by others. Participant Six conceptualized the susceptibility to pain, “It’s like people walking around with those gaping open wounds all the time.” The result of the discomfort in vulnerability is clients’ guarding themselves against exposure in several ways identified by participants. One is a resistance to discussing shame entirely. Participants identified that in session, this might look like diverting conversations, having nothing to say, minimizing their shame, or denying having feelings about difficult topics. Clients may also hide their authentic selves during session, particularly after being triggered in session, as “no one wants to have their vulnerable parts shown” (Four). Participant Six described her perception of concealing during session, “They are trying to hide those parts of themselves they don’t want other people to see, it's like trying to hide yourself under a blade of grass.” Clients may also conceal their trauma histories or the level of “dysfunction” in their lives. Participant Six described an experience of working with a client whom she had prior knowledge of their situation, which was incongruent with what was being described by the client: 61 The first couple sessions, actually, they’ll tell me that everything is totally fine, that they have everything under control, so there’s- and again I say this very kindly, there’s a façade there. This is done in a bid to protect. An unfortunate consequence of the pull to hide is that those who need it will not ask for support or have a tough time asking for it. Participant Six noted that “A lot of them won’t even ask for help.” Similarly, according to Participant Four’s experience, “It often brings them in too late, or much later than I would like to see them because they are hiding their dysfunction.” The discomfort with vulnerability and the reactionary desire to hide impacted clients’ experience in initiating and participating in mental health treatment. Disrupting the Shame Cycle Challenging Shame. Following participants’ observations of how shame impacts their clients’ sense of self, participants discussed the methods they use to shift shame and a distorted sense of self. One of the first steps identified by participants was challenging them to confront shame. Participant One explained how she approached this, “I never push it, but I also feel like most of them are quite receptive to being challenged on things once there’s a good rapport built.” When clients attempt to divert the conversation to avoid shame, she “calls them out in the nicest way possible” by acknowledging the attempt to divert the conversation and inviting them to stay with the feeling; “they have the option, so they don’t feel on the spot, but they also know that I recognize what they’re doing.” Participant Four encourages shame discussions by asking the client to name the shame out loud when it comes up in session or to acknowledge it in the next session if doing it in the present is too vulnerable. Participant Seven initiates the process of challenging shame by getting on the same page with her clients on how the shame is disrupting 62 their lives and creating the common goal of disrupting the cycle. She will then challenge the shame cycle when it comes up in session: If they’re on board with it then I’m not going to indulge it. So every time I hear it I’m going to try and block them. We’re going to team up and were going to keep that, kind of bluntly, we’re going to keep that shit out of the way. Okay, like I’m not going to respect that part at all. I not going to give it much space at all once they flush it out, we have an agreement that it's really causing suffering for them in their life and their relationships. Normalizing. Participants identified that targeting internalized blame and selfcondemnation were essential parts of healing. Normalizing shame was popular among participants to decrease self-judgement and let them know they were not alone in their struggle and that other people have similar experiences. It also reinforced the idea that current issues caused by shame and trauma were not inherent faults within the individual but were related to the trauma they experienced. Participants normalized the desire to hide and pull away, the pain of talking about shame and trauma, and normalized trauma reactions. Participant Four illustrated normalizing trauma to a client: I try to do some teaching around complex trauma and on how shame relates to complex trauma in a way that has people feel less weird about having symptoms of trauma or feel like they have to hide the symptoms of trauma, that those are normal reactions by a normal person to an abnormal situation and now your brain is doing what it’s supposed to do to keep you safe. And so I try to see some of the things that they’ve always judged themselves for and shame themselves for, I try and reframe those as strengths. Along with normalizing, several participants noted the importance of validating trauma and shame and working with it in a way that honours the individual’s experience. 63 Redirecting Emotions. Part of disrupting the shame cycle is the ability to direct emotions outward rather than internalizing negative feelings and experiences, as is common with shame. This concept was particularly emphasized by participant Seven: For some people it’s like this extraordinary phenomenon to actually have emotions towards other people, because part of the shame system has been directing it all back on them. In particular towards loved ones, it’s all just shooting right back and it’s like a full beating, and they go into the shameful kind of beaten-up deflated kind of depressive symptoms, often self-harming kind of state. She added that clients have to build the capacity to recognize and tolerate the ability to have feelings towards others, stating, “It can initially be like I’m really speaking a foreign language.” In session, clients practice identifying their feelings toward others and explore what emotions are hiding under shame. Multiple participants identified anger as typically following shame, which can be a difficult sensation for clients to tolerate; “to feel experientially in the body, which is no small feat, right, the feeling of anger that’s going to give heat rising the body, towards the loved one.” This is especially true as individuals begin to examine their complex trauma history and redirect emotion outwards to those who hurt them. Diffusing Self-Blame. Part of disrupting the shame cycle is introducing the idea that individuals were not responsible for what happened to them and therefore are not inherently flawed or deserving of bad things. Participant Five labelled this process as improving the personal experience of badness, while Participant Two described the experience as the client receiving redemption. There is a caveat that redemption can only come once the shame has been processed: 64 I bring it to a place where they can see there was nothing else [they] could do, but it goes in the system that point in a very different way. Instead of feeling dismissed, they had a chance to go through some of the shame process. (Two) Participant Two aims to facilitate clients providing their own redemption as it tends to be more effective coming from the self, “Allowing people to metabolize shame, as it happens, they come up with their own ha-ah moments. They come up with their, oh of course that’s what I did, how could I have done any different”. Ideally, clients will come to a place of redemption themselves, but she noted that is not always the case, and she sometimes has to lead the way. One method of achieving this is by encouraging clients to reflect on their age when the trauma began, “I might say, when was the last time you looked at a six-year-old. How can they defend themselves?” (Two). Participant Three provides a sense of redemption by validating the client that what happened to them was horrible and they did not deserve it. As receiving redemption and dissipating self-blame begins to erode the shame cycle, clients may experience a sense of grief and loss upon reflecting on all the ways shame has affected their life and sense of self. Participant Seven has observed that “sometimes we might see some tears that are about pain and grief and sadness of all those years of going off in that direction.” Attachment and the Therapeutic Relationship As shame and complex trauma are closely connected with attachment, each participant discussed the importance of interpersonal connections as part of treatment. This theme pertains to the relational aspect of therapy, including an overview of common attachment issues clients face and various ways interpersonal dynamics play out in the therapeutic alliance. This theme is composed of three sub-themes: interpersonal difficulties, which delves into participants’ observations of how shame affects clients’ relationships; the importance of the therapeutic 65 alliance, which explores some common dynamics in the therapeutic relationship and how the alliance contributes to clients’ treatment; and the person in the professional, which describes participant’s role and experience in the therapeutic relationship. Interpersonal Difficulties Nearly every participant discussed how shame and complex trauma negatively affect their clients’ relationships. Participant Four explained how past trauma could form the template for current relationships as “something really bad happened and them. No one supported them, and no one was there for them, and they couldn’t trust people to be there for them and how that then carries on into all intimate relationships.” Participant Five echoed this idea in that childhood attachment injuries are replayed in adult relationships as romantic partners can act as a substitute for their primary caregivers. Participant One has found that feeling shame in romantic relationships, particularly as it relates to sex, is often the inciting issue that brings people to therapy. In her work as a couple’s therapist, participant Four has found shame to be a major barrier for couples connecting in relationships, “They assign meaning to the other person’s actions relating to that self-assigned meaning that they have to themselves saying that I’m not good enough, and so it interferes with their ability to connect with each other.” She further explained that shame could inhibit a person from showing up authentically in session, “And then you want to hide. Which is really natural I get it. But when you hide, then you can’t be seen and you can’t connect and in this couple relationship that’s going to be an issue.” This not only affects couples’ relationships in general but their ability to repair the relationship in therapy. Participants report that other personal relationships were also affected by shame and complex trauma. Participant Three most frequently notices shame in clients’ familial relationships and their recounting of interactions with family. Participant Seven has found that 66 clients are more likely to cut people out of their lives rather than deal with the pain of being hurt. This is illustrated by participant Six’ observation that clients feel judged or ridiculed more easily in interpersonal interactions from misinterpreting signs such as looking tired or tone of voice. She has also seen that due to clients’ desire for connection, they may be more inclined to share the vulnerable parts of themselves with people who aren’t safe. Similarly, participant Five has found that clients are more likely to be involved in unhealthy relationships, “sometimes being involved in relationships which are sort of deleterious to their mental health and overall wellbeing.” The Therapeutic Alliance As complex trauma and shame are often caused by hurt in relationships, healing also can occur in relationships, including the therapeutic relationship. Many participants emphasized the importance of a solid therapeutic alliance. Participant Five explained this stance, “it's impossible to do any sort of therapy if there is no therapeutic alliance.” Participant Six also emphasized this point, stating, “I think the single most important and long-standing and most powerful intervention is the interpersonal aspects in the relationship that gets built… a safe and trusting boundaried relationship, where you show up for that person consistently”. Participant One similarly said “I would say 80% of them feeling comfortable talking about [shame] is just our rapport and the environment they’re in. It’s not a tactic it’s not CBT, it’s how they feel with the person they’re talking to”. Participant Four demonstrated how a trusting relationship can benefit the client by helping them feel safe, “that they know that I’m not shaming them and that I see them as beautiful and capable and struggling, but not just a hot mess that I’m judging.” Safety. According to participants, cultivating safety so clients feel comfortable and begin to trust is a critical preliminary step in building a therapeutic relationship. Participant Six 67 emphasized that she can only work with shame once there is safety in place, and similarly, participant Four stated, “If they don’t trust me and feel safe with me then we can’t do the work.” Participants reported that their clients are slow to trust, and safety can take longer to build than with other clients. Participant Two normalizes this with new clients by bringing the hesitancy to trust into the open, saying, “I don’t expect you to trust me, that’d be the stupidest thing you could do to trust me,” and that trust is built slowly over time, explaining “I give the time to people to have their nervous system assessing me… so they have the chance to figure me out a bit”. Participant Five has also found that it takes clients a while to feel that they won’t be judged, “they first need that therapeutic alliance and they start, little by little, sharing.” It is in part due to the slow trust and relationship building that many participants report that therapy with this clientele is long-term, often spanning years. Participant Six cautioned that going into deep empathy in the early stages of therapy can feel overwhelming and disingenuous to clients, so safety needs to be built before it can be effective. As part of building a safe relationship, participants also discussed the importance of boundaries. Establishing and maintaining boundaries helps create safety as they outline expectations for the therapeutic relationship. The counsellor can model setting healthy boundaries for the client and re-asserting them as necessary to build relational stability. This includes boundaries around things such as self-disclosure, receiving gifts, contact through phone and email, or contact with the therapist outside of session. Participant Six has found that participants are often unfamiliar with healthy boundaries and that they can seem rejecting. She recommended engaging in conversation with clients about boundaries so they have an idea of what to expect, “I say things like feeling safe with me is really important that doesn’t mean I’m doing to give you everything that you want, right. That’s not safety.” 68 Developing Trust. Although participants discussed the benefits of building a strong therapeutic relationship, it is not necessarily an easy task. Several challenges were brought up, beginning with the client’s unfamiliarity with engaging in a securely attached relationship. Participant Two explained that while it is normal for clients to form an attachment to their therapist, it is challenging to learn to rely on someone else; “The people who actually injured them were the people who were supposed to protect them... So I have to keep in mind the more I know them, the more dangerous I become”. Participant Four also discussed the difficulty of engaging authentically in the therapeutic relationship for fear of being rejected, “The desire to attach is huge, the terror in not feeling that sense of attachment is then equally huge.” Participant Six has found that once a relationship has been established, clients tend to attach very strongly in a way that feels like reparenting as they are engaging in a novel secure form of attachment. Participant Five also noted that due to clients’ relationship history and attachment patterns, there are often strong transferences onto the counsellor that should be addressed in therapy. Another common experience was the perception from clients that they would be judged or rejected. Participant Four explained that clients are especially sensitive to the therapist judging or rejecting them. According to participant Five, because they have been treated poorly by others in the past, they expect the therapist to treat them badly as well. Participant Six perceived this as an “absolute intense vulnerability like they were waiting to get hurt at any second.” She further illustrated, “Say my affect changes, maybe I say something or I look off in the distance, they will take that and that intense shame says, oh they’re not listening to me they don’t like me.” To address this issue, she encourages clients to discuss their perceived judgements and emotions in session, with boundaries. Another way to help clients feel more comfortable in session is to minimize the power imbalance between therapist and client. Participants mentioned several 69 methods for this, including sitting on the floor during session, using self-disclosure and counsellor vulnerability, not assigning homework, and swearing or using casual language not to seem overly formal. Several participants mentioned that it is a common experience for clients to end therapy prematurely or visit several counsellors for only a few sessions each. They identified potential reasons for this as feeling judged, having discomfort with vulnerability, being challenged in therapy, or getting triggered. Participant Four has found that while sometimes clients will say something when they are upset with her during session, other times they will not return to therapy. Participant Five encourages clients to disclose if they begin to feel this way in session: If you ever feel that you want to end your therapy say because I am judging you please do share it with me, because we can address it… if you ever feel I’m judging, because I should not be judging you, please just tell me, we can talk about it. Participant Two is also familiar with this experience; “There’s a group that will want to fire me on a regular basis because they’re not comfortable with being seen.” She addresses this with clients by naming it out loud and explaining that the desire to end therapy is a normal reaction and a flight or fight response, which seems to resonate with her clients; Yet every time I have addressed it with people, people have stayed in my practice. And then later down the road they’re like oh my god do you remember when I wanted to fire you every two sessions, I’m like oh my god I do. The Person in the Professional Personal Vulnerability. A common topic amongst participants was how therapists utilize themselves as a tool during therapy and the responsibilities of doing so. Participants Two and One noted how their humanness and ability to connect with their clients were one of their 70 greatest strengths. One of the ways they convey humanness to their clients and build connections is through personal vulnerability and increased self-disclosure. Participant Two explained, “Working with complex trauma with developmental trauma, I give more of who I am, I selfdisclose more with people.” She further illustrated the benefit for clients: They have to have a sense of who I am as a person… If I try to play therapist we don’t get much done. If we shoot the shit and I’m a person, there’s a lot of work that gets done. Participant One described that “Vulnerability is just letting them see your human side” which can be conveyed by telling clients about her weekend plans, having an authentic reaction when she stubs her toe, or showing emotion in session. Self-disclosure is often discouraged for counsellors; as participant One said, “those are the little things that I felt like we were always told not to talk about,” but has found the approach very effective for her in helping people feel comfortable to open up. She further explained: I kind of prep myself every day to go into my sessions knowing that the people that are going to be sitting across from me are going to be really uncomfortable and they are going to feel a lot of shame, and the best thing I can do is that I explained earlier, is just be human right from the get-go. Participant Two also found that sharing more of herself with clients encourages them to be more vulnerable in session, “I’m not perfect, I’m not-I don’t have it. I have shit happening in my life. And I’m an ongoing project, just like them… so if we’re allowed to fall apart, it normalizes”. Sensing Shame. Participants also discussed how their nervous system plays a role in therapy; as participant Two put it, “My best tool is my own nervous system.” By being attuned to their nervous system, participants use themselves as an instrument to evaluate clients during session. Participant Two described how she could pick up shame in her nervous system before 71 recognizing it in the client, as her nervous system resonates with the client. Participant Three shared a similar experience, “I experience like a sensation of shame sometimes like a reflective sensation of it from clients… I can sort of like mirror that experience”. Several participants discussed how they could feel shame in the room with clients. As participant Four explained, The way I pick it up is kind of just by like the energy in the room, like the pullback that you can feel and the withdrawal, which is sometimes not even something you can see, you can just sense. Other participants described the sensation as “Almost like a heavy force at play in the person and in the room” (Seven) and that “it was palpable at all times, it felt like it almost radiated off of them” (Six). Self-Work. In response to using themselves as an instrument in therapy, several participants highlighted the importance of reflexivity, self-awareness, and self-work. The therapist must be able to discern if what they are feeling is in response to the client or their personal reactions affecting their work, “Nobody really likes working with shame. Because when my client goes into shame my nervous system resonates with their nervous system, and I feel my own shame coming up” (Two). She further illustrated: I know that I’m going to feel the shame that I haven’t processed in my nervous system and I need to know what’s mine, what’s theirs, and I need to be able to tolerate my own experience of shame so I can address their own experience of shame. Participant Six explained the importance of being able to separate personal from professional reactions in order to serve the clients’ best interests, “Because their stories their patterns, it will tug at your heart, it will get under your skin. And you need to be aware of how you’re responding”. Participant One similarly stated, “I make a point to leave all my stuff at the door.” 72 Participant Four also discussed the importance of self-awareness in session, “I’ve done therapy for enough years that I’m actually pretty good at not going into shame because I can recognize when I don’t, and I can stay present and grounded.” Four of the participants mentioned their personal experience in therapy as a client, and that it is critical for being a good therapist. Participant Two believes that this is ethically necessary and advised, “Do your own work, so as a therapist you can tolerate the discomfort of your own shame when you’re working with people.” Functioning as the instrument of therapy, participants noted that the work can be intense but also rewarding. Participant Six said that some days, “I would come out of session and just feel like I had been trying to hold on to like a giant ball of energy,” but that she has also seen clients grow and really change their lives. Participant Four added, “It’s hard but beautiful when you get progress… The work that couples do around shame and complex trauma means that the next generation is going to have a different relationship with themselves and their partner”. Summary This chapter explored the findings gathered from participant interviews to answer the research question, how do counsellors perceive and treat shame in adult survivors of complex trauma? Three themes were identified in the data, each containing sub-themes. The first theme, the emotional landscape, explored participants’ observations of the relationship between shame and emotions and how it is addressed in therapy. It contains two sub-themes: an intolerable experience and building capacity. The second theme, self-concept, looked at the beliefs clients hold about themselves and how they can be addressed in therapy. This theme is comprised of three sub-themes, defective self, disguise and conceal, and disrupting the shame cycle. The final theme, attachment and the therapeutic relationship, highlights the interpersonal aspect of therapy, 73 including the challenges faced by clients and the therapists' experiences. It has three sub-themes, interpersonal difficulties, therapeutic alliance, and the person in the professional. 74 Chapter 5: Discussion The final chapter will discuss the findings of this study and explore how these research results compare to existing literature. It will also highlight the limitations of the study, possible areas for future research, implications of the findings, knowledge mobilization, and end with reflections on my journey as a researcher. Discussion An experience shared by all participants is that a history of complex trauma almost always accompanies intense shame. Through the culmination of the interviews, participants explored the main areas that are most salient during the treatment of shame in survivors of complex trauma. Broadly, these are the areas of emotion, self-concept, and attachment, which correspond to the main themes. Along with identifying posttraumatic symptoms in these areas, participants provided insight into the goals for treatment and gave examples of relevant approaches and interventions. Consistent among all methods of treatment was the warning to work slowly. Participants cautioned against moving too quickly when working on emotion regulation, during exposure to shame-inducing thoughts and memories, and while building safety in the therapeutic relationship. As clients have lived with shame for years or decades, the process of healing involves dismantling firmly engrained patterns that, if not done with great care, can overwhelm the individual. This is part of the reasoning behind therapy being long-term and involving close collaboration between the counsellor and client. The first theme, the emotional landscape, discussed the emotional toll of shame. Participants identified shame as a very uncomfortable emotion that clients have difficulty identifying, experiencing, and regulating. Shame can also impede other emotions by blocking the expression of feelings, or using anger to protect themselves from feeling shame, which is 75 consistent with findings that complex trauma can cause difficulties in emotion and affect regulation (Courtois et al., 2009; Herman, 1992; Wilson et al., 2006). Participants offered several suggestions for improving self-regulation. The first tool was psychoeducation, which normalizes clients' experiences and reduces shame while providing information and skills (Buckley, 2014; Jackson et al., 2009). Participants list trauma, shame, and posttraumatic reactions as common topics of education. Participants commonly used experiential techniques to practice emotional processing and regulation in session, which has been found to be an effective approach (Follette et al., 2009). In general, processing shame gradually in small stages was found to be beneficial. Participants’ accounts of working with emotions and regulation are reminiscent of the first phase of the tri-phasic model for trauma treatment with the aim of safety and stabilization, which includes psychoeducation, skill-building, and increasing emotional stability and the capacity to self-regulate (Courtois, 2008; Courtois & Ford, 2009). It also follows logic that building the capacity to feel shame and regulate emotions be done in earlier stages of therapy before moving to later phases, which often incite uncomfortable emotions and memories. The second theme was concerned with clients' beliefs and identity. It discussed participants’ knowledge and observations of the ways clients think and feel about themselves and how that can show up in therapy. A prominent mechanism for developing and internalizing negative beliefs, self-blame was a common topic of conversation. Children who have been through trauma organize their world in a way that results in the belief that they are flawed and deserving of abuse (Courtois & Ford, 2013). This can impact an individual’s view of self into adulthood, lead to beliefs that they are bad or flawed (Courtois & Ford, 2013; Toth & Cicchetti, 1996), and be highly self-critical (Harman & Lee, 2010). Participants made observations of their clients believing they were defective, having low self-esteem, self-critical thinking, or feeling 76 self-hatred. They also reported clients hiding parts of themselves due to low self-worth and to protect themselves from feeling shame. Participants described mechanisms of concealment, being afraid of vulnerability and authenticity, and appearing generally guarded. Hiding entirely from others or splitting off the undesirable parts of themselves are common reactions to shame (Ferguson et al., 1999; Kauffman, 1992). Participants noted that aligning with the client to work on shame is an important first step in treating this issue. They discuss the importance of normalizing shame and trauma reactions and externalizing symptoms to minimize clients’ belief that they are inherently flawed. Learning to direct emotions outwards rather than inwards and have feelings towards others was also identified by participants as a way to disrupt shame. This is especially true of anger being reflected onto the self or others, which has been labelled as shame rage (Lewis, 1971; Tangney et al., 1992). Once the idea of having feelings towards others is introduced, clients can begin to redirect blame for their trauma. This does not necessarily involve moving blame onto another but instead feeling personal redemption and developing a more positive view of themselves. Courtois and Ford (2013) have also emphasized self-concept and self-integration as important areas for treatment. The challenges and tasks under this theme are similar to phase two of trauma treatment, which focuses on trauma processing and gradual exposure to reduce the effect of trauma memories. The final theme explores client relational difficulties and how attachment issues can be addressed in the therapeutic alliance. It delves into participants’ understanding of how shame and complex trauma affect interpersonal interactions and relationships. Complex trauma has been found to impact an individual’s sense of worth in relationships and lead to distortions about the motivations of others (Pearlman, 2003). Common internalized beliefs include that no one is trustworthy, believing they deserve to be mistreated and feeling disconnected from others 77 (Lyons-Ruth & Jacobvitz, 1999). Participants had similar findings on the effects of early relational trauma as established patterns are brought into current relationships. Previously identified negative beliefs, such as believing they are deserving of being hurt, resistance to vulnerability, and the desire to hide, contribute to interpersonal difficulties. Participants have found that clients have difficulty being authentic in relationships as a means of self-protection, inhibiting their ability to connect with others. Additional observations include increased sensitivity to being hurt, assuming judgement, and engaging in relationships with unsafe people. A consistent and stable interpersonal relationship and creating a supportive environment were found to be the most important elements for treatment. Courtois and Ford (2013) have found that most healing occurs through the therapeutic relationship, echoed by Kinsler (2009), who described it as the main tool of change as it is often the client’s first experience in a secure relationship. It can also serve as a safe space for self-exploration and relational healing (Pearlman & Courtois, 2005). While a critical component of therapy, building relationships with survivors of complex trauma may be challenging (Courtois, 2008) and safety is needed before clients begin discussing shame (Talbot, 1996). Among important relational tasks mentioned by participants, building safety was particularly important. This can be a lengthy task as clients can be slow to trust and may not feel comfortable relying on another person. Especially in the beginning, clients have misinterpreted signals from participants and perceived judgement; it has been found to be relatively common for clients to be suspicious of therapists (Chu, 1992) or distrust them completely (Courtois & Ford, 2013). In part due to this tendency, participants noted that this clientele might only attend a few sessions before ending therapy; they recommend discussing the urge to end counselling and feelings towards their counsellor so they can be dealt with before treatment is ended prematurely. Finally, as participants attribute the primary 78 mechanism of healing to the therapeutic relationship, it makes sense that their best tool is themselves. Participants discuss several ways their personhood comes into play and how that can affect the therapeutic relationship and therapy in general. As co-regulation is a key task for therapists (Courtois, 2008), they may become more perceptive of clients’ states as they attune to their nervous system. With so much of themselves involved in the therapeutic process, participants were passionate about the importance of reflexivity and personal therapy. This position is shared by Pearlman and Courtois (2005), who emphasized the need for therapist integrity, reliability, self-monitoring, supportive connections, and self-care for successful therapeutic relationships. Chu (1992) acknowledges that working with this population can be draining and recommends that therapists have their own personal support. Existing Literature As demonstrated, the existing literature is congruent with the findings from the current research. Participants’ descriptions of their clients’ concerns were consistent with symptoms of shame and complex trauma identified in the literature. Many treatment tasks discussed by participants were also mentioned in prior research as key areas for treatment. The order and tasks for treatment were parallel to phases one and two of the tri-phasic model for trauma treatment (Courtois & Ford, 2009). However, a discussion of the third phase was largely absent from the participants’ interviews. Goals in the third phase include self-exploration, establishing new patterns, and applying lessons from therapy to their current life (Courtois & Ford, 2009). Making small changes in their lives can lead clients to feel empowered and develop an increased sense of agency and positive self-concept (Van Vliet, 2009). While participants talked about identifying and disrupting shame, there was minimal discussion about how clients improve deficits left by shame or how they could integrate newly developed non-shaming patterns into their lives. 79 The findings also diverge from existing literature in that discussions about the cognitive aspects of shame were largely absent from participant interviews. Research has found that certain cognitive processes, particularly attribution styles, are a major component in the development and maintenance of shame (Feiring et al., 2002; Lewis, 1971). While a few participants mentioned the importance of reducing self-blame for the trauma events and posttraumatic reactions, they did not discuss more general tendencies for attributing negative events to character flaws or the cognitive processes involved in developing destructive internal beliefs. Cognitive interventions were also absent from discussions of treating shame. Many established theories of treating complex trauma include a cognitive component, such as cognitive processing therapy, transactional analysis theory, and compassionate mind training. When exploring treatment practices, participants did not discuss using cognitive approaches or interventions to treat shame. Further research is needed to learn more about whether the omittance of cognitive practices is unique to this sample or whether practicing counsellors are moving away from cognitive interventions. The findings from this research reinforce the notion that a solid therapeutic alliance is critical for treating shame in complex trauma. While existing research does highlight the importance of the therapeutic relationship (Courtois & Ford, 2013; Kinsler, 2009), these findings emphasize that a solid relationship is one of the most critical conditions for treatment and is necessary for healing. This research also expands our understanding of the therapists’ personal reflections on the therapeutic relationship. An interesting finding is the degree to which participants’ personal selves are involved in the therapeutic relationship. Two participants, in particular, found that sharing personal details of their lives increased safety and helped to strengthen the relationship. While there is controversy in the field on the use of self-disclosure 80 with clients (Hanson, 2005), it has been used by participants as a tool to build rapport and normalize mental health issues. A common element of building a therapeutic relationship is the therapist’s nervous system attuning to their client (Geller & Porges, 2014). The current findings expand upon this by highlighting the therapists’ experience in attuning to shame. Participants described perceiving shame in their nervous systems in response to their clients and how that can bring feelings of discomfort. Participants encouraged reflexivity and personal therapy to minimize how their internal reactions affect the work with their clients. Limitations There are several limitations to the present study. As all participants were currently working in private practice, their clientele is limited to those who can afford the higher costs of counselling or have steady employment and access to insurance benefits. Interviewing counsellors working in low-barrier counselling may have offered a different perspective on working with clients with shame and complex trauma. There are also limitations to using an exploratory research design. While it is beneficial for gathering information about a topic in which not much is known, the broad, open-ended questions can provide research challenges. The interview questions allowed participants to discuss what was most salient to them; however, it also led to varying interpretations of the questions. This yielded a wide array of answers from participants that provided challenges for direct comparison of responses. Additionally, I inevitably affected the research results through my role as the researcher and as someone with experience in counselling. Researcher influence is an established phenomenon in qualitative research and is not necessarily a detriment (Ponterotto, 2005). Though I took measures to reduce researcher influence, such as using a reflective journal, my presence certainly had an effect on participants’ answers. 81 Future Research The current research was conducted using exploratory analysis, which aims to use inductive reasoning to learn about a topic in which not much is known (Stebbins, 2001). The interview questions posed to participants were broad and left room for some interpretation; therefore, it was challenging to compare participants’ answers directly. The findings from this study can be used as a starting point to develop more specified research questions, such as a more in-depth look at using somatic techniques in session or focusing on how attachment issues and shame affect the therapeutic relationship. Information can be gathered not only based on the findings from participant interviews but also on the lack of findings from interviews. While the themes did touch upon therapeutic interventions, such as somatic techniques and experiential interventions, there lacked consensus about specific approaches or theories. While many participants did discuss their theoretical orientation, there was a lack of consistency amongst participants whose answers often contradicted each other. For example, one participant practiced EMDR as their primary method of therapeutic intervention in contrast to two other participants who found EMDR too flooding for clients and no longer practiced it. Participants used a long list of theories and approaches, including acceptance commitment therapy, Gestalt, internal family systems, dialectical behaviour therapy, psychoanalysis, and intensive short-term dynamic psychotherapy. While researching theoretical orientations was too narrow for the scope of the current research, there is an opportunity for future research to look specifically at theoretical orientations, how they are implemented to treat shame, and their perceived efficacy. This research could hold the potential to demonstrate how to treat shame using specific techniques and theories. 82 Implications for Practice The findings and discussion sections contain participants’ knowledge and experience in treating shame in survivors of complex trauma. From describing signs to identify clients’ shame to highlighting what areas to target in therapy and examples of techniques, the information provided by participants may be helpful to counsellors in their practice. Additional findings from this research mirror guidance from prior researchers and practitioners on the importance of selfwork for therapists. Participants report putting a lot of themselves into therapy with their clients through building a relationship, feeling their shame, and working with them over a long period. Practices such as clinical supervision, personal therapy, and a self-care routine are beneficial not only to the counsellor but also to their clients. From the client’s perspective, there are many barriers to beginning therapy. The long-term commitment and high cost, the pain of feeling shame and the urge to hide, and discomfort with vulnerability and trusting others serve as deterrents for seeking treatment. Armed with this knowledge, practitioners can implement practices to reduce shame and barriers to beginning treatment, such as leniency for missed appointments or sliding-scale fee structures. On a larger scale, these findings reinforce the need for more community mental health services that are free and low-barrier so all those who need can receive mental health support regardless of finances or ability. Knowledge Mobilization The findings from this study will be shared through several channels. It will be added to the UNBC Thesis collection, and the Theses Canada database hosted by Library and Archives Canada. I will also upload the research to my profile on the website ResearchGate which is accessible to everyone. Distribution through the various online channels will ensure that the findings will be easily accessible and open to anyone. Additionally, a summary of the research 83 findings will be shared with all seven participants who opted to receive a copy of the results. I will also share a copy of the results summary on the ResearchGate website. Sharing the summary online will make the research findings more accessible to casual readers. In distributing the research through various avenues, I hope that those looking to learn more about treating shame in adult survivors of complex trauma will come across this research. Conclusion My experience as a new researcher was exciting, excruciating, and inspiring. While my motivation for long writing sessions and meeting self-imposed deadlines often waivered, my passion for the topic never did. As life got in the way of a streamlined thesis, this research lived in my mind for several years as I collected information and ideas to carry out the project. When I would lose steam, speaking to others about these topics often reignited my motivation and helped propel me to the next steps as I received validation that this was an important area for research. This was especially true of participants who amazed me by reaching out to a stranger to have an hour-long conversation about treating shame. These conversations were my favourite part of the research process. Participants inspired me with their passion for their clients and knowledge of shame and complex trauma. After each interview, I would reflect not only on how the conversation pertained to the research, but also on how I could implement what I learned into my therapeutic practice. The research turned another corner for me when I began analyzing and seeing patterns in the data. That is when I felt like a real researcher, that the participants and I created meaning and uncovered patterns that others could now observe. The completion of this research also brought personal growth and reflection. I wanted my thesis to be great, so I strived to be the textbook unbiased professional researcher. This quickly became a lesson in acceptance as I affected participant interviews with my paraphrasing and 84 made difficult decisions about how to theme tricky codes. Having put so much of myself into this study, I am inevitably tangled with the process and become part of the research. I began to understand that this is not a detriment, as being a “good” researcher does not mean being completely neutral, but that drawing upon personal experience, strengths, and abilities in an open and reflexive way adds a unique perspective to the study. This lesson also applies to my professional life as a counsellor, where I often feel the need to choose the best interventions and maintain a neutral composure. Hearing so many participants discuss the importance of relationship over technique and the effectiveness of integrating themselves into the therapeutic process was validating. Through completing this thesis, I learned the value of letting go of the idea of being the consummate professional and allowing more of myself into my work. Though it was a difficult road from conception to completion, this thesis was incredibly challenging and rewarding and permanently instilled a passion for research and treating shame and complex trauma. Shame can have a detrimental effect on people’s lives, and it takes great courage and strength to begin to heal. Those of us who are honoured to support clients on their journey through shame should be armed with the knowledge to facilitate the experience. It will certainly not be easy, but maybe we can make it easier. Although there are many questions left to be answered, hopefully, this research will facilitate conversations about treatment and shame with the goal of improving client care. The participants who shared their expertise provided insight into the ways that counsellors treat and perceive shame in survivors of complex trauma, creating a base that future practitioners and researchers can build upon. 85 References Adams, S. A. (2008). Using transactional analysis and mental imagery to help shame‐based identity adults make peace with their past. Adultspan Journal, 7(1), 2-12. https://doi.org/10.1002/j.2161-0029.2008.tb00038.x American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi-org.ezproxy.frederick.edu/10.1176/appi.books.9780890425596 Andrews, B., & Hunter, E. (1997). Shame, early abuse, and course of depression in a clinical sample: A preliminary study. Cognition and Emotion, 11(4), 373-381. https://doi.org/10.1080/026999397379845 Andrews, B., Qian, M., & Valentine, J. D. (2002). Predicting depressive symptoms with a new measure of shame: The experience of shame scale. British Journal of Clinical Psychology, 41(1), 29-42. https://doi.org/10.1348/014466502163778 Avrahami, D. (2005). Visual art therapy's unique contribution in the treatment of post-traumatic stress disorders. Journal of Trauma & Dissociation, 6(4), 5-38. https://doi.org/10.1300/J229v06n04_02 Barrett, K. C. (1995). A functionalist approach to shame and guilt development. In J. P. Tangney & K. W. Fischer (Eds.), Self-conscious emotions: The psychology of shame, guilt, embarrassment, and pride (pp. 25–63). Guilford Press. Bailey, S. (2007). Art as an initial approach to the treatment of sexual trauma. In Brooke, S. L. (Ed.), The use of the creative therapies with sexual abuse survivors (pp. 59-72). Charles C Thomas Publisher. 86 Barrett, K. C., Zahn-Waxler, C., & Cole, P. M. (1993). Avoiders vs. Amenders: Implications for the investigation of guilt and shame during Toddlerhood? Cognition and Emotion, 7(6), 481–505. https://doi.org/10.1080/02699939308409201 Basham, K., & Miehls, D. (2004). Transforming the legacy: Couple therapy with survivors of childhood trauma. Columbia University Press. Blum, A. (2008). Shame and guilt, misconceptions and controversies: A critical review of the literature. Traumatology, 14(3), 91-102. https://doi.org/10.1177/1534765608321070 Bowlby, J. (1973). Attachment and loss: Separation anxiety and anger (Vol. 2). Penguin Books. Briere, J., Kaltman, S., & Green, B. L. (2008). Accumulated childhood trauma and symptom complexity. Journal of Traumatic Stress, 21(2), 223-226. https://doi.org/10.1002/jts.20317 Bradshaw, J. (1988). Healing the shame that binds you. Health Communications. Bradshaw, J. (1995). Family secrets: The path to self-acceptance and reunion. Bantam Books. Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77-101. https://doi.org/10.1191/1478088706qp063oa Buckley, D. B. (2014). Exploration of the changing relationship with shame and guilt for survivors of complex trauma whilst accessing therapy: A research portfolio. The University of Edinburgh. Canadian Counselling and Psychotherapy Association (2020). Code of Ethics. https://www.ccpa-accp.ca/2020-code-of-ethics/ Carlson, V., Cicchetti, D., Barnett, D., & Braunwald, K. (1989). Disorganized/disoriented attachment relationships in maltreated infants. Developmental Psychology, 25(4), 525– 531. https://doi.org/10.1037/0012-1649.25.4.525 87 Chapman, D. P., Whitfield, C. L., Felitti, V. J., Dube, S. R., Edwards, V. J., & Anda, R. F. (2004). Adverse childhood experiences and the risk of depressive disorders in adulthood. Journal of Affective Disorders, 82(2), 217-225. https://doi.org/10.1016/j.jad.2003.12.013 Chorpita, B. F., & Barlow, D. H. (1998). The development of anxiety: The role of control in the early environment. Psychological Bulletin, 124(1), 3-21. https://doi.org/10.1037/0033-2909.124.1.3 Chouliara, Z., Karatzias, T., & Gullone, A. (2014). Recovering from childhood sexual abuse: A theoretical framework for practice and research. Journal of Psychiatric and Mental Health Nursing, 21(1), 69-78. https://doi.org/10.1111/jpm.12048 Chu J. A. (1992). The therapeutic roller coaster: Dilemmas in the treatment of childhood abuse survivors. The Journal of psychotherapy practice and research, 1(4), 351–370. Claesson, K., & Sohlberg, S. (2002). Internalized shame and early interactions characterized by indifference, abandonment and rejection: Replicated findings. Clinical Psychology and Psychotherapy, 9(4), 277-284. https://doi.org/10.1002/cpp.331 Cloitre, M., Koenen, K. C., Cohen, L. R., & Han, H. (2002). Skills training in affective and interpersonal regulation followed by exposure: A phase-based treatment for PTSD related to childhood abuse. Journal of Consulting and Clinical Psychology, 70(5), 1067-1074. https://doi.org/10.1037/0022-006X.70.5.1067 Cloitre, M., Stolbach, B. C., Herman, J. L., Kolk, B. v. d., Pynoos, R., Wang, J., & Petkova, E. (2009). A developmental approach to complex PTSD: Childhood and adult cumulative trauma as predictors of symptom complexity. Journal of Traumatic Stress, 22(5), 399408. https://doi.org/10.1002/jts.20444 88 Cloitre, M., Stovall-McClough, K. C., Miranda, R., & Chemtob, C. M. (2004). Therapeutic alliance, negative mood regulation, and treatment outcome in child abuse-related posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 72(3), 411416. https://doi.org/10.1037/0022-006X.72.3.411 Cook, A., Spinazzola, J., Ford, J., Lanktree, C., Blaustein, M., Cloitre, M., DeRosa, R., Hubbard, R., Kagan, R., Liautaud, J., Mallah, K., Olafson, E., van der Kolk., B (2005). Complex trauma in children and adolescents. Psychiatric Annals, 35(5), 390-398. https://doi.org/10.3928/00485713-20050501-05 Courtois, C. (1979). The incest experience and its aftermath. Victimology: An International Journal, 4, 337–347. Courtois, C. A. (2004). Complex trauma, complex reactions: Assessment and treatment. Psychotherapy (Chicago, Ill.), 41(4), 412-425. https://doi.org/10.1037/00333204.41.4.412 Courtois, C. A. (2008). Complex trauma, complex reactions: Assessment and treatment. Psychological Trauma, 5(1), 86-100. https://doi.org/10.1037/1942-9681.S.1.86 Courtois, C.A., &. Ford, J.D (2009). Treating complex traumatic stress disorders: An evidence based guide. Guilford Press. Courtois, C. A., & Ford, J. D. (2013). Treatment of complex trauma: A sequenced, relationshipbased approach. Guilford Press. Courtois, C.A., Ford., J.D., & Cloitre, M. (2009). Best Practices in Psychotherapy for Adults. In C.A. Courtois, & J.D. Ford. (Eds.), Treating Complex Traumatic Stress Disorders: An Evidence-Based Guide (pp 82-103). Guilford Press. 89 Creswell, J. W., & Poth, C. N. (2018). Qualitative inquiry & research design: Choosing among five approaches (4th ed.). Sage. D'Andrea, W., Ford, J., Stolbach, B., Spinazzola, J., & van der Kolk, Bessel A. (2012). Understanding interpersonal trauma in children: Why we need a developmentally appropriate trauma diagnosis. American Journal of Orthopsychiatry, 82(2), 187200. https://doi.org/10.1111/j.1939-0025.2012.01154.x De Witt, L., & Ploeg, J. (2006). Critical appraisal of rigour in interpretive phenomenological nursing research. Journal of Advanced Nursing, 55(2), 215-229. https://doi.org/10.1111/j.1365-2648.2006.03898.x Dorahy, M. J. (2010). The impact of dissociation, shame, and guilt on interpersonal relationships in chronically traumatized individuals: A pilot study. Journal of Traumatic Stress, 23(5), 653-656. https://doi.org/10.1002/jts.20564 Dorahy, M. J., & Clearwater, K. (2012). Shame and guilt in men exposed to childhood sexual abuse: A qualitative investigation. Journal of Child Sexual Abuse, 21(2), 155-175. https://doi.org/10.1080/10538712.2012.659803 Draghi-Lorenz, R., Reddy, V., & Costall, A. (2001). Rethinking the Development of “Nonbasic” Emotions: A Critical Review of Existing Theories. Developmental Review, 21(3), 263– 304. https://doi.org/10.1006/drev.2000.0524 Elison, J., Lennon, R., & Pulos, S. (2006). Investigating the compass of shame: The development of the compass of shame scale. Social Behavior and Personality, 34(3), 221-238. https://doi.org/10.2224/sbp.2006.34.3.221 Erikson, E. H. (1950). Childhood and society. W.W. Norton. 90 Feiring, C., & Taska, L. S. (2005). The persistence of shame following sexual abuse: A longitudinal look at risk and recovery. Child Maltreatment, 10(4), 337-349. https://doi.org/10.1177/1077559505276686 Feiring, C., Taska, L., & Lewis, M. (1996). A process model for understanding adaptation to sexual abuse: The role of shame in defining stigmatization. Child Abuse & Neglect, 20(8), 767-782. https://doi.org/10.1016/0145-2134(96)00064-6 Feiring, C., Taska, L., & Lewis, M. (2002). Adjustment following sexual abuse discovery: The role of shame and attributional style. Developmental Psychology, 38(1), 79-92. https://doi.org/10.1037/0012-1649.38.1.79 Ferguson, T. J., & Stegge, H. (1995). Emotional states and traits in children: The case of guilt and shame. In J. P. Tangney & K. W. Fischer (Eds.), Self-conscious emotions: The psychology of shame, guilt, embarrassment, and pride (pp. 174–197). Guilford Press. Ferguson, T. J., Stegge, H., Miller, E. R., & Olsen, M. E. (1999). Guilt, shame, and symptoms in children. Developmental Psychology, 35(2), 347-357. https://doi.org/10.1037/0012-1649.35.2.347 Finlay, L. (2002). “Outing” the researcher: The provenance, process, and practice of reflexivity. Qualitative Health Research, 12(4), 531-54. https://doi.org/10.1177/104973202129120052 Follette, V. M., Iverson, K. M., Ford., J.D. (2009). Contextual behaviour trauma therapy. In C.A. Courtois, & J.D Ford. (Eds.), Treating complex traumatic stress disorders: An Evidence-based guide (pp. 264-285). Guilford Press. 91 Ford, J. D. (2012). Enhancing affect regulation in psychotherapy with complex trauma survivors. In D. Murphy, S. Joseph, & B. Harris (Eds.), Trauma, recovery, and the therapeutic relationship (pp. 58-77). Oxford University Press. Ford, J. D., Stockton, P., Kaltman, S., & Green, B. L. (2006). Disorders of extreme stress (DESNOS) symptoms are associated with type and severity of interpersonal trauma exposure in a sample of healthy young women. Journal of Interpersonal Violence, 21(11), 1399-1416. https://doi.org/10.1177/0886260506292992 Freud, S. (1959). The Ego and the Id. In J. Strachey (Ed. & Trans.), The complete psychological works of Sigmund Freud (Vol. 19) (pp. 3-66). Hogarth Press. (Original work published 1923). Geller, S. M., & Porges, S. W. (2014). Therapeutic presence: Neurophysiological mechanisms mediating feeling safe in therapeutic relationships. Journal of Psychotherapy Integration, 24(3), 178-192. https://doi.org/10.1037/a0037511 Gilbert, P. (1997). The evolution of social attractiveness and its role in shame, humiliation, guilt and therapy. British Journal of Medical Psychology, 70(2), 113-147. https://doi.org/10.1111/j.2044-8341.1997.tb01893.x Gilbert, P. (2000). Social mentalities: Internal ‘social’ conflicts and the role of inner warmth and compassion in cognitive therapy. In P. Gilbert, & K.G. Bailey (Eds.), Genes on the couch: Explorations in evolutionary psychotherapy (pp. 118–150). Brunner-Routledge. Gilbert, P., Allan, S., & Goss, K. (1996). Parental representations, shame, interpersonal problems, and vulnerability to psychopathology. Clinical Psychology and Psychotherapy, 3(1), 23-34. https://doi.org/10.1002/(SICI)1099-0879(199603)3:1<23::AID-CPP66>3.0.CO;2-O 92 Gilbert, P., Clarke, M., Hempel, S., Miles, J. N. V., & Irons, C. (2004). Criticizing and reassuring oneself: An exploration of forms, styles and reasons in female students. British Journal of Clinical Psychology, 43(1), 31-50. https://doi.org/10.1348/014466504772812959 Gilbert, P. Irons, C. (2005). Focused therapies and compassionate mind training for shame and self‐attacking. In P. Gilbert (Ed.), Compassion: Conceptualisation, research, and use in psychotherapy (pp. 263– 325). Routledge. https://doi.org/10.4324/9780203003459-15 Gilbert, P., & McGuire, M. (1998). Shame, status and social roles. The psychobiological continuum from monkey to human. In P. Gilbert, & B. Andrews (Eds.), Shame: Interpersonal behaviour, psychopathology and culture (pp. 99–125). Oxford University Press. Gilbert, P., & Miles, J. N. V. (2000). Sensitivity to social put-down: It's relationship to perceptions of social rank, shame, social anxiety, depression, anger and self-other blame. Personality and Individual Differences, 29(4), 757-774. https://doi.org/10.1016/S01918869(99)00230-5 Gilbert, P., Pehl, J., & Allan, S. (1994). The phenomenology of shame and guilt: An empirical investigation. British Journal of Medical Psychology, 67(1), 23-36. https://doi.org/10.1111/j.2044-8341.1994.tb01768.x Gilbert, P., & Procter, S. (2006). Compassionate mind training for people with high shame and self‐criticism: Overview and pilot study of a group therapy approach. Clinical Psychology and Psychotherapy, 13(6), 353-379. https://doi.org/10.1002/cpp.507 93 Glass, J. (2006). Working towards aesthetic distance: Drama therapy for adult victims of trauma. In L. Carey (Ed.), Expressive and creative arts methods for trauma survivors (pp. 57-72). Kingsley. Glassman, L. H., Weierich, M. R., Hooley, J. M., Deliberto, T. L., & Nock, M. K. (2007). Child maltreatment, non-suicidal self-injury, and the mediating role of self-criticism. Behaviour Research and Therapy, 45(10), 2483-2490. https://doi.org/10.1016/j.brat.2007.04.002 Glover-Graf, N. M. (2007). The therapeutic use of photography for sexual abuse. In Brooke, S. L. (Ed.), The use of the creative therapies with sexual abuse survivors (pp. 86-101). Charles C Thomas Publisher. Greenberg, L. S. (2002). Emotion‐focused therapy: Coaching clients to work through their feelings. American Psychological Association. Greenberg, J. R., & Mitchell, S. A. (1983). Object relations in psychoanalytic theory. Harvard University Press. https://doi.org/10.1017/s0033291700015634 Hansen, J. T. (2004). Thoughts on knowing: Epistemic implications of counseling practice. Journal of Counseling and Development, 82(2), 131-138. https://doi.org/10.1002/j.1556-6678.2004.tb00294.x Hanson, J. (2005). Should your lips be zipped? how therapist self‐disclosure and non‐disclosure affects clients. Counselling and Psychotherapy Research, 5(2), 96- 104. https://doi.org/10.1080/17441690500226658 Harman, R., & Lee, D. (2010). The role of shame and self‐critical thinking in the development and maintenance of current threat in post‐traumatic stress disorder. Clinical Psychology and Psychotherapy, 17(1), 13-24. https://doi.org/10.1002/cpp.636 94 Henderson, L., & Zimbardo, P. G. (2001). Shyness as a clinical condition: The Stanford model. In W.R. Crozier, & L.E. Alden (Eds.), International handbook of social anxiety: Concepts, research and interventions relating to the self and shyness (pp. 431-447). Wiley. Herman, J. L. (1992). Complex PTSD: A syndrome in survivors of prolonged and repeated trauma. Journal of Traumatic Stress, 5(3), 377-391. https://doi.org/10.1007/BF00977235 Herrenkohl, T. I., Hong, S., Klika, J. B., Herrenkohl, R. C., & Russo, M. J. (2013). Developmental impacts of child abuse and neglect related to adult mental health, substance use, and physical health. Journal of Family Violence, 28(2), 191-199. https://doi.org/10.1007/s10896-012-9474-9 Ho, R. T. H. (2015). A place and space to survive: A dance/movement therapy program for childhood sexual abuse survivors. The Arts in Psychotherapy, 46, 9-16. https://doi.org/10.1016/j.aip.2015.09.004 Jackson, C., Nissenson, K., & Cloitre, M. (2009). Cognitive Behavioural Therapy. In C.A. Courtois, & J.D. Ford (Eds.), Treating Complex Traumatic Stress Disorders: An Evidence-Based Guide (pp 243-263). Guilford Press. Jaffe, P., Wolfe, D., Wilson, S., & Zak, L. (1986). Similarities in behavioral and social maladjustment among child victims and witnesses to family violence. American Journal of Orthopsychiatry, 56(1), 142-146. https://doi.org/10.1111/j.1939-0025.1986.tb01551.x Janoff-Bulman, R. (1979). Characterological versus behavioral self-blame: Inquiries into depression and rape. Journal of Personality and Social Psychology, 37(10), 1798-1809. https://doi.org/10.1037/0022-3514.37.10.1798 95 Johnson, S. (2002). Emotionally focused couple therapy with trauma survivors: Strengthening attachment bonds. Guilford Press. Jupp, V. (2006). The sage dictionary of social research methods. Sage. Kaufman, G. (1985). Shame: The power of caring (rev. ed.). Schenkman Books. Kaufman, G. (1989). The psychology of shame: Theory and treatment of shame-based syndromes. Springer Publishing Kaufman, G. (1992). Shame: The power of caring (3rd ed.). Schenkman Books. Kinsler, P. J., Courtois, C. A., Frankel, S. A. (2009). Therapeutic Alliance and Risk Management. In C. A. Courtois, & J.D. Ford (Eds.), Treating Complex Traumatic Stress Disorders: An Evidence-Based Guide (pp 183-201). Guilford Press. Koch, S. C., Wirtz, G., Harter, C., Weisbrod, M., Winkler, F., Pröger, A., & Herpertz, S. C. (2019). Embodied self in trauma and self-harm: A pilot study of effects of flamenco therapy on traumatized inpatients. Journal of Loss & Trauma, 24(5-6), 441-459. https://doi.org/10.1080/15325024.2018.1507472 Kubany, E. S., & Manke, F. P. (1995). Cognitive therapy for trauma-related guilt: Conceptual bases and treatment outlines. Cognitive and Behavioral Practice, 2(1), 27-61. https://doi.org/10.1016/S1077-7229(05)80004-5 Kubany, E. S., & Watson, S. B. (2003). Guilt: elaboration of a multidimensional model. The Psychological Record, 53(1), 51. https://link.gale.com/apps/doc/A98315578/AONE?u=u northbc&sid=AONE&xid=fae34b6d 96 Kuhlman, K. R., Robles, T. F., Bower, J. E., & Carroll, J. E. (2018). Screening for childhood adversity: The what and when of identifying individuals at risk for lifespan health disparities. Journal of Behavioral Medicine, 41(4), 516-527. https://doi.org/10.1007/s10865-018-9921-z Lawson, D. M., & Quinn, J. (2013). Complex trauma in children and adolescents: Evidence‐ Based practice in clinical settings. Journal of Clinical Psychology, 69(5), 497-509. https://doi.org/10.1002/jclp.21990 Lazare, A. (1987). Shame and humiliation in the medical encounter. Archives of Internal Medicine, 147(9), 1653-1658. https://doi.org/10.1001/archinte.1987.00370090129021 Leary, M. R., Koch, E. J., & Hechenbleikner, N. R. (2001). Emotional responses to interpersonal rejection. In M. R. Leary (Ed.), Interpersonal rejection (pp. 145–166). Oxford University Press. Lee, D. A., Scragg, P., & Turner, S. (2001). The role of shame and guilt in traumatic events: A clinical model of shame‐based and guilt‐based PTSD. British Journal of Medical Psychology, 74(4), 451-46p6. https://doi.org/10.1348/000711201161109 Lennihan, L.S. (2013). Sandplay as alchemical vessel: Healing sexual trauma and drug addiction. In Loue, S. (Eds), Expressive Therapies for Sexual Issues. Springer. https://doiorg.prxy.lib.unbc.ca/10.1007/978-1-4614-3981-3_9 Leskela, J., Dieperink, M., & Thuras, P. (2002). Shame and Posttraumatic Stress Disorder. Journal of Traumatic Stress, 15(3), 223–226. https://doi.org/10.1023/A:1015255311837 Levine, P. A. (1997). Waking the tiger: Healing trauma. North Atlantic Books. Lewis, H. B. (1971). Shame and guilt in neurosis. International Universities Press. 97 Lewis, M. (1992). Shame: The exposed self. Free Press. Lewis, M. (2000). The emergence of human emotions. In M. Lewis & J. M. Haviland‐ Jones (Eds.), Handbook of emotions (2nd ed.) (pp. 265– 280). Guilford Press. Lewis, M. D. (2005). Self-organizing individual differences in brain development. Developmental Review, 25(3), 252-277. https://doi.org/10.1016/j.dr.2005.10.006 Lewis, M., & Ramsay, D. (2002). Cortisol response to embarrassment and shame. Child Development, 73(4), 1034-1045. https://doi.org/10.1111/1467-8624.00455 Lincoln, Y. S. (1995). Emerging criteria for quality in qualitative and interpretive research. Qualitative Inquiry, 1(3), 275–289. https://doi.org/10.1177/107780049500100301 Liotti G. (1992). Disorganized/disoriented attachment in the etiology of the dissociative disorders. Dissociation, 5(4), 196–204. http://hdl.handle.net/1794/1722 Lutwak, N., & Ferrari, J. R. (1997). Shame-related social anxiety: Replicating a link with various social interaction measures. Anxiety, Stress, and Coping, 10(4), 335-340. https://doi.org/10.1080/10615809708249307 Lyons-Ruth, K., Dutra, L., Schuder, M., & Bianchi, I. (2006). From infant attachment disorganization to adult dissociation: Relational adaptations or traumatic experiences?. Psychiatric Clinics of North America, 29(1), 63-86. https://doi.org/10.1016/j.psc.2005.10.011. Lyons-Ruth, K., & Jacobvitz, D. (1999). Attachment disorganization: Unresolved loss, relational violence, and lapses in behavioral and attentional strategies. In J. Cassidy & P. R. Shaver (Eds.), Handbook of attachment: Theory, research, and clinical applications (p. 520– 554). Guilford Press. 98 Malterud, K., Siersma, V. D., & Guassora, A. D. (2016). Sample size in qualitative interview studies: Guided by information power. Qualitative Health Research, 26(13), 1753-1760. https://doi.org/10.1177/1049732315617444 Mayan, M.J. (2016). Essentials of Qualitative Inquiry (Vol. 2). Routledge. McCann, L., & Pearlman, L. A. (1992) Constructivist self-development theory: A theoretical framework for assessing and treating traumatized college students. Journal of American College Health, 40(4), 189-196. https://doi.org/10.1080/07448481.1992.9936281 MacDonald, J., & Morley, I. (2001). Shame and non‐disclosure: A study of the emotional isolation of people referred for psychotherapy. British Journal of Medical Psychology, 74(1), 1-21. https://doi.org/10.1348/000711201160731 Metalsky, G. I., Laird, R. S., Heck, P. M., & Joiner, T. E. (1995). Attribution theory: Clinical applications. In L. Krasner, & W.T. O'Donohue (Eds.), Theories of behavior therapy: Exploring behavior change (pp. 385-413). American Psychological Association. https://doi.org/10.1037/10169-014 Morrow, S. L. (2005). Quality and trustworthiness in qualitative research in counseling psychology. Journal of Counseling Psychology, 52(2), 250-260. https://doi.org/10.1037/0022-0167.52.2.250 Nathanson, D. L. (1987). The many faces of shame. Guilford Press. Pearlman, L. A. (1998). Trauma and the self: A theoretical and clinical perspective. Journal of Emotional Abuse, 1(1), 7-25. https://doi.org/10.1300/J135v01n01_02 Pearlman, L. A. (2001). The treatment of persons with complex PTSD and other trauma-related disruptions of the self. In J. P.Wilson, M.Friedman, & J.Lindy (Eds.), Treating psychological trauma and PTSD (pp. 205–236). Guilford Press. 99 Pearlman, L.A. (2003). Trauma and Attachment Belief Scale (TABS) manual. Western Psychological Services. Pearlman, l. A., & Courtois, C. A. (2005). Clinical applications of the attachment framework: Relational treatment of complex trauma. Journal of Traumatic Stress, 18(5), 449-459. https://doi.org/10.1016/j.psc.2005.10.011 Pierce, L. (2014). The integrative power of dance/movement therapy: Implications for the treatment of dissociation and developmental trauma. The Arts in Psychotherapy, 41(1), 715. https://doi.org/10.1016/j.aip.2013.10.002 Ponterotto, J. G. (2005). Qualitative research in counseling psychology: A primer on research paradigms and philosophy of science. Journal of Counseling Psychology, 52(2), 126136. https://doi.org/10.1037/0022-0167.52.2.126 Putnam, F. W. (1989). Diagnosis and treatment of multiple personality disorder. Guilford Press. Pynoos, R. S., Steinberg, A. M., & Piacentini, J. C. (1999). A developmental psychopathology model of childhood traumatic stress and intersection with anxiety disorders. Biological Psychiatry, 46(11), 1542-1554. https://doi.org/10.1016/S0006-3223(99)00262-0 Resick, P. A., Galovski, T. E., Uhlmansiek, M. O., Scher, C. D., Clum, G. A., & Young-Xu, Y. (2008). A randomized clinical trial to dismantle components of cognitive processing therapy for posttraumatic stress disorder in female victims of interpersonal violence. Journal of Consulting and Clinical Psychology, 76(2), 243258. https://doi.org/10.1037/0022-006X.76.2.243 Resick, P. A., & Schnicke, M. K. (1993). Cognitive processing therapy for rape victims: A treatment manual. Sage. 100 Richards, L., & Morse, J. M. (2007). Readme first for a user’s guide to qualitative methods (2nd ed.). Sage. Robinaugh, D. J., & McNally, R. J. (2010). Autobiographical memory for shame or guilt provoking events: Association with psychological symptoms. Behaviour Research and Therapy, 48(7), 646-652. https://doi.org/10.1016/j.brat.2010.03.017 Saakvitne, K. W., Gamble, S., Pearlman, L. A., & Lev, B. T. (2000). Risking connection: A training curriculum for working with survivors of childhood abuse. The Sidran Press. Saldaña, J. (2016). The coding manual for qualitative researchers (Third ed.). Sage. Schore, A. N. (1994). Affect regulation and the origin of the self: The neurobiology of emotional development. Erlbaum Associates. Schutt, R. K. (2019). Investigating the social world: The process and practice of research (9th ed.). Pine Forge Press. Schwandt T.A. (1994). Constructivist, interpretivist approaches to human inquiry. In N.K. Denzin & Y.S. Lincoln (Eds.), Handbook of qualitative research (pp. 118-137). Sage. Shorey, H. S., & Snyder, C. R. (2006). The role of adult attachment styles in psychopathology and psychotherapy outcomes. Review of General Psychology, 10(1), 1-20. https://doi.org/10.1037/1089-2680.10.1.1 Stace, S. M. (2014). Therapeutic doll making in art psychotherapy for complex trauma. Art Therapy, 31(1), 12-20. https://doi.org/10.1080/07421656.2014.873689 Stebbins, R. A. (2001). Exploratory research in the social sciences. Sage. 101 Stotz, S. J, Elbert, T., Müller, V. & Schauer, M. (2015). The relationship between trauma, shame, and guilt: Findings from a community-based study of refugee minors in Germany. European Journal of Psychotraumatology, 6(1), 25863–25863. https://doi.org/10.3402/ejpt.v6.25863 Talbot, J. A., Talbot, N. L., & Tu, X. (2004). Shame-proneness as a diathesis for dissociation in women with histories of childhood sexual abuse. Journal of Traumatic Stress, 17(5), 445448. https://doi.org/10.1023/B:JOTS.0000048959.29766.ae Talbot, N. L. (1996). Women sexually abused as children: The centrality of shame issues and treatment implications. Psychotherapy (Chicago, Ill.), 33(1), 11-18. https://doi.org/10.1037/0033-3204.33.1.11 Tangney, J. P. (1995). Shame and guilt in interpersonal relationships. In J. P. Tangney & K. W. Fischer (Eds.), Self-conscious emotions: The psychology of shame, guilt, embarrassment, and pride (pp. 114–139). Guilford Press. Tangney, J.P., & Dearing, R.L. (2002). Shame and guilt. Guilford Press. Tangney, J. P., Niedenthal, P. M., Covert, M. V., & Barlow, D. H. (1998). Are shame and guilt related to distinct self-discrepancies? A test of Higgins's (1987) hypotheses. Journal of Personality and Social Psychology, 75(1), 256-268. https://doi.org/10.1037/00223514.75.1.256 Tangney, J. P., Wagner, P., Fletcher, C., & Gramzow, R. (1992). Shamed into anger? The relation of shame and guilt to anger and self-reported aggression. Journal of Personality and Social Psychology, 62(4), 669-675. https://doi.org/10.1037/0022-3514.62.4.669 102 Teicher, M., Samson, J., Polcari, A., & Mcgreenery, C. (2006). Sticks, stones, and hurtful words: Relative effects of various forms of childhood maltreatment. American Journal of Psychiatry, 163(6), 993-1000. https://doi.org/10.1176/ajp.2006.163.6.993 Toth, S. L., & Cicchetti, D. (1996). Patterns of relatedness, depressive symptomatology, and perceived competence in maltreated children. Journal of Consulting and Clinical Psychology, 64(1), 32-41. https://doi.org/10.1037/0022-006X.64.1.32 Tracy, S. J. (2010). Qualitative quality: Eight “Big-tent” criteria for excellent qualitative research. Qualitative Inquiry, 16(10), 837-851. https://doi.org/10.1177/1077800410383121 Valory, M. (2007). Earning a secure attachment style: A narrative of personality change in adulthood. In R. Josselson, A. Lieblich, & D. P. McAdams (Eds.), The meaning of others (pp. 93–116). American Psychological Association. van der Kolk, B. A. (2003). The neurobiology of childhood trauma and abuse. Child & Adolescent Psychiatric Clinics of North America, 12(2), 293-317. https://doi.org/10.1016/S1056-4993(03)00003-8 van der Kolk, B. A. (2005). Developmental trauma disorder. Psychiatric Annals, 35(5), 401-408. https://doi.org/10.3928/00485713-20050501-06 van der Kolk, B. A. (2014). The Body Keeps the Score. Penguin Books. van der Kolk, B. A., & Najavits, L. M. (2013). Interview: What is PTSD really? Surprises, twists, of history, and the politics of diagnosis and treatment. Journal of Clinical Psychology: In Session, 69(5), 516-522. https://doi.org/10.1002/jclp.21992 103 van der Kolk, B. A, Perry, J. C., & Herman, J. L. (1991). Childhood origins of self-destructive behavior. The American Journal of Psychiatry, 148(12), 1665-1671. https://doi.org/10.1176/ajp.148.12.1665 Van Vliet, K. J. (2009). The role of attributions in the process of overcoming shame: A qualitative analysis. Psychology and Psychotherapy, 82(2), 137-152. https://doi.org/10.1348/147608308X389391 Wells, M., & Jones, R. (2000). Childhood parentification and shame-proneness: A preliminary study. The American Journal of Family Therapy, 28(1), 19-27. https://doi.org/10.1080/019261800261789 Whelton, W. J., & Greenberg, L. S. (2005). Emotion in self-criticism. Personality and Individual Differences, 38(7), 1583-1595. https://doi.org/10.1016/j.paid.2004.09.024 Wilson, J. P., & Drožđek, B. (2004). Broken spirits: The treatment of traumatized asylum seekers, refugees, war, and torture victims. Brunner-Routledge. https://doi.org/10.4324/9780203310540 Wilson, J. P., Droždek, B., & Turkovic, S. (2006). Posttraumatic Shame and Guilt. Trauma, Violence, & Abuse, 7(2), 122–141. https://doi.org/10.1177/1524838005285914 104 Appendix A: Information Letter and Consent Form Title: Treating Shame in Adult Survivors of Complex Trauma Who is Conducting the Study? This research is being conducted as part of a thesis for the Master of Counselling degree program. Researcher: Deanna West Masters in Counselling Program Department of Psychology University of Northern British Columbia Prince George, BC V2N 4Z9 778-322-0065 dwest@unbc.ca Supervisor: Dr. Linda O’Neill Associate Professor, Counselling Department of Psychology University of Northern British Columbia Prince George, BC V2N 4Z9 250-960-6414 linda.o'neill@unbc.ca Purpose of the Research The purpose of this research is to better understand how counsellors work with adult survivors of complex trauma relating to shame. I am interested in learning more about the specific practices counsellors take in working with shame, as well as their beliefs about shame in survivors of complex trauma. Through your participation, I hope to create a better understanding of the ways in which counsellors can help their clients heal from shame. How You Were Chosen You were selected to participate in this study because: • You are 19 years or older • You have obtained a master’s level degree in counselling or counselling psychology • You are currently practicing as a counsellor • You have experience working with shame in adult survivors of complex trauma • You have chosen to participate in this study What is Involved You will be asked to participate in a one-on-one interview with the main researcher, Deanna West. The interview will last approximately one hour and will be conducted via a secure Zoom platform. You will be asked to share your experiences working with adult survivors of complex trauma. I will be asking about your beliefs and opinions on shame in adult survivors of 105 complex trauma, as well as specific techniques or therapies you have used in working with shame. The interview will be recorded. You may decline to answer any question, and the recording may be turned off at any time. After your interview has been transcribed and analyzed, I will send you a copy with all identifying information redacted. At this time, you add comments and provide feedback regarding the interview and analysis. Participation is Voluntary You participation is completely voluntary and you may withdraw your consent for participation at any time by notifying the researcher. If you wish to discontinue, the interview will be stopped and any information received will be destroyed and not be used in the study. Upon completion of the interview, you may also choose to have your information withdrawn from the study. We will withdraw any study materials at that point, however, once the analysis of the data begins we will not be able to remove your individual contributions. If you choose to withdraw, there will not be any consequences for you and you will not be required to provide a reason. Potential Benefits While there may not be any direct benefits to you, some people may have a feeling of satisfaction or reward in sharing your knowledge or experience and contributing to research that may contribute to the field of counselling and help us understand how to treat trauma better in the future. As a token of our appreciation for your participation, you will also receive a $20 e-gift card to your choice of Starbucks or Tim Hortons. Potential Risks There are some potential risks to participating in this study. Topics that may arise in the interview, such as shame and complex trauma, may be difficult to discuss and cause emotional stress or discomfort. The interview may bring up uncomfortable experiences or memories. Should this arise, we will stop the interview and you will be asked if you wish to continue, reschedule, or withdraw. We will also provide you will be provided with a list of resources that you may choose to access for support. These are attached to this information sheet and consent form. Confidentiality We will do our utmost to ensure that the information you during the interview will be kept confidential, however, anonymity cannot be completely guaranteed. We will ensure that all data collection will occur over a secure UNBC Zoom platform. You will be assigned a number that will be used during transcription of the interview and analysis and will be recorded in a word document that only I will have access to. All electronic data will be stored on my personal drive through the UNBC servers, which is password protected and only I will have access to. The interviews will be transcribed on my personal computer in my home office that is protected through fingerprint identification and that only I will have access to. For the process of coding and analysis, the transcripts will be printed with any names and identifying information redacted. The printed transcripts along with any written notes or printed documents will be kept in a locked receptacle in my home office that only I will have access to. The analyzed transcripts will be shared with participants via the secure platform Sync, and will be password protected with and all identifying information removed. Only I and my direct supervisor, Dr. Linda O’Neill, 106 will have access to any information and we will de-identify the study data you choose to share. Any identifiable information, such as your name, will be securely stored separately from the remaining study data. Following the completion of the research project, physical notes and paper transcripts will be shredded and disposed of. Electronic data will be kept on the secure UNBC server for two years following the completion of the project. At that point I will permanently delete all files from the server. There are certain situations in which I would not be able to maintain confidentiality. This would occur under the following circumstances: there is a risk of imminent harm to yourself or a named other, if there is a suspicion of child abuse or neglect, or under court order. Research Results Your interview will be analyzed along with several others in contribution to the completed study. The research will be presented during my thesis defence at UNBC. It is anticipated that the results will be published in professional journals or reports, and be presented at community organizations or conferences. On the consent form, you will be given the option to indicate whether you would like to receive a summary of the results which will be sent to you via email upon completion of the study. You can also contact me, Deanna West, at dwest@unbc.ca, or (778)322-0065, or my supervisor, Dr. Linda O’Neill, at loneill@unbc.ca or (250)960-6414 to obtain a copy of the research results. Questions or Complaints If you have any questions, please feel free to contact me, Deanna West, at dwest@unbc.ca, or by phone at (778)322-0065. You may also contact my supervisor, Dr. Linda O’Neill, at loneill@unbc.ca or (250)960-6414. If you have any concerns or complaints about your rights as a research participant and/or your experiences while participating in this study, contact the UNBC Office of Research at 250 960 6735 or by e-mail at reb@unbc.ca. 107 Consent Form Title: Treating Shame in Adult Survivors of Complex Trauma Researcher: Supervisor: Deanna West Dr. Linda O’Neill Masters in Counselling Program Associate Professor, Counselling Department of Psychology Department of Psychology University of Northern British Columbia University of Northern British Columbia Prince George, BC V2N 4Z9 Prince George, BC V2N 4Z9 778-322-0065 250-960-6414 dwest@unbc.ca linda.o'neill@unbc.ca Consent: YES NO I have read or been described the information presented in the information letter about the project. I have had the opportunity to ask questions about my involvement in this project and to receive additional details I requested. I understand that if I agree to participate in this project, I may withdraw from the project at any time up until the data analysis stage with no consequences of any kind. I agree to be recorded. I agree to receive the interview transcript and analysis via email for the purpose of providing feedback. I would like to receive a summary of research results via email. Email: _______________________________________________________________________ 108 Your signature indicates that you consent to participate in this study. __________________________________________ Participant Signature __________________________________________ Printed Name of the Participant ________________________ Date 109 Appendix B: Resources BC Crisis Centre • 24-hour crisis line: 1-800-SUICIDE:1-800-784-2433 • Mental Health Support Line: 310-6789 Counselling (offering virtual services) • Prince George o Repiphany Counselling: 250-962-2415 o HML Wellness: 236-423-0077 o Align Counselling: 778-400-4798 • Kelowna o Okanogan Clinical Counselling Services Inc: 250-718-9291 • Vancouver o Tapestry Counselling Centre: 604-876-7600 o Clear Counselling: 604-620-5010 • Vancouver Island o The Therapy Place:250-616-3579 o WayPoint Counselling Network: 778-677-1960 110 Appendix C: Recruitment Letter Greetings, My name is Deanna West, and I am a student in the Master of Education in Counselling program at the University of Northern British Columbia. I am working on completing a thesis under the direct supervision of Dr. Linda O’Neill. I hope to gain an understanding of the beliefs and best practices of counsellors working with shame in adult survivors of complex trauma. I am interested in how counsellors conceptualize shame, as well as any specific theories or exercises counsellors have used in working with shame. I developed an interest in the treatment of complex trauma through volunteer work with marginalized children and adolescents. During this time, I observed the impact that adverse experiences can have on a child’s development that persist into adulthood. Through the experience as a counsellor with adult survivors of complex trauma, I witnessed the profound effect shame can have on a survivor’s life. I also observed some of the ways shame can impact the therapeutic process and the client’s healing. I would like to draw from practicing counsellors to learn from their experience in working with shame to contribute to the conversation about the ways counsellors can be most effective in supporting their clients. I am looking to interview counsellors who are currently practicing therapy with adults, who have obtained a master’s degree in counselling or counselling psychology. The interviews will be conducted online via Zoom and will be recorded and transcribed. To maintain anonymity, all identifying information will be removed from the transcripts and the data. Only myself and my direct supervisor, Dr. Linda O’Neill, will have access to the participant’s information. The information will be destroyed two years after the research commences. Participants will be compensated $20 for their participation. At any time during or after the interview, participants will be able to withdraw their participation and their information will be destroyed. I have contacted your agency as I am looking for your support in recruiting counsellors for the study. If you would like to participate, or know of anyone who would be interested in participating, please feel free to share the attached study information letter, and/or contact me at any time if you have questions or want more information. Thank you for your time and consideration for participation in this study. Below please find my contact information. I look forward to hearing from you. Sincerely, Deanna West dwest@unbc.ca (778)322-0065 111 Appendix D: Recruitment Poster 112 Appendix E: Interview Questions • How do you see shame appear in you work with clients? • Can you provide examples of signs that a client experiences shame? • What aspects of shame are important to address in your work with survivors of complex trauma? • What are some of the techniques or theories you use in supporting clients in healing from shame? What has been helpful or unhelpful? • In what ways, if any, do you treat shame in survivors of complex trauma differently than shame in survivors who do not report a history of complex trauma? • What are the barriers to working with this population? • Is there anything else important to the treatment of shame in survivors of complex trauma that we have not discussed?