Missed Opportunities for Growth in the Posttraumatic Helping Environment: The Role of Spirituality

Abstract

This paper focuses on social work’s understanding of how posttraumatic counselling may help or hinder recovery from trauma. A qualitative case study was conducted using an autobiographic memoir that provides an in-depth personal narrative of one woman’s experience of trauma, posttraumatic stress disorder, the posttraumatic helping environment, and healing journey. Inductive thematic analysis uncovered themes that align with the existing literature. Novel or understudied aspects for consideration also emerged, including the importance of psychoeducation, behavioural activation, and secondary factors related to the posttraumatic environment that impede healing. The analysis highlighted missed opportunities to clinically address issues of identity and meaning in a spiritually sensitive manner. Although the narrator made it clear to helping professionals that she was struggling with religious beliefs and was in spiritual crisis, helping professionals seemed to eschew exploration of these concerns. Implications for clinical social work practice and future research are discussed.

1. Introduction

Research regarding life-threatening accidents, natural disaster, sexual assault, and other major traumatic life events has led to a common understanding of trauma and posttraumatic stress disorder (PTSD), as outlined in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM–5; American Psychiatric Association 2013). This awareness and understanding of trauma has coincided with the study of trauma-specific modalities for use in treatment interventions. Helping professionals are often trained in specific evidence-based modalities to address the trauma within their discipline’s scope of practice; however, this training may limit the professional’s flexibility to respond to wider individual needs. Although there are many commonalities in symptoms and treatment of trauma, the way in which individuals process their trauma experience and journey through their healing is unique. Some literature has begun to explore these unique ways of processing and responding to trauma along with the associated helping needs that are not typically addressed within the frameworks of many evidence-based modalities (Maercker and Horn 2013).

Given social work’s perspective of person-in-environment (Barnes and Hugman 2002), social work is well-positioned to expand PTSD interventions to include consideration of contextual factors beyond the individual and their immediate trauma experience. Following recognition that the posttraumatic healing experience takes place in a context, comes the understanding that approaches to posttraumatic intervention must be holistic in nature. The deep impacts of trauma invite understandings that capture the complexity of the human experience, including less tangible aspects such as meaning, spirituality, mortality, and identity. As Briere and Scott (2015) observed, “[t]rauma can alter the very meaning we give to our lives and can produce feelings and experiences that are not easily categorized in diagnostic manuals” (p. 31). Nowakowski-Sims and Kumar (2020) describe holistic social work practice that focuses on the spiritual component or wounds of the soul as “soul work” (p. 189). The person is understood from the perspective of a mind–body–spirit connection and the importance of self-compassion in promoting healing is emphasized. Holistic care must address the whole person, encompassing professional, cognitive, emotional, physical, relational and spiritual elements of experience (Butler et al. 2019). Thus, healing is facilitated by interventions that integrate body, mind, and spirit.

Spiritual and existential aspects of the traumatic experience and posttraumatic healing have received increasing levels of attention in recent years (Day 2009; Du Toit 2017; Floyd et al. 2005; Hoffman et al. 2013; Thompson and Walsh 2010; Vachon et al. 2016; Weems et al. 2016). Existentialism, in particular, has been linked to understanding the personal trauma experience. Originating in ancient philosophy, existential thought questions human existence. Applied as a therapy, existentialism explores the nature and meaning of life and death, and frames suffering as an opportunity for healing and growth (Vachon et al. 2016). Thompson and Walsh (2010) conceptualized the resulting loss of a sense of self and shattered framework of meaning as an existential injury. Some empirical literature has demonstrated support for existential treatment interventions. For example, the existential process of making meaning for survivors of childhood sexual abuse was found to be important to their recovery (Das et al. 2016). Similarly, the use of logotherapy to address Yalom’s (1980) four existential givens or anxieties about death, isolation, freedom, and meaningless has been supported in case studies of counselling with veterans (Southwick et al. 2006).

Spirituality is a highly individualized concept for both clients and practitioners. This paper applies Benson et al.’s (2016) broad definition of spirituality that includes existential concepts of “a search for a sense of meaning, purpose, moral frameworks, and connection with what they believe is most profound or sacred” that may or may not be expressed through organized religion (p. 1373). Studies illustrating the variability and contextual aspects of spiritual experiences of trauma and posttraumatic healing are valuable contributions to the literature and can provide important lessons for social workers and other healing professionals. An in-depth study of an individual’s trauma and healing experiences can offer important learning and insights to helping professionals working with trauma survivors within their unique personal and broader contexts. Accordingly, this paper presents a qualitative study of one woman’s experience of trauma and the posttraumatic environment. The study encompassed analysis of multiple aspects of her experiences. For the purpose of this paper, a subset of the findings is presented, specifically focusing on the existential/spiritual aspects of her experiences.

2. Materials and Methods

An individual case study approach was used for this research. Case studies are useful in the analysis of detailed descriptions of situations that have many variables (Hartman 2017). Social workers work fundamentally on a case-by-case basis. They must be willing to receive, interpret, and utilize the data presented by each individual case, and adjust their intervention accordingly. The research case study is illustrative of this process, while also accessing complex and detailed knowledge that is lost in studies with larger sample sizes. In keeping with Rowley’s (2002) recommendation, this research is considered exploratory, as it attempts to elicit new knowledge and questions about an area of practice, rather than describing phenomena, or explaining or refuting established theory.

This study consists of a single case in the form of a published autobiographical memoir Impact (McLachlan 2018) of the author’s experience of a traumatic event and the subsequent experience of the helping environment. The single case contains embedded units, described by Rowley (2002) as “sub-units” such as meetings, roles, or locations that when taken together, form an overall picture (p. 19). The embedded units in this case include experiences of the author, Jane Ann:

• While alone or in a reflective state, including journaling;
• With helping professionals;
• In friend, family, work, and other non-professional social interactions.

These experiences are described across a period of approximately eight years, beginning the day of the traumatic event.

Autobiography was selected as the source of data for the case study for several reasons. Primarily, autobiography was a reasonable data source given the time and budget of the enquiry. However, more importantly, autobiography provides rich description of an experience, allowing the author to focus on aspects that are important to them, rather than what seems important to the researcher (Power et al. 2012). This particular autobiography was selected as a recent Canadian example of a memoir of PTSD that was available at the time of study. It contains detailed descriptions of the author’s internal and external experiences, and the meaning which she ascribed to those experiences. The narrative also contains detailed accounts of Jane Ann’s experiences with multiple helping professionals from several fields. The writing of the autobiography was supported by historic journals completed by the author, lending credibility to the recall of experiences.

Thematic analysis, per Braun and Clarke (2006), was used to code and analyze the data in NVivo 12.3.0 for Mac, with some modifications to suit the needs of the project. Three levels of concurrent initial coding were used to denote:

• The individual doing, saying, or thinking;
• The embedded case situation (as discussed above);
• The initial coding of theme elements.

Initial coding was completed inductively, without reference to existing theory. The one exception to this was items that specifically described symptoms of PTSD as documented in the DSM–5 (American Psychiatric Association 2013), such as a nightmare or a flashback. Initial codes were assigned from a realist perspective, using the ascribed meaning and interpretation of the author where available, and straightforward interpretations of language. The initial codes denoted significant emotions, meanings, events, interactions, and features of all people and situations present in the narrative that were relevant to Jane Ann’s posttraumatic experiences.

Following the initial coding, the elements were sorted into a structure of themes and overarching categories. The manuscript was again reviewed and coded to ensure saturation of the themes. The findings were examined against the entirety of the document to ensure that the selected data were representative of the intention of the narrative. The content of each theme was cross-referenced against the four embedded units within the case to develop comparisons across embedded units. Findings were then triangulated against existing theory and literature to confirm the findings or highlight discrepancies.

Case Description

Jane Ann McLachlan is a writer and educator who lives with her husband and three daughters in Canada. On May 1, 2003, while driving her daughter to an appointment, a jeep hurtled across the road, hitting their vehicle. Jane Ann suffered a broken arm, multiple contusions, and a concussion; and daughter, a wrenched back. Although her physical injuries were medically addressed immediately upon entering the hospital, Jane Ann’s emerging emotional and psychological symptoms were not. As her symptoms worsened, Jane Ann sought counselling from various professionals who employed a variety of approaches and modalities to address her psychological and emotional symptoms. Jane Ann was also subject to ongoing assessment from insurance representatives, and assessment and treatment by medical doctors and other physical health professionals. All of these professionals had varying levels and qualities of impact on Jane Ann’s healing process; some helpful, some indifferent, and some harmful.

In her memoir Impact (McLachlan 2018), Jane Ann describes her experiences of the accident and her subsequent healing journey articulately and in detail. Supported by reflections from her personal journal, she is able to recall her thoughts, emotions, and behaviours for several years following the trauma, including details of her interactions with several counselling, pastoral, medical, insurance, and legal professionals, as well as with her own family and friends. Jane Ann’s experience of PTSD was also complicated by historic health issues; she had suffered for several years with colitis, and the stress of the accident had exacerbated her symptoms. Jane Ann is able to draw clear links between her experiences of physical and mental health throughout the narrative. Other factors that influenced her experiences of healing include her family and her religious faith. Jane Ann provides a rich description of her healing experience within the context of her own history, personality, and beliefs, as well as the context of the helping environment following the trauma.

3. Results

After completing the initial coding of theme elements (Braun and Clarke 2006), the elements were categorized and collapsed into ten themes, which fell into three broad categories: descriptions of trauma impacts; factors and processes within the helping environment; and client posttraumatic healing experiences. The themes in each category are shown in

Table 1. Themes and categories.

Category	Trauma Impacts	Helping Environment Factors	Posttraumatic Healing Experiences
Themes	Psychological symptoms of PTSD	Process and focus of intervention	Evolving coping strategies
	Emotional experiences	Relational factors	Construction of meaning
	Physical injury and illness	Level of alignment between client and professional	Reconciling changed identity
	-	-	Relational sensitivities and growth

, in descending order of coding frequency.

This paper focuses solely on two themes from the Posttraumatic Healing Experiences category, Construction of Meaning and Reconciling Changed Identity, since they pertain to the importance of spiritual factors in posttraumatic healing. The remaining categories, although relevant to the study, do not involve any spiritual factors relevant to the focus of this paper.

3.1. Construction of Meaning

An important spiritual theme in Jane Ann’s healing journey was the construction of meaning. Jane Ann struggled to understand the reason for the accident; this struggle had deep impacts on her strong religious faith. She also negotiated the meaning of help and hope in the context of what seemed meaningless.

3.1.1. With Helping Professionals

Jane Ann’s exploration of meaning with helping professionals was limited, and professionals with whom she addressed issues of meaning tended to avoid the subject. She expressed her struggles with meaning in limited ways, such as telling her first counsellor, “God threw a jeep at me” (McLachlan 2018, p. 72), and by identifying that her soul had been hurt along with her mind and body. Following this disclosure, the counsellor suggested she speak to a pastor. When Jane Ann did speak with a pastor or engage with her church community, she struggled with social expectations (“…those are not publicly acceptable emotions; we all did what was expected of us, and kept silent”, p. 25) and trust (“…God has made no concessions for me, either. It’s guilt by association for poor Pastor Robert”, p. 63). Her cognitive therapist, when Jane Ann identified that she was angry at God, stated that he wished he “had enough faith to be angry at God” (p. 127), which ended the exchange. More restrictive modalities such as EMDR, or medical treatment with a medical doctor did not invite the exploration of meaning; Jane Ann brought it up with “Click-Clack” (as she referred to her EMDR therapist), again stating that her soul was hurt more than her body, however Click-Clack simply nodded. She did not bring it up with her general practitioner. Jane Ann’s final counsellor did use life meaning as a way to connect with Jane Ann, such as the “cycle of life” associated with looking forward to grandchildren, however, they did not address the meaning or meaninglessness of the accident. Issues of meaning were not addressed with insurance-hired professionals (i.e., psychologist and occupational therapist) who assessed her mental and physical health needs for the purpose of insurance coverage.

3.1.2. Internal Processing

At the time of the accident, waiting in the car, Jane Ann calls out to God for help, and comforts herself by thinking “help is coming” (p. 11). However, her initial experience of help in the hospital was largely negative, associated with pain, and neglect of her emerging emotional and psychological distress. This began a period in which Jane Ann reflected on meaning, about the role of God, and the nature of help.

Initially, following the accident, Jane Ann was angry at God, seeing God as callous and uncaring. She journaled,

Maybe the world is shit—it’s fertilizer—and we’re the plants it’s growing. Jesus said some of the seeds would fall on dry ground, and some would grow and be blighted, and only a few would bear fruit. Callous bastard. We’re in agony here and God’s conducting an agricultural experiment? Is that it? (Speaking as one of the blighted seeds.)

(p. 68)

She saw hope as “a thing with claws” (p. 63) and was convinced that “no help is coming” (p. 42). This period of reflection on meaning was characterized by attempts to find inherent, rather than constructed, meaning in the world and in her situation.

Although Jane Ann’s first counsellor did not explicitly address the meaning of the accident with Jane Ann, his stance that the accident was not Jane Ann’s fault prompted new reflections on meaning that she processed internally. Jane Ann began to wonder whether she was searching for meaning or fault in a situation that was inherently meaningless. She reflected on the “precise, sadistic timing” (p. 69) required to put her in the path of the accident, implying some kind of fate. From here, she moved towards believing in an “impersonal God” (p. 45) who did not care about her as an individual, but realized that this did not excuse her from being a good person, and being an active agent in her life. This point marked a transition wherein Jane Ann began to accept the impacts of the accident and construct meaning and purpose in her life, rather than searching for inherent meaning. In one impactful moment of acceptance, Jane Ann allowed herself to figuratively die, and to adjust her view of the world based on having been dead. In this reflection, she used and modified the concept of trusting peripheral vision that was encouraged by her cognitive therapist:

The future is something that lies straight ahead, but my life has ended—there’s no longer a straight vision forward. Anything that happens now is on the sidelines of my life. I begin to look at everything with a kind of peripheral vision: a vision devoid of expectations, which are, by definition, linear… Anything I do can only be compared to nothing, to having died. It’s a crazy idea, but it works. When I step out of the shower, my depression has been washed away. By letting myself die, I think I may have found a way to live.

(p. 138)

She began to see the commandment “to love God” (p. 68) as an action, rather than a passive emotion; in her most difficult moments she whispered to God “I love you” (p. 73), fiercely and defiantly. Finally, she felt the presence of God in her life again, reflecting, “I see God in a mountain and in a soaring work of architecture; I hear God in the wind and in a pure chord of music. The Divine exists, within and without. I will not reduce God to what he can do for me” (p. 278).

Similarly, Jane Ann’s reflections on help moved from a passive stance; “no help is coming” (p. 54) to a more active, engaged stance “I am help” (p. 285). Jane Ann re-created meaning around help in her life, by donating medicines and supplies to medical clinics in Cuba, leading to deep internal peace. Overall, Jane Ann appears to navigate a shift in her understanding of the nature of meaning, the role of God, and help from a more passive approach and expectation of inherent meaning, to an active, constructivist approach.

3.1.3. With Family, Friends and Co-Workers

Jane Ann did not directly address issues of meaning with others in her life and interactions with co-workers were not generally associated with construction of or reflection on meaning. However, strangers occasionally prompted reflections on meaning, which she processed while alone. For example, after meeting with a friend with a disability at church, Jane Ann reflected, “I envy her faith. I’m barely hanging on, myself. And I’m ashamed, because it seems she’s been through so much worse than me, and it’s only made her faith stronger. Why did she turn toward God when so much was taken from her? Why did I turn away?” (p. 244). Interactions with family also provided comfort based on reflections of meaning in life. After singing hymns with family, Jane Ann thinks, “we only have to shed a little light in our small corner of life. I don’t have to be perfect. I don’t even have to be whole. It’s enough if I bring a bit of light to the small, dark corner I inhabit” (p. 259).

In summary, Jane Ann’s healing was significantly impacted by her ability to transition from a search for inherent meaning to acceptance of the impacts of the accident, and active creation of meaning. This process largely took place alone, although her reflections were often prompted by her experiences of helping professionals, or family and friends.

3.2. Reconciling Changed Identity

One of the most difficult issues Jane Ann dealt with during her recovery was the issue of her changed identity. She struggled to reconcile the tough, stoic and capable woman she had been before the accident and the emotional, dependent, physically weakened person she had become following the accident. One of the ways she described this change in identity was to both personify and internalize the concept of fear, saying “I have swallowed fear, taken it deep into myself. I can feel it spreading through me, malignant and relentless, changing me, devouring me, becoming me” (p. 43). She began to see herself as “a Fraid” (p. 78), as if fear were the defining characteristic of who she had become.

3.2.1. With Helping Professionals

Similar to the issue of meaning, even though identity was an important theme for Jane Ann personally, it was rarely addressed directly in helping relationships. Several times with helping relationships, Jane Ann thought of her changed identity, for example calling herself a “humiliating spineless creature” (p. 61), but did not express this thought aloud. While Jane Ann identified decreased physical and mental abilities, she tended to discuss them as symptoms rather than as identity-forming traits. This was in contrast to her reflections on identity while alone, or when writing in her journal (see below). Only with her last counsellor did she address her disappointment in no longer feeling “independent” in her marriage. When the counsellor reflected back this sense of helplessness, Jane Ann “shut down” (p. 252). Thus, although Jane Ann discussed aspects of her experience that related to identity, her experience of identity change was not clearly labeled and processed by helping professionals.

Jane Ann’s interactions with insurance professionals exacerbated her experience of changed identity. She frequently described the negative impact of having to write “lists of inadequacies” (p. 44) on her sense of independence, and often had the sense of being incapable of dealing with the stress of the insurance system and its requirements. The overall sense of suspicion from the insurance industry also impacted her sense of self and led her to question her own motivations: “The constant suspicion of dishonesty that hangs over me is demoralizing in itself. I’m beginning to feel insecure, constantly on the defensive, like no one trusts or believes me anymore. Maybe their suspicions are correct?” (p. 110). Jane Ann sometimes changed the way she would normally have behaved to placate insurance representatives, leading her to question who she really was:

This isn’t me. I’m not someone who’d whisper “What would you prefer?” to a person who’s just suggested something I know damn well is inappropriate. I’m not someone who sits in a hotel room crying in front of a stranger. This isn’t me. But I don’t say it out loud, because evidently this is me.

(p. 173)

Although some insurance assessors identified Jane Ann’s positive attributes, such as being self-directed, persistent, and stoic (p. 147), Jane Ann did not report that these experiences significantly impacted her sense of identity in a positive way. Thus, the net results of Jane Ann’s interactions with the insurance industry appeared to be destabilization of identity and assimilation of a negative self-image.

3.2.2. Internal Processing

When reflecting or writing in her journal, Jane Ann frequently compared her current and past selves. For example, upon returning to work and preparing for her classes, she reflected, “just looking at it, thinking about it, is tiring. What to teach when, what tests to give, and when. I close my eyes. How am I ever going to get through this? I used to enjoy planning a course” (p. 115). Eventually she began to accept her changed identity, and her attempts to move forward: “I am still lost and frightened, unable to feel at home with the person I’ve become, unable to find my way back to who I was. And yet, despite my fear, I am still somehow driving forward, trying to find my way” (p. 122).

Jane Ann also related her struggle with identity to her struggle to find or create meaning, stating, “I realize the battle was not only about faith, but about my self, about who I am at my very core. I could not let the accident take this, also, from me” (p. 153). She found stability in the idea that she could lose so much of herself, but still choose this aspect of her identity.

It was while alone, reflecting on a comment made by her husband, that Jane Ann made perhaps the most powerful realization related to her sense of lost identity:

Fear and constant pain lowered my sense of control and the critical comments several people made decreased my confidence—blow after blow. And then I set myself up for failure by going back too soon, going back full-time, and placing so much emphasis on it. ‘I’m a teacher, I’m in control, capable, smart’—when I wasn’t any of those things any more. I was so busy holding myself together, I couldn’t see what was happening.

(p. 168)

It was at this point that Jane Ann realized that her sense of self had been slowly degraded, and that her resultant frantic attempts to re-establish her pre-accident identity, rather than integrating her experiences into a new sense of identity, were detrimental. This realization was supplemented by a book about PTSD that her last counsellor provided to her. The book provided psychoeducation about the role of the victim in trauma, and the secondary wounding that takes place in the posttraumatic environment. Jane Ann used this information to analyze her own negative posttraumatic helping experiences. At the end of the narrative, Jane Ann released the need to recover a pre-accident identity, and accepted the integration of the trauma experience into a new sense of identity, which was no longer defined solely by fear:

I will never be the person I was before the accident. I’ve lived for awhile in darkness, and sometimes it will come back. But I have not had a recurrence of nightmares or panic attacks because of this surgery. The puzzle held… I’m not a Fraid anymore.

(p. 299)

3.2.3. With Family, Friends, and CO-Workers

Interactions with family and friends, although often supportive, generally reinforced Jane Ann’s perception the differences between her past and current selves. She referenced her brother being “shocked” (p. 37) when he saw her, and a friend who admitted that she could see Jane Ann’s new issues with cognition during conversation. One friend commented after visiting, “I came over here in a good mood and now you’ve just depressed me” (p. 135), leading Jane Ann to believe that when friends called, “the person they’re calling is no longer here” (p. 135). Even supportive family members were experienced by Jane Ann as unable to understand how much she had “lost” (p. 82) herself. When Jane Ann interacted with her church community, she was immediately connected by her pastor to other church members who had experienced accidents. This experience led to negative comparisons of herself with the other survivors, and Jane Ann no longer felt a sense of belonging with the church, stating:

I don’t return to church. I can’t face them. Pastor Robert has a gift for encouraging participation in the life of the church, offering people just the right opportunities to use their gifts and strengths. But I have no strengths to share now, and I’m ashamed of my weakness.

(p. 25)

Jane Ann’s return to work began hopefully, with the expectation that she would be a teacher again and leave the accident behind. However, the mental and physical drain and distress caused by full-time work, combined with the high expectations of her managers, supported Jane Ann’s beliefs that she had been dramatically altered. One manager attacked Jane Ann’s identity and integrity, sarcastically remarking, “what I wonder about…is, you’re going to be teaching ethics?” (p. 154) after Jane Ann excused herself from teaching a course due to illness. This echoed the message from the insurance industry that undermined Jane Ann’s sense of self.

In summary, although the integration of a healthy post-accident identity was a major theme in Jane Ann’s healing journey, it was not explicitly addressed by helping professionals. The insurance industry generally undermined Jane Ann’s sense of self and caused her to reflect more on her inabilities than her abilities. Similarly, the workplace had a negative impact on Jane Ann’s perception of herself. Family and friends, even when well-meaning, often served as reminders of how much of her previous self that Jane Ann had lost.

Jane Ann, largely independently, went through a process of comparing current and past selves, defining herself through fear as a result of the trauma, and then deciding she needed to move forward rather than cling to her pre-accident identity. This was accomplished through the process of creating meaning related to the core of her identity (i.e., choosing to love God), identifying the impacts of the accident and the secondary wounding in the helping environment, and integrating the “puzzle pieces” (p. 139) of her pre- and post-accident experiences. Similar to Jane Ann’s trajectory through her understanding of meaning, Jane Ann’s understanding of her identify is characterized by a shift from a rigid, static understanding of identity to a more flexible and constructivist understanding of identity that accommodated her experience of trauma.

4. Discussion

Construction of meaning and reconciling her changed identity encompassed the findings of two key areas of missed or negated opportunities for helping professionals to support Jane Ann in her healing journey. Although Jane Ann broached issues of spiritual and existential importance, such as her shifting relationship with God, the nature of hope, and her sense of identity, with several helping professionals, these helping professionals eschewed deeper reflection upon these issues.

Failure of helping professionals to address the issue of meaning or meaninglessness represents one of the most significant missed opportunities within the narrative, particularly because Jane Ann’s preoccupation with meaning was such a substantial theme in her personal reflections. Meaning (including spiritual meaning) has been identified as an important factor in posttraumatic healing (Grad and Zeligman 2017; Jirek 2017; Van Hook 2016). Yalom (1980) suggests that by developing meaning in life, we may achieve satisfaction and alleviate death anxiety. Empirical evidence supports the idea that meaning making is important to posttraumatic recovery and growth (Das et al. 2016; Schuman 2016; Southwick et al. 2006). Helping professionals neglected to initiate discussions of meaning, and, when Jane Ann raised the issue, they tended to avoid it or address it superficially.

Reconciling her changed identity was another aspect of healing that Jane Ann undertook largely independently. With therapists, Jane Ann did not raise the issue of identity directly, and therapists did not inquire, although some of the psychoeducational material that one therapist provided was useful in prompting reflections on identity. The role of identity and sense of self is well documented in existential and cognitive perspectives of trauma, and erosion of self-concept is common following trauma (Ebert and Dyck 2004; Ehlers and Clark 2000; Keshet et al. 2019).

The common characteristic of each of these missed opportunity factors is that they are not clearly related to the typical symptoms (i.e., re-experiencing, avoidance, and hyperarousal) of a non-interpersonal trauma (Hyland et al. 2017). These characteristics are more often associated with the construct of complex PTSD following prolonged interpersonal trauma, as elucidated by Herman (1992). This may in part explain why they were overlooked by helping professionals. However, examination of interpersonal and non-interpersonal trauma suggests that both trauma types may be associated with negative views about the self and the world (Cromer and Smyth 2010), confirming the finding that helping professionals should attend to identity, worldview, and meaning with clients with all types of trauma.

The findings of this case study support the importance of meaning-making and spirituality in the process of trauma therapy and suggest that some practitioners may neglect or even actively avoid this issue. This is supported by a study of behavioural and cognitive therapists that found 36% reported discomfort in addressing spiritual and religious issues with clients, and 71% had no training in this domain (Rosmarin et al. 2013). A qualitative study of clinical social workers’ integration of religion and spirituality into their practice suggested that the personal religiosity of the therapist, as well as appropriate training, supported the integration of these elements into their practice (Oxhandler and Giardina 2017). Although many respondents did not endorse barriers to spiritual integration, those who did cited lack of training, discouragement from clients, or the perception of religion and spirituality as taboo. Some also reported that professional and agency-related factors (such as time constraints) contributed to hesitancy. It is possible that the fact that Jane Ann’s search for meaning was expressed through a religious interpretation contributed to the neglect of meaning issues in therapy. However, when Jane Ann interacted with the church, she engaged in negative comparisons of herself with others, a sense of not belonging due to changed identity, and internal conflict related to a sense of meaning and the role of God, which she was not willing or able to express to her pastor. This highlights a competency gap in the network of helping professionals, where counsellors and social workers may feel unable to address spiritual concerns, while spiritual helpers may lack the understanding of trauma that is required to fully support survivors.

Spiritually responsive practice presents one approach to addressing the existential or spiritual wounding associated with a traumatic event. Recent advances in psychology and related fields have highlighted the centrality of spirituality in the human experience, including the experience of life challenges and traumatic events. It has been argued that spirituality should be included as a central human intelligence (Emmons 2000; Skrzypińska 2021), that it should be included in metrics of posttraumatic growth (Tedeschi et al. 2017), and that “soul work” is a critical component of social work (Nowakowski-Sims and Kumar 2020, p. 189).

The definition of spirituality is elusive; it may mean different things to different people. Spiritually responsive practice could include awareness of spiritual and existential concerns in relation to trauma, spiritual self reflection and reflexivity on the part of the helping professional, and active eliciting and engagement with spiritual and existential dialogue as part of holistic therapy. This may include general practice elements such as having a person-centred approach, recognizing religious/spiritual coping strategies, including these topics in the assessment process, developing experience with religious and spiritual issues, and responding to client-initiated discussions of religion and spirituality (Oxhandler and Giardina 2017). In discussion with helping professionals, Jane Ann used key terms, such as God and soul. To facilitate spiritually responsive practice, therapists should attend to spiritually oriented language and then engage in a richer dialogue to understand the meaning she attributed to spiritual concepts and concerns. This may require some deviation from the more typically structured modalities (e.g., exposure therapy) to accommodate the unique nature of traumatic impacts.

Vis and Boynton (2008) reviewed literature that related concepts of spirituality specifically to trauma healing, they found that spirituality has been conceptually linked to trauma as an extension of worldview, coping, meaning making, and posttraumatic growth. They suggest that social work clinical interventions for trauma should include “spiritual therapeutic discourse” (p. 78). This requires social workers to examine their own belief systems and spiritual backgrounds, assess client spiritual views, experiences and resources, and engage in spiritually oriented interventions. Examples of integration of spirituality into clinical practice included positive spiritual rumination, spiritual narrative construction, and engagement in spiritual self-care. Jane Ann practiced journaling as a way of processing, not only her trauma, but her spiritual concerns and growth. Therapists who are aware that their clients use journaling as a processing tool could leverage this tool to support the construction of a spiritual narrative. The use of spiritual bibliotherapy (aligned with client’s belief systems) may also support this process of narrative construction; similar to Jane Ann’s use of PTSD self-help material.

The use of a case study methodology has inherent limitations. Questions arise as to the transferability of case data, whether any conclusion may be drawn, and whether the knowledge derived from a case may be illustrative or explanatory (Longhofer et al. 2017). Although alignment with existing literature provides some evidence of reliability, evidence from this study should be interpreted as exploratory, and used by clinicians in conjunction with evidence-based approaches and sound clinical judgment. Issues of transferability are also related to the nature of the subject of the case. This is a case of a middle-class, educated, white, Christian, Canadian female in a traditional heterosexual marriage. Variations on this social location would likely generate different findings.

5. Conclusions

This case study of Jane Ann’s memoir offers important insights and opportunities for learning about posttraumatic healing and growth to social workers and other helping professionals. It also invites consideration of the internal healing processes that can occur in parallel with formal therapeutic interventions. The therapist is privy to only a small portion of the client’s thoughts and emotions, and therefore, should nurture and encourage this resiliency with this awareness. Spiritual aspects of therapy are too often avoided or considered out of scope for many helping professionals. Yet, practicing in a spiritually responsive manner with clients who are struggling with spiritual aspects of healing, such as life’s meaning or reconciling changed identity, could offer more effective support. Helping professionals do not need to be experts in religion or spiritual matters to provide spiritually responsive support. Spiritual responsiveness has the potential to elevate trauma specific practice to address more than the symptoms of trauma; it has the potential to support survivors in developing resilience, engaging in posttraumatic growth, and reaching a new understanding of their identity, place in the world, and life’s meaning.