Detecting child sexual abuse in child and adolescent psychiatry: a survey study of healthcare professionals' assessment practice

BACKGROUND

Research shows that only around half of all survivors of child sexual abuse (CSA) disclose the abuse during childhood and adolescence. This is worrying, as CSA is related to substantial suffering later in life. The proportion of children and adolescents who have been exposed to CSA is significantly higher in Child and Adolescent Psychiatry (CAP) than in the general population. Healthcare professionals report that uncovering CSA is a complex and challenging task. However, we know little about how they proceed when uncovering CSA. More knowledge of healthcare personnel's experience is therefore necessary to facilitate and increase CSA disclosure. The study aims to explore how CAP healthcare professionals in Norway proceed when assessing and detecting CSA, how they experience this work, and what hinders or facilitates their efforts.

METHODS

The study employed a mixed method approach. Data was collected through an anonymous online survey, generating both quantitative and qualitative data. The sample consisted of 111 healthcare professionals in CAP, of whom 84% were women, with a mean age of 40.7 years (range 24-72; sd = 10.8). Mean years of CAP clinical experience were 8.3 years (range 0-41; sd = 7.5). The quantitative data was analysed using descriptive statistics, correlations, and independent sample t-tests, while the qualitative data was analysed using a team-based qualitative content analysis.

RESULTS

The results showed that detection of CSA was viewed as an important, but complex task in CAP, and the existing procedures were deemed to be insufficient. The therapists mostly felt confident about how to proceed when they suspected or detected CSA, yet they seldom detected CSA. In their initial assessment they applied standardised procedures, but if their suspicion of possible CSA persisted, they seemed to rely more on clinical judgement. Specific challenges and facilitators for CSA detection were identified, both in the individual and in the organisation.

CONCLUSIONS

The study highlights the challenges and complexities healthcare professionals and the CAP system face when assessing CSA, which may account for the low detection rate. The results show that healthcare professionals believe room for clinical autonomy and targeted competence development may improve CSA detection. Additionally, the findings suggest a need for CAP to define roles and responsibilities within and between agencies.

Training students to become responsive therapists: implications from a sequential mixed-methods study on situations that therapists find challenging

OBJECTIVE

To draw implications for training of therapist responsiveness from a sequential mixed-methods study on challenging clinical situations.

METHOD

Study 1: online survey mapping frequency and perceived difficulty of 15 clinical situations in a representative sample of psychologists. Study 2: online survey mapping frequency and perceived difficulty of 19 clinical situations among therapists in child and adolescent psychiatry. Study 3: focus group study exploring the situations identified through study 1 and 2.

RESULTS

Study 1 and 2 showed that ratings of each situation varied between individuals and context. Study 3 showed that the degree to which a situation was challenging was described as depending on the characteristics of the therapist and the context. Experientially, challenging situations were characterized by lacking access to necessary information, falling short, and disturbing arousal. Perceiving therapeutic opportunities despite the challenging nature of the situation, collegial support, self-knowledge, and engagement were important resources.

CONCLUSION

Six implications of the results from the three studies for training of responsiveness are discussed: (1) building self-awareness and conceptualization skills; (2) personalizing training; (3) transforming disturbing arousal into engagement; (4) being exposed to a broad range of clinical situations; (5) training on commonly encountered situations; and (6) building tolerance for uncertainty and capacity to seek support.

Clients' experiences with a Trauma-sensitive mindfulness and compassion group intervention: a first-person perspective on change and change mechanisms

Background: Trauma-related symptoms are common and there is a need for treatment interventions targeting underlying core vulnerabilities regardless of the client's diagnosis. Mindfulness and Compassion interventions have shown promising results in trauma treatment. However, little is known of how clients experience such interventions. Objective: This study describes clients' experiences of change after participating in a transdiagnostic group intervention, Trauma-sensitive Mindfulness and Compassion Group (TMC). Method: All 17 participants from two TMC groups were interviewed within one month of completing treatment. Transcripts were analysed using reflexive thematic analysis with a focus on how the participants experienced change and change mechanisms. Results: Three main themes of experienced change were developed: Becoming empowered; A new relationship to oneself and one's body; and Gaining more freedom in relationships and life. Four main themes were developed to capture clients' experiences of change mechanisms: New perspectives give understanding and hope; Accessing tools facilitates agency; Significant moments of awareness open up to new possibilities, and Circumstances in life that facilitate change. Conclusion: We discuss and reflect upon participants' experiences of the effects of participating in a TMC group and the mental and emotional costs of doing the work and present a broader perspective on change processes overall.

From seeing difficult behaviour to recognizing legitimate needs - A qualitative study of mothers' experiences of participating in a Circle of Security Parenting program in a public mental health setting

OBJECTIVE

Mental health challenges can interfere with caregivers' self-efficacy and their ability to engage with their children in developmentally appropriate ways. The goal of this study was to explore whether the intervention Circle of Security Parenting (COS-P) was experienced as a meaningful adjunct to psychological treatment.

METHOD

Individual qualitative semi-structured interviews were conducted with twelve female COS-P participants, exploring how taking part in COS-P had changed the way they related to themselves and others. Data were analyzed using a team-based, reflexive thematic analysis.

RESULTS

The analysis resulted in three main themes: (i) Connecting dots: A new perspective on one's past, (ii) Seeing oneself more clearly: Increased capacity to recognize and tend to own needs, and (iii) Gaining a map: Becoming a more competent parent.

CONCLUSION

Taking part in COS-P as an adjunct to psychological treatment positively impacted participants' sense of competence as mothers. They used the COS-P framework to make sense of their interaction with their child, enabling them to understand the child's behaviour and communication as expressing legitimate attachment needs. They also experienced that the course strengthened central psychological capacities, such as insight into their own developmental histories as well as increased self-awareness and self-care. Implications are discussed.

Grief trajectories among bereaved parents after the 2011 Utøya terror attack: A qualitative analysis

This study took a qualitative approach to explore terror-bereaved parents' long-term experiences with grief. Data were drawn from a larger, longitudinal study, and interviews with 10 bereaved parents were selected based on their reported change in scores on Inventory of Complicated Grief (ICG) over a period of 6.5 years, including the five parents with the largest change (group 1) and the five parents with the least change (group 2). Reflexive thematic analysis of the interview transcripts resulted in four main themes: "I felt completely lost and helpless, like I was stuck in a whirlwind" and "I have been fighting to get back to my everyday life", which both groups contributed to. Participants in group 1 contributed to the theme "I have found a way to a new life," while participants in group 2 contributed to the theme "I cannot seem to find a way to a new life." Findings suggest that sense of control, acceptance, and social support enhanced experienced coping following terror-related bereavement, while comorbid mental health problems, difficulties with acceptance, and repetitive thoughts about the death was experienced as contributing to long-term struggles following terror-related bereavement.

Possible paths to increase detection of child sexual abuse in child and adolescent psychiatry: a meta-synthesis of survivors’ and health professionals’ experiences of addressing child sexual abuse

Background

Efforts are directed both towards prevention and early detection of Child sexual abuse (CSA). Yet, only about 50% of CSA survivors disclose before adulthood, and health professionals rarely are the first disclosure recipients. Increasing the detection rate of CSA within the context of Child and Adolescent Psychiatry (CAP) therefore represents a significant secondary prevention strategy. However, facilitating CSA disclosure when the survivor is reluctant to tell is a highly complex and emotionally demanding clinical task. We therefore argue that efforts to increase detection rates of CSA within CAP need to rest on knowledge of how both survivors and health professionals experience addressing CSA.

Method

Using meta-ethnography as method, we present separate sub-syntheses as well an overarching joint synthesis of how survivors and health professionals experience addressing CSA.

Results

Results show how both survivors and health professionals facing CSA disclosure feel deeply isolated, they experience the consequences of addressing CSA as highly unpredictable, and they need support from others to counteract the negative impact of CSA.

Conclusion

The results indicate that adapting the organization of CAP to knowledge of how the survivors and health professionals experience addressing CSA is critical to facilitate earlier disclosure of CSA within CAP.

Negotiating System Requirements to Secure Client Engagement - Therapist Strategies in Adolescent Psychotherapy Initiated by Others

Background: Many adolescent clients come to treatment reluctantly, at the initiative of others. Adolescents also quit therapy prematurely more often than adult clients do. This points to the value of finding good ways to engage adolescent clients in treatment and understanding more of what therapists do to achieve this task.

Methods: We used focus group methodology to explore therapist strategies and behaviors to engage adolescent clients who come to therapy at the initiative of others. Ten focus group interviews with a total of 51 therapists were conducted with existing treatment teams from seven different clinics in community mental health care for children and youth. Reflexive thematic analysis was used as a framework to guide the analytical process.

Findings: Navigating a position allowing the therapist and adolescent to meet and work toward a shared understanding of the situation and what could help was considered the main gateway to client engagement. To do this, therapists had to manage the pull between system requirements and their obligation to the individual adolescent client, represented by the theme Managing system requirements. The process of working with the adolescent to ensure engagement is represented by the four themes: Counteracting initial obstacles for client engagement – “You are not trapped here”; Sharing definitional power – “What does it look like to you?”; Practicing transparency – “I want you to know what I see”; and Tailoring as ideal – “I will design this therapy for you.”

Implication and conclusion: Therapists want to understand their adolescent clients’ position better, and subsequently adjust the treatment goals and techniques to establish sufficient common ground to allow both the therapist and adolescent to find the therapeutic project worthwhile. However, system requirements and service organization were found to obstruct and influence these processes in several ways, pointing to the significance of exploring the interplay between system organization and therapeutic practice more thoroughly. There was also a variation between therapist behaviors described by different therapists within the same treatment teams, as well as systematic differences between treatment teams, pointing to the importance of future research differentiating wanted from unwanted variation in treatment.

Finding One's Footing When Everyone Has an Opinion. Negotiating an Acceptable Identity After Sexual Assault

Identities used to describe oneself after trauma may influence recovery, and searches for acceptable identities after sexual assault can be challenging. Fifteen Norwegian female survivors of sexual assault were recruited at a clinical center, and were individually interviewed about post-assault discussions with others. Our focus was on the experiences of non-blaming and believing interactions with others, and how these interactions can be understood as a process of searching for acceptable identities after sexual assault. A reflexive thematic analysis resulted in four themes: navigating between other people's stories and one's own; realizing the seriousness of the assault without drowning in the upset of others; finding a place between too much closeness and too much distance; and being more than a victim. We discuss the importance of participants retaining agency in post-assault interactions. We suggest that being a survivor of sexual assault increases the probability, even in believing and non-blaming interactions, of being cast in a subject-object relationship with less freedom and agency than before. Navigating toward acceptable identities may mean working one's way back to being a subject in a subject-subject relationship again.

Parenthood-Lost and Found: Exploring Parents' Experiences of Receiving a Program in Emotion Focused Skills Training

Background

Parents play a crucial role in the development, maintenance, and deterioration of child difficulties. Emotion focused skills training (EFST) targets parents’ capacity to provide their child with emotion-oriented skills in order to promote good child mental health. Few qualitative studies have specifically investigated parents’ experiences of receiving such programs.

Objective

This study aimed to explore how parents experience working with their own and their child’s emotions undergoing a short-term program in EFST; in particular, changes in their experience of being a parent and in everyday life are reported.

Method

Semi-structured in-depth qualitative interviews were conducted with 14 parents who had completed a short-term EFST program (2-day group training and 6 h of supervision). Interview transcripts were analyzed using a reflexive thematic analysis approach.

Results

A total of 14 parents (40% men, four couples, Mage = 39.5, SD = 4.4) participated in the study. Our analysis resulted in the following three themes: (1) “Coming home” as a parent, with the following subthemes: (a) New ways of being with their child and (b) Parents’ painful inner world; (2) Reclaiming parenthood—applying new tools and learning in challenging situations; and (3) This is us—changing the heart of the story. The first theme was related to the descriptions of the changes that emerged in parents’ inner lives, the second revolved around the employment of their skills intuitively and creatively based on what was required by the challenging situations, and the third theme referred to new discoveries on family dynamics.

Conclusion

Parents’ experiences of having wisdom and calmness inside them (being) and doing parenting differently, as well as the changed perspectives of the family (living), resonate with the theoretical ground of emotion-focused therapy (EFT). The findings also indicate that therapists should be aware of potential parental distress when working in view of changing unpleasant emotions in such skill-based programs.

Barriers and Facilitators in Adolescent Psychotherapy Initiated by Adults-Experiences That Differentiate Adolescents' Trajectories Through Mental Health Care

Mental health problems start early in life. However, the majority of adolescents fulfilling the criteria for mental health disorders do not receive treatment, and half of those who do get treatment drop out. This begs the question of what differentiates helpful from unhelpful treatment processes from the perspective of young clients. In this study, we interviewed 12 young people who entered mental health care reluctantly at the initiative of others before the age of 18. Their journeys through mental health care varied significantly despite sharing the same starting point. Our analyses resulted in a model of three trajectories. We describe relational and structural facilitators and obstacles within each trajectory and have formulated narratives highlighting core experiences differentiating them. Trajectory 1 (I never saw the point - Being met as a case) was characterized by a rapid loss of hope, leading the adolescents to conclude that mental health care was not worth the investment. Trajectory 2 (I gave it a go, but nothing came of it - Being met by a therapist representing a rigid and unhelpful system) was characterized by a lingering hope that never materialized into a constructive therapeutic process despite prevailing efforts by both therapists and adolescents. Trajectory 3 (Something good came of it - Being met by a therapist who cares and wants to help) was characterized by genuine meetings, allowing the therapist to transform from an unsafe stranger into a safe, competent, and benevolent adult. We discuss how our results have implications for understanding agency displayed by adolescent clients in therapy, therapist flexibility and authenticity, service organization, and attributional processes influencing clinical judgment and therapeutic processes when adolescent psychotherapy has a difficult starting point (i.e., initiated by adults).

What Do Survivors of Child Sexual Abuse Believe Will Facilitate Early Disclosure of Sexual Abuse?

The purpose of this study was to explore what adult survivors of child sexual abuse (CSA) believe will facilitate early disclosure of sexual abuse. We conducted semi-structured interviews with 12 adult survivors of CSA aged 18-57 years, and analyzed the transcripts using reflexive thematic analysis. Our analysis resulted in three main themes: Adults making it possible to tell; Adults daring to consider the unthinkable; and Conveying knowledge of CSA that facilitates understanding. The findings highlighted the importance of adults facilitating disclosure and making it possible for survivors to tell about their experiences, but also the responsibility adults have to dare to consider the possibility of CSA when children struggle. Another important finding was the significance of enhancing the general population's understanding of the complexity of CSA, including why disclosure is difficult, so adults are given the tools needed to understand and know what to do when they suspect CSA. The findings also have important implications for the planning and implementation of interventions to facilitate early disclosure of CSA.

The nature of youth in the eyes of mental-health care workers: therapists' conceptualization of adolescents coming to therapy at others' initiative

Background

Adolescent clients often come to therapy at the initiative of others and show a higher drop-out rate compared to adult clients. Therapeutic relationships are critical for preventing drop-outs and attaining good outcomes, yet few empirical studies have investigated how therapists conceptualize and meet adolescent clients who come reluctantly to therapy.

Methods

We conducted ten focus-group interviews in this study with a total of 51 therapists at different Norwegian specialist outpatient clinics for children and adolescents with mental-health problems to explore how therapists view and understand adolescents who come to therapy at the initiative of someone else. We used a reflexive approach to thematic analysis to analyze the transcripts.

Results

We found five main themes, expressing variations in participants’ understanding: The hurt and distrustful adolescent; The adolescent lacking hope for the future; The adolescent engulfed in the burden of mental-health suffering; The adolescent as something more than a psychiatric patient; and The adolescent meeting a system with varying flexibility and space for engagement.

Conclusions

Several conceptualizations of the adolescent client coexist within and between clinics, resulting in variability of services for adolescents even within the frames of a strong welfare system.

Does it get easier over time? Psychologists' experiences of working with suicidal patients

Does working with suicidal patients become easier with time? A representative national survey of 375 psychologists (72% women, Mean age 44 years) showed that years of experience (r = -.13, p = .01) and frequency of contact with suicidal patients (r = -.15, p = .004) correlated only weakly with perceived difficulty. Thematic analysis of respondents' descriptions of difficult suicide-related situations on an open survey-question yielded four themes: Unreachable patients, choosing between therapy and security, therapist's boundaries and empathy with death-wishes. We conclude that improved confidence in coping with suicidality may require specific training rather than simply years of work.

Pathways to Understanding - How Adult Survivors of Child Sexual Abuse Came to Understand that they had been Sexually Abused

While child sexual abuse is recognized as a global challenge in need of attention, all too often it takes years before sexual abuse is disclosed. We therefore need to understand more of the process leading to disclosure of child sexual abuse. The purpose of this study was to investigate how adult survivors of child sexual abuse came to understand that they had been sexually abused. We conducted semi-structured interviews with 8 women and 3 men (18-57 years old) and analyzed the interview transcripts using a hermeneutic-phenomenological approach to thematic analysis. Our analysis resulted in three main themes: The ambiguity of memory: "To remember the catastrophic"; The language of the body: "Let the body speak"; and Encountering an observant other: "The significance of being seen and recognized". The findings highlighted the complexity of the individual process of understanding that one has been sexually abused. The availability and intrusiveness of traumatic memories, bodily sensations and symptoms, and encounters with others proved to be contributing factors in the process. The findings give insights into why disclosure of sexual abuse can be difficult and have important implications for health professionals and policy makers working to help victims of child sexual abuse.

A Qualitative Study of Use of Mindfulness to Reduce Long-Term Use of Habit-Forming Prescription Drugs

Objective: The aim of this study was to study how participants used a mindfulness-based program-Mindfulness Based Relapse Prevention to reduce use of habit-forming prescription drugs after long-term use. We explored participants' descriptions of their post-intervention strategies for controlling medication intake. Method: Eighteen participants provided semi-structured qualitative interviews shortly after completion of the program and 13 participants were also interviewed 1 year after completion. Participants were asked about the conditions that originally led to use of medication, how they had attempted prior to the course to cope with problems associated with these conditions and their prescription drug-use, and whether and how their coping strategies had changed after participation in the program. Thematic analysis was performed within the framework of a realist epistemology, with an emphasis on researcher reflexivity. Results: The following themes were identified in the material: Increased present-moment sensory awareness, Observing without controlling, Self-acceptance, Making conscious choices, Non-judgmental self-guidance, Sense of control, and Challenges of learning and using mindfulness. Although these findings are closely related to the specific needs of our sample-mainly coping with tapering use of prescription drugs-they are largely in line with existing research on mindfulness interventions. An exception is the theme "Non-judgmental self-guidance," which encompasses change in individuals' inner dialogue and practical self-care. Conclusions: Analyses suggested that mindfulness might increase individuals' control over medication intake by shifting individuals' attention toward present-moment sensory awareness of concrete stimuli, thereby facilitating other kinds of control, such as non-judgmental inner self-guidance and more adaptive ways of reducing distress. We suggest that it is the moment-to-moment sensory awareness and non-controlling observation of distress, together with inner self-guidance, that differentiates mindful control from dysfunctional attempts at direct, top down control of medication-use.

Becoming Aware of Inner Self-Critique and Kinder Toward Self: A Qualitative Study of Experiences of Outcome After a Brief Self-Compassion Intervention for University Level Students

This qualitative study investigated ways in which student participants in a three-session self-compassion course became more compassionate toward themselves and challenges related to this change. Ninety-four participants completed an online survey and 12 participants were interviewed face-to-face. First, a thematic analysis of the responses from the online survey was conducted, and then sorted by frequency, indicating their representativeness in the written responses. The following themes were identified: (1) being more supportive and friendlier toward self, (2) being more aware of being too hard on oneself, (3) feeling less alone when having painful feelings, (4) having more acceptance of painful feelings, and (5) feeling more stable and peaceful. These five most frequent themes served as a basis for a structured phenomenological analysis in the next analytic stage. They were used as a template for a content analysis of the interview material. Subsequently, a phenomenological analysis was conducted on the interview transcripts covering the five thematic areas.

"You Feel They Have a Heart and Are Not Afraid to Show It": Exploring How Clients Experience the Therapeutic Relationship in Emotion-Focused Therapy

Background: The therapeutic relationship is regarded as an important source of change in emotion-focused therapy (EFT) (Greenberg, 2014; Watson, 2018), but few qualitative studies have specifically investigated how clients experience the role of the relationship in EFT. Aim: The purpose of the present study was to explore what clients experienced as helpful or hindering aspects of the therapeutic relationship when undergoing EFT for depression, anxiety, and severe self-criticism. Methods: We interviewed 18 clients after a clinical trial of time-limited EFT, to explore their experiences of the relationship with their therapist during treatment. The interviews were analyzed using hermeneutic-phenomenological thematic analysis (Braun and Clarke, 2006; Binder et al., 2012). Results: We identified four main themes: (1) Forming a trusting relationship or finding it hard to connect, (2) Collaborating and struggling to find new ways to relate to painful feelings, (3) Alliance ruptures and needs for repair when working with distressing emotions, and (4) The significance of new relational experiences. Conclusion: Clients described therapists' genuineness and the establishment of trust in the relationship as important preconditions to open up to vulnerability and painful feelings, and engaging fully in specific EFT interventions. The findings also indicate that the therapists need to be mindful of different client preferences and monitor potential alliance ruptures when working to change distressing emotions in therapy.

"We all have a responsibility": a narrative discourse analysis of an information campaign targeting help-seeking in first episode psychosis

BACKGROUND

Intervening at an early stage of psychosis improves the chances of recovery from first-episode psychosis. However, people who are experiencing distress and early psychotic symptoms generally seem to delay seeking help. Therefore, multifaced information campaigns targeting help-seeking behavior of potential patients and their network are considered important tools within early detection and intervention strategies. In this study, we aimed to explore which discursive meaning content, including roles and actors, such information campaigns build on and construct. Our intention was not to provide objective answers, but to contribute to a discursive debate about potential conflicts in messages conveyed in such campaigns.

METHODS

A broad sample of information material utilized by TIPS Stavanger University Hospital (Norway) was examined. The material consisted of posters, booklets and brochures, newspaper ads, Facebook ads, and TIPS Info's website, representing various campaigns from 1996 to April 2018. A narrative discursive approach was applied at an epistemological level. At a practical level, a team-based thematic analysis was utilized to identify patterns across data.

RESULTS

Diversity and several changes in strategy were recognized throughout the information material. Furthermore, three main themes and four subthemes were found to constitute the meaning content built in the information campaigns: knowledge is key; (almost) an illness among illnesses; and we all have a responsibility (comprising of the subthemes; to respond quickly; to step in; to provide an answer; and to tag along).

CONCLUSION

Our findings pointed to common dilemmas in mental health services: How to combine professional expert knowledge with collaborative practices that emphasize shared decision-making and active roles on behalf of patients? How to combine a focus on symptoms and illness and simultaneously express the importance of addressing patients' recourses? And how can we ask for societal responsibility in help-seeking when professionals are placed in expert positions which may not be optimal for dialogue with potential patients or their network? We discuss whether highlighting practices with more weight on resources and active roles for patients and their surroundings in information campaigns could promote earlier help-seeking.

From Cumulative Strain to Available Resources: A Narrative Case Study of the Potential Effects of New Trauma Exposure on Recovery

This article presents a narrative case study of a client with a history of multiple traumas and severe symptomatology, coupled with an ongoing recovery process. A hermeneutical-phenomenological approach was used to analyze two interviews with the participant over a period of 1 year, following a trauma treatment program. Her husband's suicide in between the two interviews allowed for an exploration of the possible effects of new trauma exposure on the process of recovery. Analysis of the data revealed how the participant's early trauma experiences had resulted in escalating symptomatology. Through her relationship with her husband, she gradually became ready to engage in therapy in a way that allowed her to benefit from it. Her husband's suicide forced her to reconsider her own part in her recovery, resulting in a strengthened feeling of inner security and self-efficacy parallel to what is seen in posttraumatic growth. The results contribute our understanding of individual processes of change and recovery, including processes of growth following cumulative trauma. Plausible mechanisms for growth in the present case was the ability to recognize and tolerate feelings, making sense of one's own reactions, as well as a sense of control and trust in available resources.

How Do People Experience Early Intervention Services for Psychosis? A Meta-Synthesis

We conducted a study to explore how people diagnosed with first-episode psychosis experienced their contact with early intervention services for psychosis and the way these experiences relate to their recovery processes. Our aim was to integrate and describe the service users' experiences in a rigorous and comprehensive way. A broad literature search was performed in June and July 2016. After screening, 17 qualitative studies were included. We analyzed the findings in two main steps: (a) translating studies into one another and (b) synthesizing the findings from the studies. Through these interpretative processes, we found five new and overarching themes: (a) something is wrong, (b) do for myself, (c) it's about people, (d) a price to pay, and (e) ongoing vulnerability. We describe these themes as a process that service users' maneuver through in their contact with the services. Our findings are discussed in light of relevant research.

"If there's no stability around them": experienced therapists' view on the role of patients' social world in recovery in bipolar disorder

BACKGROUND

Recovery in severe mental illness has traditionally been described as a deeply personal process. At the same time, researchers are increasingly attending to the social nature of such processes. In this article, we aim to supplement the growing knowledge base regarding these social aspects by exploring the perspectives of experienced therapists: how do they view the role of the social world in processes of healing and growth for people with bipolar disorder? And in what ways can the social world impede recovery?

METHODS

We conducted 12 semi-structured individual interviews and analyzed the resulting transcripts using a team-based thematic analysis method.

RESULTS

We identified three themes: (a) establishing a sense of belonging; (b) backing ongoing therapy; and (c) relational ripple effects.

CONCLUSIONS

We relate our findings to existing theory and research, discuss clinical implications, and highlight study limitations. We argue that our findings underscore the need to integrate an understanding of recovery as a personal and social process in the mental health care services that we provide.

From painstaking work to a new way of meeting the world-Trauma clients' experiences with skill training in a stabilization group approach

OBJECTIVE

The study explored how former trauma clients experienced the inclusion of skill training in their treatment, their ways of relating to and using these skills, and how this changed over time.

METHOD

Semi-structured qualitative in-depth interviews were conducted with 13 clients within three months of their completion of treatment, and again 11-13 months later.

RESULTS

Analysis of the material resulted in three main themes: (1) Being ready to find new ways to deal with trauma-related problems as a motivational starting point at intake, (2) Finding new agency through skills and understanding, and (3) One year on-Meeting the everyday world in a new way. An overreaching theme was the significant effort clients put into their treatments.

CONCLUSIONS

The results show how skills over time became integrated and were linked to profound changes, including changes in emotional processing and an increased sense of agency. An experiential interrelationship between understanding and action was found, that supports the practice of coupling skill training with psychoeducation in trauma-specific treatment.

The process leading to help seeking following childhood trauma

In this article we explore the process leading to help seeking following childhood trauma among women who were currently in treatment. We interviewed 13 participants from six treatment groups for clients exposed to human-inflicted traumas. Transcripts were analyzed using a hermeneutical-phenomenological approach. Help seeking was initiated after a prolonged period of time (13 to 58 years after first trauma exposure), during which participants relied heavily on a strategy of managing on their own. Self-management contributed to delays in help seeking, but was also an important resource. High levels of distress were reported prior to help seeking, often without help seeking being considered as an option. The participants sought help when encountering situational demands exceeding available resources, resulting in experiences of exhaustion and loss of control. We present a model of the help-seeking process, underlining the importance of respecting and exploring the individual process of seeking help when offering trauma-specific treatment.

Stories from the road of recovery - How adult, female survivors of childhood trauma experience ways to positive change

The aim of this study was to explore how female survivors of childhood trauma who have sought treatment experience ways to positive change. Little knowledge exists regarding the first-person perspective of the recovery process following childhood trauma, and getting access to this perspective might contribute to better understanding of these processes, hence offering opportunities for health promotion. All clients (31, including 3 who dropped out) from six stabilization groups for women exposed to human-inflicted traumas were invited to participate in the study. Experiences of the recovery process were not restricted to the period of receiving treatment, and all clients who volunteered were included in the study. Qualitative, in-depth interviews with 13 consenting clients were carried out shortly after completion of the group treatment. All interviews were transcribed verbatim, and a hermeneutical-phenomenological approach to analysis was applied. The analysis resulted in five interrelated, but distinct main themes: finding new ways to understand one's emotions and actions, moving from numbness toward vital contact, becoming an advocate of one's own needs, experiencing increased sense of agency, and staying with difficult feelings and choices. The themes support, yet supplement trauma theory, by underlining the relationship between emotional contact and meaning-making, while downplaying the necessity of symptom elimination in the experience of recovery. The findings also underline that the active role trauma survivors play in their processes of recovery.

A meaningful struggle: trauma clients' experiences with an inclusive stabilization group approach

The present study explores how trauma clients experience participation in an inclusive stabilization group approach. Upon completion of treatment, all 31 clients from six stabilization groups for women were invited to participate in a qualitative post-therapy interview study. Thirteen clients consented to participate. All interviews were carried out by a team of three health-care workers shortly after completion of treatment. Five main themes were identified: Dreading and Hoping-Preparing for Participation; Tuning in and Staying Put; Meeting Other Trauma Survivors; Acquiring a Stabilizing Ballast; and Being Receptive to Change. Participating in the stabilization group was experienced as demanding, while also providing new and helpful experiences. Participants emphasized the importance of being receptive to help in order to benefit from treatment.

A Stabilization Group Approach for Heterogeneous Populations of Trauma Clients

High prevalence and long-lasting implications of human-inflicted trauma call for effective treatment approaches reaching clients in need of trauma-specific treatment. Numerous approaches exist, but often with limited empirical support. There is also a tendency toward segregating treatment approaches depending on type of exposure history and presenting symptoms. This might exclude clients in need of trauma-specific treatment; therefore, treatment approaches that can reach more heterogeneous groups of clients are needed. In this article, a group-based treatment approach adjusted to include clients with a wide range of trauma-related problems and traumatic experiences will be presented. A brief outline of the approach is presented, together with the theoretical and empirical background, to facilitate implementation by practitioners and empirical testing.

Living in exile when disaster strikes at home

As the number of migrants,- forced or voluntary,- increases, there is a growing need to understand how negative events in the country of origin influence those residing abroad. This issue has been actualized by the recent earthquakes in Haiti and Chile. Persons in exile have frequently been exposed to severe human rights violations and other stressors prior to emigration. The present study explored possible associations between ongoing and former stressors and mental health problems among persons living in exile as the Tsunami disaster of 2004 struck their country of origin. The contribution of former exposure and exilerelated difficulties in explaining current mental health problems was explored together with Tsunami related bereavement and social support. Following the Tsunami disaster of 2004 a questionnaire was administered to individuals of Tamil and Acehnese origin residing in Norway. The results suggest an independent contribution of exilerelated difficulties, former exposure and social support in explaining current mental health problems in this group. The study also disclosed methodological challenges involved both in relation to recruiting participants and in isolating the contribution of a particular stressor in populations with high levels of former exposure as well as ongoing stress.