Talking therapy services for adult survivors of childhood sexual abuse (CSA) in Scotland: perspectives of service users and professionals

What do adults who experienced child sexual abuse want to convey about therapy?

BACKGROUND

Child sexual abuse (CSA) studies have significantly advanced the understanding of its prevalence and adverse consequences. Tremendous efforts worldwide have been devoted to CSA interventions. However, surprisingly, there is a lack of research dedicated to learning about experiences with therapy among adults who experienced CSA.

OBJECTIVE

This study was designed to address this gap by exploring the perspectives and experiences with therapy among adults who experienced CSA.

METHODS

Thirty-nine written testimonies comprised the current sample. All of the testimonies were provided to the Israeli Independent Public Inquiry into CSA by adults who experienced CSA and received therapy at one point in their lives. A qualitative inductive thematic analysis guided the exploration of the testimonies.

RESULTS

The testimonies provided an important glance into significant characteristics of therapy, such as the timing and reasons leading to therapy, and perceptions regarding what constitutes appropriate therapy. Although beneficial and rehabilitating therapy experiences were mentioned by some of the participants, the majority of the testimonies focused on experiences related to the obstacles and challenges to accessing and engaging in therapy faced by those who experienced CSA.

CONCLUSIONS

The testimonies not only addressed essential aspects of therapy, but also highlighted the importance of thoroughly comprehending the broad context of a person's life that leads them to seek therapy. The discussion points to grave social and policy lacunas that prevent people who experienced CSA from receiving therapy that is accessible, timely, subsidized, stigma-free and multifaceted.

Disclosure of Sexual Victimization: Effects of Invalidation and Shame on Re-Disclosure

Research on disclosure of sexual victimization has consistently demonstrated that the act of disclosure and the disclosure recipient have a synergistic effect in facilitating either positive or negative post-assault outcomes. While negative judgments such as victim blame have been argued to serve a silencing function, experimental investigations of this claim are lacking. The current study investigated whether invalidating feedback in response to self-disclosure of a personally distressing event produced feelings of shame, and whether shame influenced subsequent decisions around re-disclosure. Feedback type (validating, invalidating, no feedback) was manipulated in a sample of 142 college students. Results partially supported the hypothesis that shame resulted from invalidation, however shame was better predicted by individual perceptions of invalidation than the experimental manipulation. Although few participants opted to make changes to the content of their narrative for re-disclosure, those who did had higher levels of state shame. Results suggest that shame may be the affective mechanism by which invalidating judgments silence victims of sexual violence. The present study also supports the distinction previously made between Restore and Protect motivations in managing this shame. This study provides experimental support for the notion that an aversion to being shamed, communicated via an individual's perception of emotional invalidation, features in judgments of re-disclosure. Perceptions of invalidation, however, vary individually. Professionals working with victims of sexual violence should be mindful of the importance of shame attenuation in facilitating and encouraging disclosure.

Impact, Ramifications and Taking Back Control: A Qualitative Study of Male Survivors of Childhood Sexual Abuse

There is increasing recognition of the occurrence and frequency of male childhood sexual abuse (MCSA). Quantitative and qualitative research has demonstrated a number of adverse outcomes associated with MCSA in terms of mental health, physical health and difficulties in behavioural, social or interrelationship functioning. The present study gives voice to male survivors of childhood sexual abuse by exploring themes around the impact of MCSA over the course of their life. Interpretative phenomenological analysis (IPA) of semi-structured interviews with nine male survivors of childhood sexual abuse identified a single overarching theme of control and six related superordinate themes of: (i) responsibility, blame and shame; (ii) development of knowledge about sex and abuse; (iii) avoidance of coping with abuse; (iv) effects on relationships as adults; (v) disclosure of abuse to others; and (vi) gaining a sense of meaning of the abuse. The findings showed that being sexually abused defines and controls a person's life, and that despite the difficulties experienced by victims to move past the abuse, some experienced a degree of personal growth. The findings illustrate the way in which individuals can create meaning around their abuse experiences and take back control.

Survivor, family and professional experiences of psychosocial interventions for sexual abuse and violence: a qualitative evidence synthesis

BACKGROUND

It is well-established that experiencing sexual abuse and violence can have a range of detrimental impacts; a wide variety of interventions exist to support survivors in the aftermath. Understanding the experiences and perspectives of survivors receiving such interventions, along with those of their family members, and the professionals who deliver them is important for informing decision making as to what to offer survivors, for developing new interventions, and enhancing their acceptability.

OBJECTIVES

This review sought to: 1. identify, appraise and synthesise qualitative studies exploring the experiences of child and adult survivors of sexual abuse and violence, and their caregivers, regarding psychosocial interventions aimed at supporting survivors and preventing negative health outcomes in terms of benefits, risks/harms and barriers; 2. identify, appraise and synthesise qualitative studies exploring the experiences of professionals who deliver psychosocial interventions for sexual abuse and violence in terms of perceived benefits, risks/harms and barriers for survivors and their families/caregivers; 3. develop a conceptual understanding of how different factors influence uptake, dropout or completion, and outcomes from psychosocial interventions for sexual abuse and violence; 4. develop a conceptual understanding of how features and types of interventions responded to the needs of different user/survivor groups (e.g. age groups; types of abuse exposure; migrant populations) and contexts (healthcare/therapeutic settings; low- and middle-income countries (LMICs)); 5. explore how the findings of this review can enhance our understanding of the findings from the linked and related reviews assessing the effectiveness of interventions aimed at supporting survivors and preventing negative health outcomes.

SEARCH METHODS

In August 2021 we searched MEDLINE, Embase, PsycINFO and nine other databases. We also searched for unpublished reports and qualitative reports of quantitative studies in a linked systematic review, together with reference checking, citation searches and contacting authors and other researchers to identify relevant studies.

SELECTION CRITERIA

We included qualitative and mixed-methods studies (with an identifiable qualitative component) that were linked to a psychosocial intervention aimed at supporting survivors of sexual abuse and violence. Eligible studies focused on at least one of three participant groups: survivors of any age, gender, sexuality, ethnicity or [dis]ability who had received a psychosocial intervention; their carers, family members or partners; and professionals delivering such interventions. We placed no restrictions in respect of settings, locations, intervention delivery formats or durations.

DATA COLLECTION AND ANALYSIS

Six review authors independently assessed the titles, abstracts and full texts identified. We extracted data using a form designed for this synthesis, then used this information and an appraisal of data richness and quality in order to stratify the studies using a maximum variation approach. We assessed the methodological limitations using the Critical Skills Appraisal Programme (CASP) tool. We coded directly onto the sampled papers using NVivo and synthesised data using a thematic synthesis methodology and used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess our confidence in each finding. We used a narrative synthesis and matrix model to integrate our qualitative evidence synthesis (QES) findings with those of intervention review findings.

MAIN RESULTS

We identified 97 eligible studies and sampled 37 of them for our analysis. Most sampled studies were from high-income countries, with four from middle-income and two from low-income countries. In 27 sampled studies, the participants were survivors, in three they were intervention facilitators. Two included all three of our stakeholder groups, and five included two of our groups. The studies explored a wide range of psychosocial interventions, with only one type of intervention explored in more than one study. The review indicates that features associated with the context in which interventions were delivered had an impact on how individuals accessed and experienced interventions. This included organisational features, such as staff turnover, that could influence survivors' engagement with interventions; the setting or location in which interventions were delivered; and the characteristics associated with who delivered the interventions. Studies that assess the effectiveness of interventions typically assess their impact on mental health; however, as well as finding benefits to mental health, our QES found that study participants felt interventions also had positive impacts on their physical health, mood, understanding of trauma, interpersonal relationships and enabled them to re-engage with a wide range of areas in their lives. Participants explained that features of interventions and their contexts that best enabled them to benefit from interventions were also often things that could be a barrier to benefiting from interventions. For example, the relationship with the therapist, when open and warm was a benefit, but if such a relationship could not be achieved, it was a barrier. Survivors' levels of readiness and preparedness to both start and end interventions could have positive (if they were ready) or negative (if they were not) impacts. Study participants identified the potential risks and harms associated with completing interventions but felt that it was important to face and process trauma. Some elements of interventions were specific to the intervention type (e.g. faith-based interventions), or related to an experience of an intervention that held particular relevance to subgroups of survivors (e.g. minority groups); these issues could impact how individuals experienced delivering or receiving interventions.

AUTHORS' CONCLUSIONS

We had high or moderate confidence in all but one of our review findings. Further research in low- and middle-income settings, with male survivors of sexual abuse and violence and those from minority groups could strengthen the evidence for low and moderate confidence findings. We found that few interventions had published quantitative and qualitative evaluations. Since this QES has highlighted important aspects that could enable interventions to be more suitable for survivors, using a range of methodologies would provide valuable information that could enhance intervention uptake, completion and effectiveness. This study has shown that although survivors often found interventions difficult, they also appreciated that they needed to work through trauma, which they said resulted in a wide range of benefits. Therefore, listening to survivors and providing appropriate interventions, at the right time for them, can make a significant difference to their health and well-being.

Older immigrant Latino gay men and childhood sexual abuse: Findings from the Palabras Fuertes project

Childhood Sexual Abuse (CSA) and maltreatment have long-term negative impacts on survivors, including older adults. Yet, limited qualitative examinations of how these experiences impact the lives of older adults exists and even fewer among older Latino gay men. We drew data from life-history narratives the first author conducted with five Spanish speaking older Latino gay men in New York City. Our analyses were guided by an Ecological Model, a Suffering lens, and our clinical social work experience with older adults, sexual minorities and people of color. All participants reported sexual experiences prior to the age of 15 and possible emotional and physical maltreatment. Yet, not all participants perceived these experiences as abuse. Our findings indicate how cultural, linguistic and contextual factors may affect disclosure and coping. Despite the fact that CSA and maltreatment occurred decades ago, these early experiences affected long-term psychosocial functioning. Our findings support a need for future research and clinical practice that considers the subjective perceptions of childhood sexual experiences and maltreatment and how these relate to psychosocial functioning in Latino gay men during older adulthood.

Mental health nurses' perceived preparedness to work with adults who have child sexual abuse histories

WHAT IS KNOWN ON THE SUBJECT?: The high prevalence of adults presenting to the mental health services places mental health nurses (MHNs) in a unique position to help to identify and support the person with the associated challenges of child sexual abuse (CSA). Feelings of discomfort have been identified by mental health nurses (MHNs) when working with survivors of CSA due to a lack of knowledge, poor confidence and feeling unprepared to inquire and respond to such a sensitive topic. WHAT DOES THE STUDY ADD TO EXISTING KNOWLEDGE?: MHNs are willing to engage in CSA dialogue; however, the level of engagement is often conditional with clear parameters set by participants. Whilst all participants reported they were willing to engage in conversation initiated by the service user, some were unwilling to listen to details of the CSA and used strategies to censor service users from providing details of the CSA. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Whilst self-protecting boundaries helped MHNs to engage in CSA dialogue, strategies to censor aspects of the service user's dialogue may reinforce the belief that their experience of CSA is too shameful to talk about, hence denying the reality of their experience and contributing to feelings of re-shaming. MHNs need a combination of theoretical knowledge and psychosocial skills to achieve clinical competence when working with CSA; therefore, training should not only include information pertaining to facts and statistics but also case presentations, clinical training and supervision. Clinical supervision was highlighted by all participants as a necessary means of formal support, more specifically group clinical supervision whereby peer support can also be availed of in a formalized setting. ABSTRACT: Introduction The high prevalence of adults presenting to the mental health services places mental health nurses (MHNs) in a unique position to support the person with the associated challenges of CSA, yet little is known about the preparedness of MHNs to work with this client population. Aim To explore MHNs' perceived preparedness to work with adults who have CSA histories, and to elicit their views, skills and confidence in relation to working with this sensitive issue. Method In-depth semi-structured interviews were conducted with five consenting MHNs. A qualitative descriptive methodology informed the study. A thematic analysis framework guided the data analysis. Results The findings assert that MHNs are willing to work with survivors of CSA despite feeling unprepared to so, MHNs described feeling ill-prepared in how to respond to CSA, calling for not just education and training specific to CSA but also citing the need for clinical supervision and additional guidelines to enhance their preparedness. Discussion Results of this study further highlighted the omission of CSA within nursing curricula and the absence of role models within clinical practice as a major barrier to preparedness to work with survivors of CSA. Recommendations are made for training, education and the inclusion of clinical supervision.

Working in the Field of Complex Psychological Trauma: A Framework for Personal and Professional Growth, Training, and Supervision

The aim of this article is to explore the positive and negative impacts of working therapeutically in complex psychological trauma (CPT), particularly the field of gender-based violence (GBV) and childhood sexual abuse (CSA), from the clinicians' perspective. The focus was on the prospect of positive gains and growth for therapists. Twenty-one clinicians (n = 21; counselors/psychotherapists and psychologists) from National Health Service (NHS) specialist trauma services, a community mental health team, and specialist sexual assault counseling organization participated. Interpretative phenomenological analysis (IPA) was utilized to conduct single one-off interviews and analysis. Six themes were identified: Called to the work; Connection, Separation, and Oneness; Into and out of the darkness; Chaos into meaning; Reparation not repetition; and Expansion and growth. The first "Therapist Led Framework of Growth in Trauma Work" is presented. Vicarious posttraumatic growth (VPTG) was a key finding, with CPT therapists experiencing a "challenge/benefit/change" growth process. Adoption of actively relational strategies to enhance clinicians' growth process through trauma work is being proposed. The benefits of conceptualizing both the positive and negative impacts of such work for supervision, training, shaping the formal curricula, service management, and continuing professional development (CPD) are being discussed. The need for good practice guidelines on self-care internationally is highlighted.

Patient and Therapist Perspectives on Treatment for Adults with PTSD from Childhood Trauma

This study aimed to explore patients’ and therapists’ experiences with trauma-focused treatments in patients with posttraumatic stress disorder from childhood trauma (Ch-PTSD). Semi-structured interviews were conducted with patients (n = 44) and therapists (n = 16) from an international multicentre randomised clinical trial comparing two trauma-focused treatments (IREM), imagery rescripting and eye movement and desensitisation (EMDR). Thematic analysis was used to identify key themes within the data. Patients and therapists commented about the process of therapy. The themes that emerged from these comments included the importance of the patients’ willingness to engage and commit to the treatment process; the importance and difficulty of the trauma work, observations of how the trauma focused therapy produced changes in insight, and sense of self and empowerment for the future. In addition, therapists made suggestions for optimising the therapist role in the trauma-focused treatment. This included the importance of having confidence in their own ability, confronting their own and their client’s avoidance and the necessity and difficulties of adhering to the treatment protocols. These reported experiences add further support to the idea that trauma-focused treatments, without a stabilisation phase, can be tolerated and deepens our understanding of how to make this palatable for individuals with Ch-PTSD.

"I'm tired of being pulled from pillar to post": A qualitative analysis of barriers to mental health care for trauma-exposed young people

AIM

Traumatic experiences in childhood are pervasive and associated with a range of deleterious mental health outcomes. Despite this, trauma-exposed young people often do not seek help from mental health services. While barriers to care for general mental health concerns are well established, less is known about those specifically facing young people who have experienced trauma. The present paper sought to examine the barriers in seeking mental health care faced by trauma-exposed young people through a qualitative analysis of online forums where individuals discuss and seek informal support for trauma.

METHODS

This study used a qualitative, netnographic design, following the six-step LiLEDDa framework, developed for the analysis of online forums. Posts about trauma written in 2016 from five Internet forums targeting young people were included and analysed via thematic analysis.

RESULTS

Barriers to mental health care for trauma-exposed young people were categorized into two interrelated themes: (a) structural and (b) relational barriers. Structural barriers related to practical challenges faced when accessing and engaging with mental health services. Relational barriers focused on interpersonal relationships with mental health service providers and how these influenced experiences of, and consequent engagement with, services.

CONCLUSIONS

Trauma-exposed young people appear to experience multiple barriers to mental health care, whereby interactions between structural and relational barriers determine ongoing engagement. Service-wide reform including trauma-informed mental health training for practitioners is urgently needed to improve access to care and engagement for this vulnerable group.

Service needs of young people affected by adverse childhood experiences (ACEs): A systematic review of UK qualitative evidence

BACKGROUND

Adverse Childhood Experiences (ACEs) such as, physical and sexual abuse, neglect, or living in a household with domestic violence or substance misuse, can have negative impacts on mental and physical health across the lifecourse. A deeper understanding of the kinds of services that people affected by ACEs feel they need to overcome these negative impacts is required.

REVIEW QUESTION

How do people affected by ACEs between the ages of 3 to 18 experience support and services in the UK? What are their needs relating to services and support?

METHODS

Systematic review of qualitative evidence. We harvested relevant studies from existing systematic reviews of qualitative evidence located through a search of 18 databases. Included studies needed to be published in or after 2008, conducted in the UK, and report the views of people exposed to ACEs relating to their service needs. We included studies with participants who were affected by ACEs between 3 and 18 years old with no restriction on the age at which they accessed services.

RESULTS

We identified 71 reviews from which we harvested 238 references on title and abstract screening. Following full text screening and quality and relevance appraisal we included 20 studies. Each of the included studies focussed on a specific ACE population. Almost half focused on young people who were fostered, looked-after or leaving care. No studies focussed on parental incarceration or divorce. Young people value emotional and practical support. Service providers were most valued for displaying empathy, being non-judgemental, and being active listeners. Supportive relationships, especially with adults, are a key factor in feeling understood.

CONCLUSIONS

People affected by ACEs describe the importance of stability and continuity in the support they receive. These factors are important for allowing necessary time to overcome obstacles and build up trust. Research often frames response to ACE in terms of short term individual psychological outcomes but these findings highlight the importance of focussing on wider social factors to encourage meaningful engagement with services.

Therapeutic Change in Group Therapy For Interpersonal Trauma: A Relational Framework for Research and Clinical Practice

Our understanding of therapeutic change processes in group therapy for complex interpersonal trauma has been limited. The present study aimed at addressing this gap by developing a framework of therapeutic change in this field from a survivor and therapist perspective. This is a qualitative study, which utilized semistructured individual interviews. Transcripts were analyzed using interpretative phenomenological analysis (IPA) to identify recurrent themes. A final sample of n = 16 patients and n = 5 facilitators completed the interview. Main change processes identified by survivors were as follows: self versus others, trust versus threat, confrontation versus avoidance, and "patching up" versus true healing. Therapeutic processes identified by therapist facilitators included managing group dynamics, unpredictability and uncertainty, and process versus content. The proposed framework explains therapeutic change in group therapy in relational terms, that is, therapeutic dissonance, the dynamic interaction of self and experience as well as building empathic trusting relations. The importance of managing dissonance to aid personally meaningful recovery was highlighted. These findings have implications for the usefulness of relational and person-centered approaches to clinical practice in the area of interpersonal and complex trauma, especially in the early identification, prevention, and management of dropouts.

Personally meaningful recovery in people with psychological trauma: Initial validity and reliability of the Individual Recovery Outcomes Counter (I.ROC)

Individual Recovery Outcomes Counter (I.ROC) is a brief tool measuring personal recovery designed for collaborative use within support. This study aimed to investigate the psychometric properties of a self-report version of the I.ROC within a trauma population. A total of 107 adults attending trauma interventions in an NHS service in Scotland completed I.ROC alongside measures of self-esteem, mental illness symptoms, and functional impairment. Scores on each measure were compared to evaluate the convergent validity of I.ROC. Internal consistency and factor analytical techniques were also used to assess the structural validity and reliability of the measure. Results of internal consistency, convergent validity, and factor analysis provide preliminary support for I.ROC's validity within a trauma population. Previously proposed models were a poor fit for the current sample; principal components analysis suggested a three-factor structure with acceptable internal consistency, comprising ten of the original twelve items (I.ROC-10). Correlations with all measures reached significance for the original and modified I.ROC and its subscales. I.ROC appears to be a valid and reliable tool for use in measuring recovery within a trauma population, but further research is needed to examine the structural validity of I.ROC.

Trust as a mediator in the relationship between childhood sexual abuse and IL-6 level in adulthood

Childhood sexual abuse (CSA) has been shown to predict the coupling of depression and inflammation in adulthood. Trust within intimate relationships, a core element in marital relations, has been shown to predict positive physical and mental health outcomes, but the mediating role of trust in partners in the association between CSA and inflammation in adulthood requires further study. The present study aimed to examine the impact of CSA on inflammatory biomarkers (IL-6 and IL-1β) in adults with depression and the mediating role of trust. A cross-sectional survey data set of adults presenting with mood and sleep disturbance was used in the analysis. CSA demonstrated a significant negative correlation with IL-6 level (r = -0.28, p<0. 01) in adults with clinically significant depression, while trust showed a significant positive correlation with IL-6 level (r = 0.36, p < .01). Sobel test and bootstrapping revealed a significant mediating role for trust between CSA and IL-6 level. CSA and trust in partners were revealed to have significant associations with IL-6 level in adulthood. Counterintuitively, the directions of association were not those expected. Trust played a mediating role between CSA and adulthood levels of IL-6. Plausible explanations for these counterintuitive findings are discussed.

Experiences of fatherhood among men who were sexually abused in childhood

BACKGROUND

Fatherhood is a complex psychological process, which is shaped at a profound level by reflections on past childhood memories and parenting experienced in childhood. Fathers who were sexually abused in childhood may experience particular challenges for their fathering identity and parenting role.

OBJECTIVE

This qualitative study explored the experiences of fatherhood for men who were sexually abused in childhood and how they perceived themselves in the fathering role.

PARTICIPANTS AND SETTING

Eleven participants were recruited to the study from three therapy services for adult survivors of abuse in the Republic of Ireland.

METHODS

Data collection comprised face to face semi-structured interviews, which were audio recorded and subsequently transcribed verbatim. Data analysis drew on Interpretative Phenomenological Analysis and two superordinate themes with associated subthemes were identified.

RESULTS

Participants' experience of childhood sexual abuse provided a lens through which they experienced fatherhood and themselves in a fathering role. Fatherhood influenced participants to confront unintegrated aspects of the trauma they experienced in childhood, which manifested in hypervigilance with regard to their children's safety and doubt that they were good enough fathers. However, fatherhood also offered an opportunity to heal. This occurred through striving to provide a better father-child relationship and through connection in restorative relationships, including the therapeutic relationship.

CONCLUSION

Fatherhood was seen as a potential resource for positive change and can influence long held internal working models of the self and others.

Talking about trauma in therapy: Perspectives from young people with post-traumatic stress symptoms and first episode psychosis

AIM

Despite recommendations from national guidelines, individuals with first episode psychosis (FEP) are currently unlikely to have the effects of their traumatic experiences assessed and treated within psychosis treatment. This may be due to the mismatch between the objectives of trauma-specific treatments (directly targeting post-traumatic stress symptoms by talking about the trauma) and trauma-informed care (limiting practices that may retraumatise clients). We aimed to gain an understanding of what it was like for young people to talk about trauma in FEP treatment, and how their experiences related to the broad conceptualisations of trauma-informed and trauma-specific treatment approaches.

METHODS

Semi-structured interviews were conducted with eleven participants (18-27 years) with FEP and post-traumatic stress disorder (PTSD) symptoms after the completion of an intervention for the effects of trauma. Transcripts were analysed using an interpretative phenomenological approach.

RESULTS

Two superordinate themes were identified, each with subordinate themes. 1. Reluctance to approach the trauma memory: 1a. Not wanting to talk about trauma; 1b. Difficulty acknowledging that the trauma had occurred; 1c. Not wanting to re-experience emotions associated with trauma. 2. Factors aiding the process: 2a. Desire for change; 2b. Not being pushed to talk; 2c. Valuing the case manager; 2d. Time.

CONCLUSIONS

A majority of participants in the study experienced reluctance when recounting their trauma memories. Being in control of how trauma memories are shared and having time for the therapeutic relationship to develop enhanced participants' readiness for talking about trauma. Incorporating trauma-informed principles and motivational interviewing could aid in facilitating the processes around talking about trauma.

How Does Therapy Harm? A Model of Adverse Process Using Task Analysis in the Meta-Synthesis of Service Users' Experience

Background: Despite repeated discussion of treatment safety, there remains little quantitative research directly addressing the potential of therapy to harm. In contrast, there are numerous sources of qualitative evidence on clients' negative experience of psychotherapy, which they report as harmful.

Objective: To derive a model of process factors potentially leading to negative or harmful effects of therapy, from the clients' perspective, based on a systematic narrative synthesis of evidence on negative experiences and effects of psychotherapy from (a) qualitative research findings and (b) participants' testimony.

Method: We adapted Greenberg (2007) task analysis as a discovery-oriented method for the systematic synthesis of qualitative research and service user testimony. A rational model of adverse processes in psychotherapy was empirically refined in two separate analyses, which were then compared and incorporated into a rational-empirical model. This was then validated against an independent qualitative study of negative effects.

Results: Over 90% of the themes in the rational-empirical model were supported in the validation study. Contextual issues, such as lack of cultural validity and therapy options together with unmet client expectations fed into negative therapeutic processes (e.g., unresolved alliance ruptures). These involved a range of unhelpful therapist behaviors (e.g., rigidity, over-control, lack of knowledge) associated with clients feeling disempowered, silenced, or devalued. These were coupled with issues of power and blame.

Conclusions: Task analysis can be adapted to extract meaning from large quantities of qualitative data, in different formats. The service user perspective reveals there are potentially harmful factors at each stage of the therapy journey which require remedial action. Implications of these findings for practice improvement are discussed.

Perspectives of Adult Survivors of Child Sexual Abuse: An Exploration of the Adjustments to Self-Structure through Meaning-Making in Therapy

This critical literature review explored how adult survivors of child sexual abuse experienced adjustments to their self-structure through meaning-making in therapy. Following extensive searches of academic databases, 15 studies were identified for review. Using thematic analysis, eight themes emerged. The eight identified themes of trust, acknowledgement, evolution, acceptance, integration, congruence, relational, and agency represented distinct but interrelated components of self-structure. The findings also indicated that self-structure components may be both intra- and interrelational in nature and that movement in one theme may facilitate movement in another. While recognizing that the nature of the research captured a composite of experiences, it was found that there was a consistent movement and fluidity as to how participants arrived at an adjusted position for each of the themes. A suggested theoretical framework was developed showing the components of the self-structure impacted by meaning-making and the nature of the adjustments made. Recommendations are made regarding future research.

How Do Adult Survivors of Childhood Sexual Abuse Experience Formally Delivered Talking Therapy? A Systematic Review

This systematic review explored how adult survivors of child sexual abuse experienced nonspecific and trauma-focused talking therapies. Following extensive systematic searches of academic databases, 23 qualitative empirical studies were chosen for review. Using a line-by-line thematic synthesis, four analytical themes developed. These themes were: The Therapeutic Process as a Means for Forming Connections, which discusses therapeutic relationships; Developing a Sense of Self Through the Therapeutic Processes, which identifies stages of developmental recovery; Therapeutic Lights and Black Holes in the Shadows of child sexual abuse, which reflects on how a history of child sexual abuse influenced experiences of therapy; and Healing or Harrowing: Connecting With Others and First-time Experiences, which explores what was helpful, hindering, and new throughout the therapeutic journey. Findings related to participants developing new options for interpersonal relationships through the experience of authentic trust and the experiential learning of control and choice. Recommendations are discussed in relation to developing therapeutic practice and future research.

The perspectives of stakeholders of intellectual disability liaison nurses: a model of compassionate, person-centred care

AIMS AND OBJECTIVES

To investigate the experiences of patients with intellectual disabilities, family and paid carers regarding the role of liaison nurses and the delivery of compassionate, person-centred care. From this to propose a model of person-centred care embedded in these experiences.

BACKGROUND

People with intellectual disabilities have a high number of comorbidities, requiring multidisciplinary care, and are at high risk of morbidity and preventable mortality. Provision of compassionate, person-centred care is essential to prevent complications and avoid death.

DESIGN

A qualitative design was adopted with Interpretative Phenomenological Analysis for data analysis.

METHODS

Semistructured interviews and focus groups were conducted. Data were analysed with a focus on compassionate, person-centred care elements and components. Themes were modelled to develop a clinically meaningful model for practice.

RESULTS

Themes identified vulnerability, presence and the human interface; information balance; critical points and broken trust; roles and responsibilities; managing multiple transitions; 'flagging up' and communication.

CONCLUSIONS

The findings provide the first 'anatomy' of compassionate, person-centred care and provide a model for operationalising this approach in practice. The applicability of the model will have to be evaluated further with this and other vulnerable groups.

RELEVANCE TO CLINICAL PRACTICE

This is the first study to provide a definition of compassionate, person-centred care and proposes a model to support its application into clinical practice for this and other vulnerable groups.

Adult Disclosure of Child Sexual Abuse: A Literature Review

Victims of childhood sexual abuse carry the experience of abuse into adulthood. One of the dilemmas victims face during adulthood is the decision to disclose or conceal the abuse. Although adult disclosure may be affected by former disclosure during childhood, adult survivors face new challenges and dilemmas, such as to whom, when, and how to tell. The purpose of this article is to review the domains found in the literature on survivors' experiences regarding disclosure of child sexual abuse during adulthood, all of which were published between 1980 and 2013. Domains include decisions to disclose during adulthood, barriers and facilitators to disclosure and potential recipients of the disclosure, as well as the process of telling and its impact on survivors' well-being. The authors present implications for policy, practice, and research.

Recovering from childhood sexual abuse: a theoretical framework for practice and research

Research on survivors' experiences of recovering from childhood sexual abuse (CSA) has been limited and focused on those with severe mental health difficulties. This study elicited experiences of recovery from CSA in male and female survivors who have/have not utilized mental health services. The tangible end-point was to propose a theoretical model of personally meaningful recovery. This is a qualitative study, which utilized semi-structured individual interviews following the critical incident technique. Transcripts were analysed using Interpretative Phenomenological Analysis to identify recurrent themes. A total 22 adult survivors of CSA. Main themes identified were: The Affected Self, Factors Hindering Recovery, Factors Enhancing Recovery, The Hurdles of Recovery and the Recovering Self. The affected self included: lack of boundary awareness and self-blame, over self-reliance, over-vigilance and guilt, shame, aloneness and social stigma. The recovering self was characterized by increasing confidence, assertiveness, ability to self-care and self-acceptance, and by embracing vulnerability. These findings have potentially major implications for clinical practice, service provision, policy development and professional training in this field. The importance of disclosure in the healing process seemed paramount and can have major implications for current service protocols.