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City Research Online City, University of London Institutional Repository Citation: Clark, R.M. (2010). Loss, trauma and post-traumatic growth. (Unpublished Doctoral thesis, City University London) This is the accepted version of the paper. This version of the publication may differ from the final published version. Permanent repository link: https://openaccess.city.ac.uk/id/eprint/8706/ Link to published version: Copyright: City Research Online aims to make research outputs of City, University of London available to a wider audience. Copyright and Moral Rights remain with the author(s) and/or copyright holders. URLs from City Research Online may be freely distributed and linked to. Reuse: Copies of full items can be used for personal research or study, educational, or not-for-profit purposes without prior permission or charge. Provided that the authors, title and full bibliographic details are credited, a hyperlink and/or URL is given for the original metadata page and the content is not changed in any way. City Research Online: http://openaccess.city.ac.uk/ publications@city.ac.uk Loss, trauma and post-traumatic growth Ruth M. Clark (CPsychol) Professional Doctorate in Counselling Psychology (DPsych) City University Department of Psychology January 2010 IMAGING SERVICES NORTH Boston Spa, Wetherby West Yorkshire, LS23 7BQ www.bl.uk THESIS CONTAINS CD Table Of Contents Acknowledgements 9 City University Declaration 10 Section A: Preface 11 Section B: Research: "A phenomenological exploration of clinicians' lived experiences with suicidal clients and following client suicide' 16 Abstract 17 Chapter 1. Introduction: Literature Review 18 1.1 Client suicide: 'an occupational hazard' for clinicians in mental health care 18 1.2 The place of the researcher 19 1.3 Ethical and legal issues 22 1.3.1. Professional responsibilities 22 1.3.2. Confidentiality 23 1.3.3 Dilemmas concerning suicidal clients 24 1.3.4 The right to die 25 1.3.5 Assisted suicide 26 1.4. Therapeutic intervention with suicidal clients and the effect of client suicide on clinicians: a review of research and theoretical perspectives 29 1.4.1 The impact of client suicide on those within psychiatry 30 1.4.2 Does the experience of the clinician affect their response to client suicide? 33 1.4.3 Aspects that may increase the distress of the clinician 34 1.4.4 Client suicide: a traumatic event? 35 1.4.5 Perceptions of a lack of support following client suicide 36 1.4.6 Reluctance to seek professional assistance 36 1.5 The integral place of clinical supervision 38 1.6 The National Health Service investigation following a client suicide 41 1.7 Stigma from a sociological perspective 43 1.8 The concept of loss and theoretical underpinnings 44 1.8.1. Humiliation and shame 44 1.8.2 A social-contextual theory 45 1.9 Summary of findings and limitations of existing research 47 2 1.10 The purpose of the present study: research aims and questions 49 Chapter 2. Methodology 50 2.1. Adopting a qualitative approach 50 2.1.1 Rationale for adopting Interpretive Phenomenological Analysis (IPA) 51 2.1.2 Rationale for adopting an interview schedule 52 2.2 Ethical considerations 52 2.3 Sampling and participants 53 2.4 Interviews 53 2.5 Analytic strategy 54 2.6 Credibility of the research 55 2.7 Inherent subjectivity 56 2.8 Transferability of the findings 56 2.9 The presentation of data 56 Chapter 3. Analysis and Discussion 57 3.1 The participants' experiences of treating suicidal clients and of client suicide 58 3.2 Overview of themes: Working with and beyond client suicide 58 3.3 Superordinate theme one: Being with suicidal clients 61 3.3.1 Understanding the client and self 63 3.3.2 Vulnerability 67 3.4 Superordinate theme two: Impact of client death 75 3.4.1. Inexplicability and fear 77 3.4.2 Starting to make sense: The therapeutic relationship 80 3.4.3 Failure 85 3.4.4 Searching for reasons 86 3.5 Superordinate theme three: Subsequent influential experiences 91 3.5.1. Being under scrutiny: Powerless in unfamiliar territory 93 3.5.2 Exposure 94 3.5.3 Seeking comfort as protection 98 3.6 Superordinate theme four: Evolving 106 3.6.1 Changed responses 108 3.6.2 Emotional needs 111 3.6.3 Self perception 113 3 Chapter 4. Synthesis 120 4.1 Overview of the research findings 120 4.2 Review of the application of theoretical frameworks 121 4.3 Limitations and future areas of research 124 4.4 Applications to Counselling Psychology and recommendations 126 4.5 Personal reflexivity 129 Chapter 5. Section C: Critical literature review: 'The challenges of traumatic loss: the phenomenon of post-traumatic growth' 132 5.1 Introduction 132 5.2 An integrated theory of post-traumatic growth and existing concepts of humanistic psychology 135 5.3 Validity of the concept of post-traumatic growth 138 5.4 Post-traumatic growth following bereavement 139 5.5 Assessing post-traumatic growth 140 5.6 Can the individual influence post-traumatic growth? 143 5.7 Summary and future directions for research 144 5.8 The principles of post-traumatic growth applied to clinical interventions 145 Chapter 6. Section D: Case Study: 'The use of 'reliving' interventions and optimising psychological strengths in a client suffering with Post Traumatic Stress Disorder' 155 6.1 Part A: Introduction 155 6.1.1 Rationale for the choice of case 155 6.1.2 Summary of theoretical frameworks 156 6.1.3 A cognitive model of PTSD 156 6.1.4 Context of the referral 157 6.2 Part B: The initial assessment 159 6.2.1 Convening the first session 159 6.2.2 The presenting problem 159 6.2.3 Background and family history 160 6.2.4 The assessment process 160 6.2.5 Choosing an appropriate treatment approach 161 6.2.6 Case formulation 161 6.2.7 Negotiating a contract and the goals of therapy 163 4 6.2.8 The approach taken 163 6.3 Part C: The development of therapy 165 6.3.1 The pattern of therapy 165 6.3.2 Beginning therapy 165 6.3.3 Initial difficulties in the work 166 6.3.4 Key interventions 166 6.3.5 Liaison with other professionals 169 6.3.6 Changes to the formulation and plan 169 6.3.7 The use of supervision 170 6.4 Part 0: The conclusion of therapy 171 6.4.1. Outcome of therapy 171 6.4.2 The therapeutic ending 172 6.4.3 Reflections of the therapeutic process and my own learning 172 References 175 5 List of Appendices Section B: Research Appendix 1: Letter of approval from the Local Research Ethics Committee 208 Appendix 2: Letter of approval from the Research Governance Committee 211 Appendix 3: Letter of Introduction 212 Appendix 4: Letter of Invitation 214 Appendix 5: Participant Information Sheet 215 Appendix 6: Letter of support for the study 217 Appendix 7: Semi-structured interview schedule 218 Appendix 8: Consent form 219 Appendix 9: De-briefing 220 Appendix 10: Process Issues: Reflexive Diary 221 Appendix 11: Draft of information sheet' What to do after a client dies by suicide' 226 Appendix 12: Table of examples of superordinate and subordinate themes 229 Section 0: Case Study Appendix 13: A model of Post Traumatic Stress Disorder 235 Appendix 14: PTSD client leaflet 236 6 List of Tables Section B: Research Table 1: The experiences of participants of treating clients who were suicidal and of client suicide 57 Table 2: Being with suicidal clients 61 Table 3: Impact of client death 76 Table 4: Subsequent influential experiences 91 Table 5: Evolving 106 Section C: Critical Literature Review Table 6: A summary of studies of post-traumatic growth 149 7 List of Figures Section B: Research Figure 1: An explanatory model outlining the process of working with and beyond client suicide. Theme 1: Being with suicidal clients 60 Figure 2: An explanatory model outlining the process of working with and beyond client suicide. Theme 2: Impact of client death 74 Figure 3: An explanatory model outlining the process of working with and beyond client suicide. Theme 3: Subsequent influential experiences 90 Figure 4: An explanatory model outlining the process of working with and beyond client suicide. Theme 4: Evolving 105 8 Acknowledgements I would like to express my deepest gratitude to the participants in this study, for whom I have the deepest respect. I give my warmest thanks to my husband, Lawrence and to my mother. I am grateful to Dr Malcolm Cross for his humour and support and Dr Jenny Newton for her encouragement and constructive criticism. Finally, I give my thanks and my appreciation to my dear friends Paddy, Jackie and all my other friends and my colleagues. 9 Declaration of discretion to the librarian I grant powers of discretion to the University Librarian to allow this thesis to be copied in whole or in part without further reference to me. This permission covers only single copies made for study purposes, subject to normal conditions of acknowledgement. 10 Section A: Preface The central theme of this thesis is the promotion of understanding of the potential effect of a loss or a traumatic event on the individual. The thesis aims to raise awareness of the unfortunate reality of client death by suicide, how clinicians react to clients who are suicidal and how a client suicide may be experienced, including the threat to their professional identity. The thesis illuminates a range of possible individual response to trauma or to loss. It is claimed that the profession of Counselling Psychology arose from a concern with the fulfilment of potential (Woolfe & Dryden, 1996) and on well-being, rather than pathology.