"I'm so grateful it happened": The Lived Experience of Post Traumatic Growth following Road Traffic Accidents

1. "I'm so grateful it happened": The Lived Experience of Post Traumatic Growth following Road Traffic Accidents and EMDR treatment David C. Blore PhD Student School of Health Sciences

2. Synopsis of researcher’s interest in topic and background to research • I have frequently been intrigued by statements like “I’m glad it happened” from victims of trauma. I have specialised in the treatment of psychological trauma for the past 20 years (from RTAs and occupational trauma to humanitarian work in Turkey and Russia – From 1993 onwards (since the Bilsthorpe Colliery Disaster) I have specialised in EMDR • EMDR was discovered by Francine Shapiro in 1987. First paper on EMDR published 1989. I was trained by FS in 1995/96 in UK & NL. In March 2005, EMDR became one of the 2 NICE treatments of choice for PTSD now with 20 RCTs and 5 meta-analyses… • …but no qualitative research and currently no positive psychology guidelines for EMDR clinicians – although general guidelines do exist (Positive Therapy – Joseph & Linley 2006) • EMDR ‘intriguing’ therapy described as ‘counterintuitive’ and with a ‘positive-as-standard’ component to the basic protocol for its application • The ‘success’ heuristic in mental health treatments (and clinical governance) = reduction in negative symptoms (RNS), but EMDR produces ‘more than’ RNS regularly. Is EMDR’s success underestimated? if so what about other treatments of all types? Should we ditch DSM altogether… and what of 9 years of clinical governance? • Researcher has second interest: co-founder of The Jane Tomlinson SIG for Post Traumatic Growth: Centre for Applied Positive Psychology (University of Warwick)

3. Aim of research • To utilise the lived experience of involvement in an RTA to: • identify the process of PTG and its components • inform clinicians and clinical practice • ‘lay the ground’ for a later reassessment of EMDR effectiveness (and other treatments) in terms of a ‘total beneficial outcome’ (RNS + achievement of PTG*) • (* this is based on a potentially contentious perspective: who says we have the remit to help achieve PTG? Is PTG wanted anyway? Who ‘owns’ PTG as a ‘proto-diagnosis’ etc. etc.?) • To address Maslow’s criticism of psychology…

4. Aim of research Maslow’s criticism of psychology… “The science of psychology has been far more successful on the negative than on the positive side. It has revealed to us much about man’s shortcomings, his illness, his sins, but little about his potentialities, his virtues, his achievable aspirations, or his full psychological height. It is as if psychology has voluntarily restricted itself to only half its rightful jurisdiction, and that, the darker, meaner half.” (Maslow 1954 p.354)

5. Methodology (and issues for the researcher) so far • Phenomenological • Hermeneutical • …and mainly because of its current popularity and thus potential for methodological comparisons: • Interpretative Phenomenological Analysis (IPA) This needed a complete change of research perspective from quantitative to qualitative and from positivism to a post-modern, post-structural orientation …‘Moving over to phenomenology’ presentation UoB May 2005

6. Methodology (development of SS questionnaire) so far • Development of SSIQ (6 editions covering a year and using famous PTSD victim known worldwide for his positive post trauma attitude, to act as ‘end point referee*) (*in this instance no attempt was made to judge the person’s ‘positive post trauma attitude’ - it was accepted on the base of widespread acclaim and assumed that he would have a better understanding of the questions required to access the phenomena being studied) • SSIQ needed to cover the entire post RTA narrative to access any process occurring - it was assumed from the outset that PTG was a process not an outcome • It was thought the ‘Ideal’ methodology would be a longitudinal study – but cross-sectional was chosen with the intention of inductively reasoning longitudinal progress from multiple cross-sectional points across the participants interviewed • Ethical submission and approval

7. Methodology (recruitment of participants) so far • Recruitment (very slow to start with… thought we might have a snowball sample but snow melted!) • Initial contact by treating EMDR clinician (PorC) who provided information sheet • If ‘yes’ received: response communicated to researcher with telephone number • Telephone contact made with potential interviewee to discuss and questions raised (usually related to venue and times), if still ‘yes’: • Consent form signed by researcher to show interviewee before signing that researcher would abide by consent as well + covering letter + 24 hour voicemail number sent by post • Consent returned: arrangements finalised then interview (f2f around country, at clinics or via telephone according to participants’ choice and convenience etc.)

8. Methodology (recruitment of participants) so far • 17research participants entered study (consent not sought from1victim as she had not undergone EMDR. Remaining16provided consent) • 3of the16were sexual abuse victims (of these, all3interviews were conducted,2transcribed and validated – subsequently focus of research narrowed from PTSD generally, to RTA victims only) • 13RTA victims who had undergone EMDR (unfortunately1RTA victim was unable to answer all the questions – interview was aborted) • Final cohort planned to consist of12RTA victims: all12interviews conducted, presently 11 transcribed and validated – (2 further, potential participants remain in pipeline) – this ‘over subscription’ is a direct artefact of recruiters now getting skilled at spotting PTG – interesting parallel with Maslow’s early comments

9. (Almost) final cohort: 8 females and 4 males Alison: in rear end shunt – impact car was 2 cars back Christine: in car involved in rear end shunt whilst parked in lay-by David: on motorbike hit car + separate victim of road rage Fiona: passenger in an end-over-end crash due to speeding Isabelle: in car struck a glancing blow by a refuse truck John: on motorcycle hit by van turning right across his path Linda: in car, victim of hit-and-run collision with lorry on motorway Mike: passenger in police car involved in almost head on collision Nicola: stationary on bicycle, received glancing blow from lorry Olga: in car, head on collision with overtaking car on flyover Pat: pregnant, in car with all the family, head on collision with drunk driver Tim: in brand new car, van turned right across his path

10. Methodology (interview transcriptions) • Interviews (initially by minidisc, later abandoned for ‘retro technology’ – tape recorder - all transcription and DA has been done manually by the researcher) 1st edition transcription - ‘verbatim’ transcription, transcript conventions tabulated, items for confidentialising identified and tabulated 2nd edition transcription – ‘cleaned and confientialised’ – returned for comments to participant on confidentialisation, alterations and any additional material 3rd edition of transcript – ‘validated’ by participant with modifications, alterations and additions made… > data analysis 4th edition of transcription – ‘DA format’ altered to prepare for via IPA double-hermeneutic: portrait to landscape + addition of text box on either side of centralised, double-space and line numbered transcript

11. Methodology (data analysis) • 4th edition of transcription – script read and reread and 1st (left hand) IPA hermeneutic (IPAH) commenced • Further rereading including part rereading as comments placed into 1st IPAH for each comment text extra is ‘bold bracketed’ for ease of re-examining and quoting • Once 1st IPAH completed, 2nd (right hand) IPAH in which 1st IPAH is moved to higher level of abstraction – result is ‘emerging themes’* (* First transcript for data analysis was 2nd interview – it was the longest interview at over 16000 words and generated 330, 2nd IPAH ‘emerging themes’) • 2nd IPAH emerging themes now collated separately and sequentially, 2nd IPAHs now provisionally given ‘superordinate’ theme (ST) prefix codes + line numbers added for each 2nd IPAH item • Sequential list of 2nd IPAHs now re-collated according to ST list (‘clustered’) • As each transcript goes through the above process, each preceding clustered ST list is revisited for alterations in the light of later data analysis (DA)

12. Methodology (data analysis) so far • The initial list of superordinate themes (ST) are reconsidered to establish whether the ST need expanding/contracting etc. Some initial ST are subsumed into other ST whilst other ST are relabelled to better reflect the initial material coming through the DA process • Each ST is given a ‘definition’ which is constantly updated during the data analysis (DA) process • Right from the first transcript DA the ST are represented in diagrammatic form. Initially this starts with each ST on a separate card. The cards are arranged according to the ‘best fit’ with each other based on the first transcript • As each transcript goes through the DA process, and modifies the previous transcript’s DA, the diagrammatic version of the ST is also modified • Current situation: All 12 interviews conducted, 11 transcribed and validated, 3 transcripts completed DA and 1, part completed. The diagrammatic model is already the 8th edition

13. 12 Superordinate themes (ST): examples from ‘Christine’s’ interview Negative post trauma processes “…I would suddenly stop talking I would lose all track of what I was saying it was almost as if there was a traffic jam and I had to pause then something else would come through…”(Note the ‘driving’ metaphor) Coping “…I would sit rocking in a corner… unable to do anything… on some days just getting up and making something to eat which was invariably something very simple was very difficult… I would have weeks where I wouldn’t sleep in bedrooms I would sleep on bean bags in the corner of the floor on the floor…” Secondary traumas “…I suggested to them (the doctors at the hospital) that I went to Clearhead Association…for help they told me not to bother they said that it wasn’t for the likes of me and that the… it was only people with serious head injuries which in hindsight was one of the most crippling things they ever did or one of the most damaging things they ever did…” Control “…I went to 2 other solicitors for advice I was told that I had… a case for… malpractice or negligence whatever the term is… but they advised me not to pursue it because the case was so near… Court…”

14. 12 Superordinate themes (ST): examples from ‘Christine’s’ interview Hankering “…I lost everything I lost… totally everything… that had been my life… I lost the clinic I lost my patients I lost the teaching I lost the ability to use me head I lost the ability to write I lost the ability to read the ability to understand…” Hindsighting “…I’ve always been a fighter anyway because I lost both of my parents by the time I was 27 I lost my Dad at 13… and Mum at 27 so… I then met Anthony and we were together for 13 years… but I’ve always been a very independent person because I suppose I’ve had to have been really because I’ve had nobody to say [childish voice] oh Mum will you help with [normal voice] you know? So yea I’ve always been I’ve always had drive in me…”(Again note the underlined ‘driving’ metaphor) Wisdom “…Overall counselling did zero for the symptoms from the RTA and did zero positive unless you take into consideration it taught me about myself…EMDR got rid of the emotions and think positively in ways I hadn’t thought before.” Post Traumatic Growth “…learning to like and love the… this form which isn’t the one that everybody liked loved and wanted because she was so useful and such a good provider and did everything that’s a real challenge… because like you know… this is a totally different me…”

15. 12 Superordinate themes (ST): examples from ‘Christine’s’ interview Aspirations “…my next big challenge is put meself in a situation where I could go into a relationship… because… this Christmas I actually… I didn’t come back till just before Christmas… so I didn’t do anything Christmasy… I went to friends for Christmas and I was totally miserable…” Own understanding and philosophy “…realised that the panic attacks it… they were panic attacks rather than flushes because… before I had a hot flush I had this overwhelming feeling of not being able to cope must get out… I couldn’t deal with something and it was always associated with stress…” New success heuristics “…trained initially in the physical therapies realised which was the massage and the spine works which is an alternative technique to osteopathy which doesn’t involve clunk clicking…”(Again note the ‘driving’ metaphor) Spirituality “…my (spiritual) connection was everything to me…and it’s the one thing that’s taught me saved me… its … just everything…”

16. Results: (working model) “Dual Processes Model of PTG” THE PERSONAL MEANING PROCESS SPIRITUALITY OWN UNDERSTANDING & PHILOSOPHY > > NEW SUCCESS HEURISTICS ASPIRATIONS POST TRAUMATIC GROWTH ROAD-BASED TRANSPORTATION IMPACT EVENT (RTA) WISDOM HINDSIGHTING HANKERING CONTROL NEGATIVE POST TRAUMA PROCESSES SECONDARY TRAUMAS COPING THE READJUSTMENT PROCESS

17. A key to development of the ‘Dual Processes model’…Collated ‘driving’ metaphors: personal meaning and readjustment interface • “clunk clicking” to describe the experience of osteopathy • “I drove everybody nuts”to describe the effect of hypervigilance on those driving the client around • “more drive… more energy”to describe the effect of having a huge amount of enthusiasm for her new course in life • “I’ve always had drive in me” to describe premorbid personality • “as if there was a traffic jam and I had to pause then something else would come through” to describe the experience of cognitive problems after the head injury • “it was like having a traffic jam in me head if you’ve got 3 lines of traffic I got a traffic jam in 2 of those lanes” to describe more intricate experience of cognitive problems • “ because the left brain is not in gear as much” to describe the experience of no longer being overwhelmed by intrusive imagery after EMDR treatment • “the accident was actually to propel me on my spiritual path” to describe the purpose of a rear-end shunt • “most people I suppose are geared towards growth and enlightenment” – to describe the majority of people as positive not negative (very Aristotelian !) • “at a cross roads in life” the experience of how one can decide which occupation to follow once physically better • “certainly put the brakes on” to describe the sudden and unexpected effects of setbacks to coping • “as though someone was steering me” to describe the sense of being led on a mission in life • “I had the full MOT” to describe the thoroughness of the hospital doctor’s examination

18. Discussion: initial implications • For clinical practice • That there is more than merely focusing on RNS in therapy • That EMDR (at least) can produce positive outcomes over and above RNS • That clinicians can facilitate PTG in clients • That treatment ending with ‘no symptoms’ is not the final outcome • For EMDR training • That EMDR training needs a component that focuses on how best to provide clinicians with the skills to generate PTG • For theoretical explanations • What the role of therapy and clinical governance actually is? • Is PTG something that should or shouldn’t be ‘DSM-ised’?

19. References Bisson, J.I., Ehlers, A., Matthews, R., Pilling, S., Richards, D., & Turner, S. (2007) Psychological Treatment for chronic Post-Traumatic Stress Disorder: Systematic review and meta-analysis. British Journal of Psychiatry, 190: 97-104 Blore D.C. (1995) Eye Movement Desensitization / Reprocessing (EMD/R): A case series evaluation. University of Nottingham: Unpublished BSc(Hons) dissertation Blore, D.C., (2005) Moving over to Phenomenology. Research presentation, School of Health Sciences, University of Birmingham 11.5.05 Janoff-Bulman, R., (1992) ‘Shattered Assumptions’. New York: Free Press Joseph, S., & Linley, A. (2006) ‘Positive Therapy’. London: Routledge Maslow, A.H., (1954) ‘Motivation and Personality’. New York: Harper NICE (2005) Post-traumatic stress disorder: The management of PTSD in adults and children in primary and secondary care. The Internet: http://guidance.nice.org.uk/CG26/guidance/pdf/English Shapiro, F. (1989) Eye Movement Desensitization: a new treatment for Post-Traumatic Stress Disorder. Journal of Behavior Therapy & Experimental Psychiatry, 20(3): 211-7 Smith, J.A., & Osborn, M. (2003) Interpretative Phenomenological Analysis. In J.A. Smith (Ed.) Qualitative Psychology: A practical guide to research methods (pp.51-80). London: Sage

20. …and finally: “…he (the driver that caused the RTA) was actually an instrument in giving me a gift rather than something that’s destroyed me life…” ‘Christine’3:1020ff