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research-article2014

VAWXXX10.1177/1077801214549639Violence Against WomenUllman

Article

Interviewing Therapists About Working With Sexual Assault Survivors: Researcher and Therapist Perspectives

Violence Against Women 2014, Vol. 20(9) 1138­–1156 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1077801214549639 vaw.sagepub.com

Sarah E. Ullman1

Abstract This article provides an account of the author’s experience interviewing clinicians about their work with sexual assault survivors and clinicians’ experiences working with this population. Twelve clinicians who worked with sexual assault survivors practicing in a range of professional settings completed semi-structured face-toface interviews. Grounded theory and open-coding analyses were conducted on the researcher’s log, case summaries, and verbatim-transcribed interview transcripts to uncover themes regarding (a) the researcher’s experience of the interviewees and (b) the therapists’ reports of their experiences working with survivors. Conclusions are drawn for researchers conducting interviews with therapists and clinicians working with sexual assault survivors. Keywords interview, qualitative, researcher, sexual assault, therapist Few accounts exist of researchers’ personal experiences doing interviews of select professional groups about their work with sexual trauma survivors. Such information is important, given that sexual assault survivors commonly seek help from mental health professionals (see Ullman, 2007, for a review). How these experiences unfold may be informative to novice researchers and to those interested in understanding how our perceptions of interview participants influence our internal reactions and appraisals of what interviewees say during research interviews. In sociology, autoethnographers

1University

of Illinois at Chicago, USA

Corresponding Author: Sarah E. Ullman, University of Illinois at Chicago, 1007 West Harrison Street, Chicago, IL 60607-7140, USA. Email: [email protected]

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weave their personal experiences of specific life experiences into the stories they tell about those they study with the same experience. Ellis and Bochner (2000) advocate autoethnography, a form of writing that “make[s] the researcher’s own experience a topic of investigation in its own right,” rather than seeming “as if they’re written from nowhere by nobody” (pp. 733-734). An account of one’s experience doing research is not quite the same as an autoethnography that also includes accounts of participants studied by the researcher. Still, researchers’ accounts of their experiences studying sensitive issues such as trauma can be helpful, both to ourselves as researchers studying difficult topics and to populations such as trauma survivors, as well as to others in the field, where our perspectives on doing this work are frequently hidden and/or not discussed (see R. Campbell, 2002; Ullman, 2005, 2010). While researchers have yet to write about interviewing mental health professionals who work with survivors, others have written about how to carefully train oneself and one’s research team and how to take care of interviewers and survivors during research projects involving interviewing trauma survivors (Brzuzy, Ault, & Segal, 1997; R. Campbell, 2002; Hlavka, Kruttschnitt, & Carbone-Lopez, 2007). Furthermore, there is a significant literature on how to conduct sensitive research and deal with ethical dilemmas (J. C. Campbell & Dienemann, 2001; Fontes, 2004) and critical issues such as staying safe that can arise in doing research on sensitive topics such as trauma (Coles & Mudaly, 2010; Connolly & Reilly, 2007; DicksonSwift, James, Kippen, & Liamputtong, 2009). There is also significant research on secondary traumatic stress and vicarious trauma experienced by therapists working with trauma survivors (Baird & Jenkins, 2003; Devilly, Wright, & Varker, 2009), which are also relevant concerns for researchers (Etherington, 2007; Gilbert, 2001). Given the extensive research on these subjects, they are not covered here. Instead, in this article, I reflect on my experience interviewing therapists about their work with sexual assault survivors. I discuss the impact of doing the interviews and how they led me to self-reflect about my own role as a researcher asking other professionals about their work with sexual assault survivors. I also present therapists’ reactions to their experiences working with sexual assault survivors. Such data may provide important information about how therapists view survivors in the therapy context and their ability to help with this particular problem. In a prior, more general article about my experience conducting qualitative interviews with advocates and clinicians (Ullman, 2005), I discussed issues of status differentials between myself and clinicians and how I coped with them during the interviews. I also discussed my experiences interviewing sexual assault survivors in a chapter of my book, Talking About Sexual Assault: Society’s Response to Survivors, in which I dealt with many issues that clinicians are likely to face routinely in their work with survivors, including negative aspects (e.g., barriers in health care services, secondary traumatic stress, transference and countertransference, somatic and physical health symptoms) and positive aspects (e.g., seeing clients empowered to make changes in their lives, witnessing survivors heal; Ullman, 2010). In this article, I elaborate on instances that occurred during interviews, and how I handled them in the moment and processed them later in my research log and

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sometimes while talking with other colleagues, in an effort to debrief myself following each interview and reflect on the meaning of the interactions I had with clinicians. I will also discuss how this experience was unique and required a shift in my schema from a personal client’s perspective to a researcher’s perspective, because of having seen a therapist in my own life. Despite this shift in my role, I still processed what the therapists told me, both as a researcher studying sexual assault and help-seeking as described by these professionals, but also as a woman who has grappled with my own issues related to this subject as a client in therapy.

My Experience Coming Into Interviewing First, to situate myself, I should explain that I came at this process as someone who had had therapy myself on and off for a significant portion of my life to deal with personal issues and as a tool for self-insight, growth, and coping with the aftermath of stressful life experiences. I see therapy as highly useful, as a way of getting support, having a trusted person to listen, and someone to help in working through issues of daily life as well as long-standing emotional issues. Despite this, I know from the literature and my own experience that therapists vary significantly in training, orientation, empathy, and ability, just like any professionals. Because I was never formally trained in how to do interviews, it is possible that some of the issues I raise here would not have been issues for me had I had formal training, although I read a lot about interviewing, did mock interviews, and had mentoring from other colleagues trained in the use of these methods (see Ullman, 2005, for a description of my learning process in moving from quantitative to qualitative methods). Because psychologists may have more power due to greater occupational prestige than social scientists (Hauser & Warren, 1996), this may have led to uncomfortable interactions and/or reactions on my part that reflected my lower status position in the interview situation. Status differences may make it harder to build rapport during an interview, particularly if the high-status person does not see value in the lower status person’s position. Perceptions of mutual respect may be very important not only in obtaining valid data but also in facilitating rapport building that is likely to be the foundation of a successful interview. While my status as a professor was lower, my research background and knowledge as a sexual assault researcher was something I had that may have been seen as a valuable resource by those I interviewed. Other factors that may affect power differentials and thus building rapport during interviews include age, gender, social class, professional experience, and experiences of violence. Another fundamental theme was how much I liked the person and/or perceived that they liked me. Clearly when meeting a stranger for a one-time interview, the stakes are fairly low for both parties, yet if the two people are not comfortable with each other or the interview situation or don’t seem to hit it off in getting a dialogue going, the interview can be somewhat stressful and potentially of low yield in terms of the quality and quantity of data obtained. Rapport building may also be enhanced by answering interviewees’ questions, as often they want to know about who you are, where you are

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coming from, and having answers to such questions may increase their comfort with doing the interview (see Reinharz & Chase, 2002, on feminist interviewing). This article provides my reflections on my experiences interviewing therapists about their work with sexual assault survivors and their reflections on their work with survivors. In so doing, it provides a self-reflexive account of my experience collecting the data and perceptions of therapists’ experiences as they told me about their work with victims. Such an account illustrates the complexities of conducting such interviews, including being aware of one’s own reactions, listening to what the interviewee is saying, and being present for and fully listening to them, and dealing with the effects of the experience, while trying to write an honest account that reflects what participants said and what one’s own reactions and interpretations are of the accounts. This is valuable because it shows how researchers’ interpretations are subjective, based on both what interviewees say and on our reactions to what they say, and those reactions affect our interpretations of the data.

Method Sample The sample was comprised of 12 women who were therapists working in a large Midwestern metropolitan area. This sample is part of a larger study of both clinicians and advocates working at a variety of social service agencies, including rape crisis centers (see Ullman & Townsend, 2007, for a detailed description of the larger study). Letters were sent to female therapists listed in Chicago area telephone directories, the International Society of Traumatic Stress Studies directory, and a recent local meeting of the national sexual violence prevention conference. All those who called the researcher or responded to the researcher’s phone calls did participate in the study. Therapists only needed to have had any experience working with clients having a history of sexual assault, but did not have to be specialists in working with this population. Five participants had PhD-level degrees, including PhD in clinical psychology (n = 3), a doctorate in social work (n = 1), and a PsyD or counseling degree (n = 1). Seven participants had master’s-level degrees in social work, including a MSW (n = 3), a LICSW (n = 1), and an MA (n = 3). All currently worked in private practice, except one who was working in community mental health, and some therapists had past experience in other settings including hospitals and community mental health settings. All had experience working in the field with a range of 6 to 40 years, with 1 having 6 years of experience, 4 having 10 to 15 years of experience, 5 having 16 to 30 years of experience, and 2 having more than 30 years of experience. Women had an average of 23 years in mental health practice experience and 18.6 years of experience working with sexual assault victims. The estimate of the number of their clients who had a sexual assault history ranged from 3 to hundreds. Half had worked with 10 or fewer clients with sexual assault, and the rest had more or didn’t know the numbers. Percentage of client load with sexual assault histories were estimated from 3% to 99%,

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with half working with 50% or more sexual assault victims and the other half working with less than 50% sexual assault victims. In all, 8 therapists worked in the city, 2 worked in suburban locations, and 2 worked in both urban and suburban settings. Women were an average of 53 years of age, and all were White; 2 were single, 1 was cohabiting, 2 were divorced, and 7 were currently married. In terms of income, 2 earned less than US$30,000; 1 earned US$20,000 to US$30,000; 1 earned US$40,000 to US$50,000; 2 earned US$60,000 to US$70,000; 2 earned US$80,000; and 4 refused to give their income. Women were asked to check all applicable items in a checklist that characterized their treatment orientation: 5 endorsed a feminist orientation; 12 endorsed other treatment orientations, mostly either psychoanalytic or psychodynamic. Finally, in terms of evidence-based trauma-specific treatments, 3 endorsed a cognitive behavioral orientation and 1 endorsed Eye Movement Desensitization Therapy (EMDR). In terms of training, 2 had all four types of training assessed (e.g., child abuse, domestic violence, sexual assault, and violence against women in general), 4 had no training in any of these four areas, 1 had sexual assault only, 1 had child abuse only, 1 had EMDR only, and 3 had two to three types of training (e.g., sexual assault, child abuse, and/or domestic violence training). While other types of trauma treatment, such as dialectical behavior therapy, were mentioned anecdotally during one interview, this was not noted as a treatment orientation when therapists were asked this specifically.

Procedure I interviewed all participants in person at a time and location convenient for them, which was generally their work or home offices, from November 2002 through May 2003. Interviews ranged from 41 min in length to 1 hr 30 min, with the average interview length of just over an hour (M = 71 min). Prior to interviews, participants completed signed informed consent forms and a brief background information form (e.g., demographics, experience working with sexual assault survivors, education, training, and treatment orientation). Semistructured interviews asked about women’s training and work experience with survivors of sexual assault as well as other relevant work experience, how disclosures of sexual assault tended to occur, how interviewees typically respond to disclosures, difficult and rewarding aspects of working with survivors, barriers to working with survivors and to survivors obtaining services, and solutions that might improve services to this population. Participants were also asked about their views about the role of mental health professionals in working with sexual assault survivors. In this article, I focus on my impressions, reactions, and interpretations of the interview situation and therapists’ views of survivors and their work with this population not reported elsewhere.

Analysis Strategy First, I identified and coded my own experiences from a journal I kept during the interview process, case summaries of the interviews I wrote after doing each interview, and

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what I actually said during the interviews from actual interview transcripts. Second, I coded interviews for information about therapists’ appraisals of their work with survivors and their reactions to doing such work. A grounded theory approach was used for data analysis, including both open and axial coding (Charmaz, 2006; Strauss & Corbin, 1998). Open codes emerged from the text to break the data into discrete parts. Axial coding extended the analysis from the textual level to the conceptual level. The goal was to identify and interpret any themes or patterns about my experiences and insights from interviewing therapists about their work with survivors.

Results My Reactions to Participants and Their Meaning/Effects Few of us acknowledge or think about our roles as researchers, what we expect from participants, and how our own approaches, personalities, and interaction styles may affect the interview process. What I mean by this is that many times one approaches a research interview with a goal of getting participants to answer questions and to enhance one’s understanding of the subject at hand. However, participants have their agendas as well, and those agendas become apparent or questions may come unexpectedly as the researcher and the participant negotiate their respective roles in the interview context. This may or may not be explicitly stated or discussed during the interview. In the early stage of an interview, I had one woman ask me out of the blue if I was Jewish, to which I said yes. Nothing more was said about it than just that one question interjected during the early part of the interview. I thought her asking this question was a bit strange at the time, but looking back, I think this participant may have been sizing me up and perhaps trying to figure out who I was and how she could define or categorize me in relationship to herself. Alternatively, she may have wanted to find this out to have some commonality that would help her feel at ease talking to me, as I believed this participant to be Jewish herself (although religion was not something I asked participants about). I did not expect to have my own reactions be so salient during and after interviews, but I noticed that certain interviewees evoked reactions in me that I tried to deal with to facilitate the interview. This can be tricky, because as researchers we want to focus on the person being interviewed, but our own reactions can be important in guiding us in how to best conduct an interview and adjust to different people we talk to. This is a lot easier to deal with when one easily likes the person and vice versa. Like any interpersonal interaction, rapport and “liking” may be more likely for some interview– interviewee dyads than others, which of course may facilitate a more fruitful interview. When this does not occur, it can be difficult to manage one’s own reactions as the interviewer and stay on target in focusing on the participant and the interview itself. For example, when re-reading the transcript of one woman whom I did not like at all, I realized that she interrupted me a lot and would not answer my questions. During the interview, I found myself not liking her, despite wanting to, because I felt she was

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making it hard for me to establish rapport. But I also realize I did not like her, and still did not like her in re-reading her transcript, because her behavior toward me reminded me of how my mother treated me: not respecting of boundaries. The interview seemed like a power struggle, which was likely the result of my viewing relationships involving conflict as involving a power dimension. Strong emotional reactions like these and their reasons may not be evident during the interview or even for some time after that, but they are likely to affect the interviewer’s behavior toward the interviewee, even if unconsciously, and certainly their feelings after the interview. This is akin to countertransference that therapists likely experience with their clients and have to manage during therapy. As I did not have experience in managing these reactions, I had to do my best to suppress them during the interview, but I was definitely annoyed by her behavior, and in reading over transcripts after the interviews and later on, I am sure that my own reactions affected my view of the participant and perhaps made it harder for me to listen and take in what she was saying. As much as researchers, including myself, want to be unbiased and nonjudgmental of participants, when they evoke strong feelings or simply are difficult to manage in the interview situation, we understandably may feel annoyed and also that we are getting a poorer quality interview if we either give up and just let the interviewee take over and talk or try to keep it on track, but thereby struggle to get what we need from them when they have their own agenda. I focused on trying to engage my participants in a positive manner and tried to be flexible in trying different strategies when one approach was not working. For example, in some cases, I let the interviewee talk at length or be silent for longer periods than I might have liked to show flexibility and patience in my approach and to be noncontrolling in the hope that this would lead to greater comfort for the interviewee. One problem I experienced was that I found that getting some interviewees to talk was challenging. As I wrote in my research log about one early interview I conducted, I was struck at how hard it was to build rapport and her apparent fear of being scrutinized or saying the wrong thing. The interview started with really short one word/one sentence answers, but got better in time, but I had to really work hard to get her to talk.

This difficulty building rapport was in sharp contrast to my experience interviewing rape victim advocates working at rape crisis centers during the same period of time (see Ullman, 2005; Ullman & Townsend, 2007). Another issue I did not like about some participants was if they expressed negative views about sexual assault or about working with survivors. For example, one therapist told me that she had trouble personally dealing with the larger social realities of rape and preferred to deal with this at a more individual, manageable level. In particular, she felt ineffective at dealing with very traumatized, complex posttraumatic stress disorder (PTSD) cases, did not get adequate supervision related to this issue, and felt she had to wait longer than she should have to get supervision. Interestingly, my reaction (not stated aloud) to her saying this was that I felt I could relate in terms of having

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a parallel reaction in dealing with rape as a researcher, which to me seems more manageable than being an activist or even a therapist or crisis worker in this field. For me, it was a big step at the time to interview those who work with victims, as opposed to only doing surveys of victims, which was the scope of my previous work before embarking on this project. Later on, I also did interviews with sexual assault survivors, an experience about which I wrote in detail in a chapter of my book (Ullman, 2010). Some therapists I interviewed were critical of other therapists and felt that they did not have training to deal with survivors, although I perceived that some of these people were unaware of what it was like outside of the therapy realm to work with survivors (e.g., in a crisis center or in legal situations). One social worker with a moderate level of experience working at a trauma-counseling agency said, I have an enormous amount of respect for the rape crisis centers, but my impression sometimes is that they tend to have very new young grads and I don’t know how much paraprofessionals are still being used, where the person may not even have specific mental health training and then you get somebody coming in who has an experience like this, sometimes it’s the first time they called. Even though they’re great [new young grads], in so many ways, it starts looking like less and less of a good match.

Another reaction I had early on when interviewing clinicians was sadness and anger at the realization that there was really a clear two-tiered system of treatment for sexual assault survivors where the rich, insured, often White survivors, like myself, could go to private therapists, whereas poor, often ethnic-minority survivors were stuck with crisis services or other badly strained public mental health system care. Clearly, access to longer-term therapy, to say nothing of feminist-informed trauma therapy with someone who has knowledge and training in the area of sexual victimization, was limited to those with resources, except for a few lucky clients that private therapists noted they took on as pro bono cases. A number of therapists were also critical of advocates and crisis centers and felt they did not have enough mental health training and thought that their so-called “party line” response to rape (e.g., telling the survivor it’s not your fault) was not going to work and was inadequate. I recall finding this interview stressful and disliking the power dynamic, which I felt was present because she would not sit close to me, so I was concerned about audibility of the tape. Also she was very lecturing, self-directed in the interview, and did not respond to a lot of what I asked her during the interview though I managed to get some material from her. When I say this, I do mean to express my initial view of the interview, which was obviously problematic, but I felt I was also there to obtain information and learn about the participant’s experiences. Having this goal orientation to the interview is normal in that this is the purpose of doing an interview, but the interpersonal interaction must be established with at least some degree of rapport for that goal to be accomplished. While we may have goals in our research, participants often have their own agendas and use interviews to express what they want us to hear and/or to be known by those doing research. In this case, during much of this participant’s interview, she railed against organizations and other professionals

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who are “no good,” and particularly psychiatrists who are not trained in trauma, whose patients often came to her after being maltreated by these sources. She explained, One of the problems within organizations, either a large private practice or an agency, a government agency, is that you tend to be given patients, this is your patient, whether I want her or not, this is your patient, and the clinicians are seen as sort of interchangeable. If you go on vacation or you leave the agency, the patient belongs to the agency as opposed to being able to technically refer and/or take the patient with you. Very often people have to go surreptitiously, which for patients is a terrible thing. (Experienced trauma therapist)

This is clearly a major problem that would apply to any patient and was not necessarily specific to sexual assault clients, but was something frustrating to her that she felt I should know about, as it could impede the therapy process and probably trauma recovery for some clients, which depends on trust between client and therapist built up over time. I encountered newer therapists who did not have trauma training, such as some from social work programs, who needed to upgrade their training and have additional supervision regarding these issues. One therapist told me how annoyed she was that this was not covered in graduate school and that she now had to learn it and pay for more training herself due to encountering survivors in therapy. I felt sympathetic toward her, being thrown out there to work with clients who had issues for which she did not have training in terms of how to adequately respond to them. I had one experienced trauma therapist tell me that there is a dearth of available services for survivors, that no one wants to work with these clients, and that they are blamed for their symptoms by the systems. She said good therapy techniques, such as cognitive behavioral therapy and dialectical behavior therapy that she uses, are not used by community mental health agencies. In this interview, I recalled not feeling comfortable initially. In my log I wrote, “I liked her but it took time to get her to relax some and build some rapport. Her fancy house was a bit cold and the dog was sniffing at me a lot, but otherwise it was fine.” This therapist told me she used a relational model in doing therapy and that she would tell clients about her feelings when clients assumed she felt something, usually negative, about them and she did not. She said that therapy must be about more than building an empathic connection and teaching coping skills, but also must contradict their (clients’) faulty impressions and acknowledge her (the therapist’s) own feelings. She noted that Constance Dalenberg (2000), a well-known trauma therapist, talks about this in her book on countertransference. This made me think of my own history of psychodynamic therapy, a type of treatment which this interviewee viewed negatively, where the therapist is more of a blank slate for the client to project on and how maybe I had transferred that model to my current feminist therapist (at the time I was doing these interviews) and found it hard to open up more personal dialogue that is scary. I wondered about this as this woman said this is very important. I found myself agreeing with her and thinking that one

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cannot change one’s relational inner working model without doing this. This made me realize that because I need such clear boundaries in relationships, that it may limit what I can do to change these relational patterns. This was the first time I had a personal reaction and insight into my own experiences in past therapy to what an interviewee said about working with trauma survivors. I decided to ask my therapist about this later and decided that I liked this woman and that she liked me during the interview. This experience also made me aware that I have multiple hats while doing this research, not only as an interviewer but also as a therapy client and a trauma survivor. In essence, I was interviewing mental health professionals about their work with sexual assault survivors, which was sort of like asking them about working with people like me, at least in that one respect. I think having multiple hats has a positive and a negative side: positive in that I was able to see things from multiple perspectives and thus draw on my thoughts and emotions with respect to all three of those roles and negative in that it made things more complicated in sorting out my own reactions to the interviewees and the material they provided.

Therapist Refusal to Disclose Information Sometimes interviewees would not answer specific questions or simply talked about different things than what I was asking. I found it interesting that the four clinicians who refused to tell me their incomes were in private practice and appeared to be well off, although I could not be sure that this was in fact true. Demographic information, including income, was collected only on a personal data sheet that participants filled out right before the interview. This nondisclosure of information may simply reflect the commonly observed finding that income is less likely to be disclosed than other sensitive issues by research participants. I asked about income to be able to report on the nature of my sample, but also because I assume that therapists with more resources might be more able to get supervision and support to deal with their own issues in doing this work. It is not uncommon for novice therapists or those working in nonprofit organizations to get little and/or poorer quality supervision due to fewer resources in those settings as compared with those working in private/group practice settings who typically earn more and can afford to pay for their own supervision and/ or may have it provided by their workplace. In terms of broader issues, I had one clinician who did the interview and was friendly but seemed unwilling to really answer my questions or connect with me at all. I doubted that she perceived any of that. She could not recall how many survivors she had worked with. Her phone rang several times and she answered it each time, though the interruptions were short. She seemed uninterested in the interview and to just be going through the motions. Several times during the interview she brought up cases of false rape and sexual abuse reports and her belief that this happens a lot in cases of divorce. I recalled thinking this was somewhat annoying and realized that she had a much different view of rape, seeing it in much more gender-neutral terms than I did. She was very general and resisted speaking in detail about clients or saying anything about her experiences working with them. I wrote in my log, “I felt very

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uncomfortable with her—not interpersonally, because she was friendly—but only because she would not answer my questions.” Interestingly, during the course of the interview as she recalled that more and more of her clients had a sexual assault history, she would be surprised and tell me she remembered another person with this history several different times. In cases like this one, I sometimes wondered why the person actually had wanted to do the interview, though in some cases I felt like participants were also trying to get my views about what they did in their work with survivors or even learn more about sexual assault in general. I recall thinking that perhaps some therapists with less knowledge about sexual assault were looking for a way to talk about working with this population and to learn more about this from doing the interview. I was very clear from the outset that I was a researcher, not a clinician, and that I was there to learn from them about doing clinical work with this population. While refusal to disclose information may have been a lack of rapport in some cases, at least some of the reticence of some women I interviewed may have been due to confidentiality concerns. At least one therapist mentioned not wanting to go into detail for fear of disclosing information and/or identities of individual clients. While, naturally, I made it very clear that I would not ask any specifics about clients they worked with and/or any other details about them during the interviews, this very real limitation and the responsibility of professionals to protect the confidentiality of their clients present a dilemma in doing such interviews. Therapists may have decided to err in the direction of generality and engage in greater self-monitoring that may have led to less comfort in the interview process and perhaps even difficulty talking more freely about their feelings and thoughts regarding working with survivors. This is a real and practical problem that cannot be overcome by researchers assuring confidentiality, because such confidentiality does not make it alright for therapists to violate therapist– client confidentiality, a moral and legal obligation of mental health professionals.

Therapist Objectivity, Rationality, and Distance Some therapists diverged in whether they focused on true engagement on an emotional level with clients, which they felt was essential for working with survivors, particularly those using relational and feminist approaches. Others felt objectivity and distance were necessary in therapy and for not burning out. One therapist told me being objective and rational was very important several times during her interview; another said that if you do not maintain a “clinical stance,” you may burn out, meaning you need to keep your distance. The therapists who were psychoanalytic, psychodynamic, or otherwise traditional in their training were much more likely to endorse objectivity, the need for distance, and even in some cases, aversion to working with survivors. They may also have felt stressed in dealing with such clients and found it easier to deal with them by staying at a comfortable emotional distance. One described survivors as “a mess” and did not feel working with them was rewarding; I felt this therapist had a real antipathy toward these clients. She said she has “empathy” and that is how she connects with clients regardless of their victimization history. She lets them bring it up and goes where they need to go, but she was definitely not a specialist and saw these

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clients as stressful. She told me she only takes a few of them and does not need to deal with this. Interestingly, early on this woman alluded to her own victimization history and was the only person who hesitated about being recorded. In my log I wrote, She said it was okay [to tape record] and I assured her I’d turn it off if she didn’t want it on, but she let me record. Afterwards, I wondered if it might have been a different interview without the taping, though I assured her I keep identities confidential. I felt that it was hard for her to just respond to my questions and be the interviewee and think that this was a control issue with several therapists used to being in charge in therapy and asking the questions, not answering them. She did not want to talk about working with these clients, except to express her disgust and lack of enjoyment in dealing with them and being a target of their rage. I asked her about supervision and support in doing this work, dealing with countertransference from these cases, and she replied that she had had that [supervision] in her training and therapy (analysis), but she only gets it if she needs it, which sounded to me like she probably never does. This interviewee was psychoanalytically trained and I definitely felt she was much more distant and analytical in much of what she said during the interview. I believe that the distancing behavior of some of these therapists with these clients may have been due to the type of training they had received (e.g., perhaps more traditional psychodynamic/psychoanalytic) that values greater distance between the therapist and client, including the therapist attempting to be more objective, distanced, and non self-disclosing.

Therapists’ Views of Sexual Assault Versus Mine I believe that in addition to interpersonal rapport, which varied between myself and those I interviewed from excellent to fair or perhaps even poor in a couple of cases, I also realized I was assessing or picking up on what their views about sexual assault and sexual assault victims actually were from their comments. When I felt they liked working with survivors; had enlightened or, in my view, “feminist” views about sexual assault; and might actually be doing good work with this population, I tended to like them more and feel more comfortable during the interview. If I felt they judged survivors or subscribed to rape myths or did not see sexual assault as a gendered phenomenon, I did not like them as much and, in some cases, wished I could say something to them about their views (which of course I did not) or wondered what happened to survivors who had them as therapists and whether they disclosed assault or abuse to them or not. In a few cases, the therapists wanted to talk only about male clients with sexual abuse histories or emphasized this problem and wanted to talk about it feeling it was neglected, instead of the subject I was asking them about, which was adult sexual assault survivors. Perhaps because of my own strong views about sexual assault and my own history of victimization, I had high standards for what I expected mental health professionals to do or say about this issue. Yet I did ask them to tell me their views about working with this population, including both difficult and rewarding aspects, so it was not reasonable for me to then not like hearing negative things, which came up at times. In a way, I was grateful when this happened, because I felt that this meant they were being

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honest and felt the interview was a safe place to vent some of their frustrations. In general, though, those interviewed were likely a biased sample in volunteering for a study to talk about their work with survivors and were more likely to enjoy working with this group and have more experience and training in trauma work and with victims than other therapists. This means that the bias in what these persons said was probably toward being much more positive and knowledgeable and experienced with these issues than a random sample would have revealed.

Therapists’ Orientation to Work With Survivors Therapists I liked were those who had more experience with and respect for trauma survivors, particularly those with a feminist perspective. One seasoned trauma therapist explained her approach to her work with survivors as follows: I think my relational approach to trauma has helped. And I’ve learned that that’s probably the most important thing for trauma survivors and that when they can understand how their relationships revive the trauma, then we can really figure it out. And I would use my reactions to trauma survivors in the session to help them understand relationships. Cause often what they expect we think and what I do think are radically different. And so to express the, well, what did you think I was thinking? And then, just to have that conversation is very key. It’s also something that’s very reassuring for them to know if I am angry with them. Then it’s not this big mystery, you know, even if it’s a negative feeling. To be able to go over those interactions really openly has been enormously helpful. The traditional approach is a blank screen which I think is terribly deceptive, particularly for child abuse survivors because then with it, then they end up with no connection, their imaginations will go and imaginations are usually very negative and there’s no language, there’s no way to correct those perceptions.

Other therapists with limited training and/or experience with trauma populations and sexual assault survivors in particular I found much harder to connect with during the interviews and felt were more tense, formal, and distant during the interview itself. For example, one doctoral level clinician with 15 years of experience doing therapy but limited experience with survivors discussed how she currently had several patients with sexual abuse histories and how difficult that was for her. I’m 41 now and two or three’s [sexual assault clients] enough, no more than that. It depends on what your life is like, I’m married, I have a child, I’m not putting up with that, that’s enough, because they’re time-consuming. To take care of yourself, to take care of the patient, yeah, that person I was describing to you—I used to get massive headaches.

Other therapists spoke of the importance of objectivity coming from the traditional psychoanalytic/psychodynamic perspective and training acquired in graduate school: Oh, I mean, I don’t mind listening to it, if it’s had that kind of impact on me, imagine how the victim feels, because I’m hearing it second-hand really, you know, so it makes you

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wonder how sometimes people are able to go on and survive. I think it’s incredibly important to maintain your objectivity, because as a therapist if you have a countertransference, you better understand where that comes from and you better look at it, because that countertransference may make it very difficult to be able to help that person.

This very experienced psychoanalytic/psychodynamic therapist went on to describe how therapists have to sort out who they are comfortable treating and, if they are not, to refer clients to others instead, which seemed to me to be a realistic assessment of one’s abilities and limitations of training in the trauma area. She explained, Exactly, cause otherwise you’re carrying very upsetting information around with you all the time, gotta have something, cause we can’t talk about what we do, you know so it’s a setting that you can discuss it and it’s gonna be confidential and I do. You know, I just think very important, there’s some patients that you’re not gonna treat, cause you’re not comfortable treating them. I think people should only treat those that they are comfortable in treating and feel that they can make a difference with. If it makes you uncomfortable, don’t treat them, send them someplace else. Know that if someone calls you and says I’ve had a rape, you know is this what you treat? You say, no, I don’t, but I will have a referral for you [another therapist], and you better know what the referral sources are.

This therapist denied having clients with sexual assault histories currently but then recalled during the interview many different clients that she realized actually did have such a history throughout the interview. She referred to talking about such clients in supervision and to referring them to other therapists if that was the presenting issue. Typically, therapists with traditional training said they also had the experience necessary to work with sexual assault survivors, even though they did not have any specialized training. These persons claimed that it was like any other presenting problem and that the same therapeutic techniques could be applied as with any other presenting problem they would encounter. I was not really convinced that this would be adequate as trauma is quite different, especially sexual trauma, and to me it showed a lack of full appreciation of the unique nature of sexual trauma and how it is experienced by women in society. Of course, that reaction reflected my own personal bias. During some of these interviews, I felt like survivors might not even feel comfortable disclosing their experiences to such therapists, which may have been accurate but probably was also a reflection of my own feelings of how I would have felt as their client.

Discussion This study examined both researcher and therapist perspectives on working with sexual assault survivors and provides insights into how therapists view their work with this subgroup of trauma survivors, including how their training and orientation affect this work, as viewed and interpreted through the researcher’s lens. The dual focus on researcher and therapist perspectives reveals how the therapists’ accounts of their work

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and the researcher’s reaction to those accounts both influence results and interpretations of the interview data. The findings show how therapists’ treatment orientation and views of sexual assault influence their views of work with survivors, while the researcher’s views of therapists and their accounts of working with survivors were influenced by my perspective as a feminist researcher studying sexual assault and my own past experiences in therapy as a survivor. While including my perspective and seeing and reporting on therapists’ experiences through my lens as a researcher, therapy client, and trauma survivor strengthen the research by providing my insights about what they said from my perspective, it is also a limitation because that lens naturally influences my perceptions of those I interviewed and interpretations of what they said. I would argue that our own views and perspectives are simply an inherent part of doing such interviews, even though they are not discussed in detail in more traditional reports of results from interview studies, except to give a general explanation of the researcher’s role and perspective. This experience interviewing therapists was undertaken with a selective sample of more traditional White experienced therapists in the context of a larger interview study of a larger spectrum of workers who deal with sexual assault survivors (e.g., victim advocates, mental health professionals in various settings). My perceptions of the clinicians discussed here who were not working in the rape crisis context and had no experience in that context probably led my perceptions of them to be formed, at least in part, in contrast with the rape crisis advocates. While some therapists seemed supportive of survivors and to have a feminist perspective and understanding of sexual assault and its uniqueness, others did not, nor seemed supportive or interested in working with survivors. It is possible that a more contemporary sample of therapists with more eclectic training less focused on traditional psychodynamic therapy would have had a more obviously feminist and supportive stance toward sexual assault survivors. I came away with the perception that it would potentially be more difficult for traditionally trained therapists (e.g., psychodynamic/psychoanalytic) using a more objective, neutral, blank-slate stance to be truly supportive of survivors in the way that feminists and those in the rape crisis world recommend (e.g., active listening, validation/belief of survivors’ experiences, telling them it’s not their fault, discussing gender bias and the patriarchal societal context that gives rise to rape). However, this was simply my belief and may or may not be the case as interpersonal characteristics and other qualities may matter more to clients. Surprisingly, research shows no correlation of professional training with psychotherapeutic efficacy (Luborsky et al., 1986; Stein & Lambert, 1984). Professional technical expertise and knowledge do not necessarily predict success. Instead, effective therapists and other people have qualities of warmth, empathy, and genuineness (Frank & Frank, 1991), which may not come from professional training or certification. Similarly, these qualities may not always correlate with those who have trauma training or even those coming from a feminist perspective. Still, it is quite possible that such persons would have more understanding and ability to provide more effective support to survivors.

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Perhaps it was my expectation that these therapists should have had more of a passion about this issue and anger about it similar to what I have that led me to feel some of them were ill equipped at best and insensitive at worst to this population. Other researchers (McLindon & Harms, 2011) have found evidence that mental health professionals often do not have adequate training in this area, do not feel comfortable dealing with disclosures of sexual assault, and do not refer clients to sexual assault crisis centers that do have such expertise. Further work is needed to understand the issues therapists face in working with survivors and how to help them feel more comfortable with this issue. Most clinical psychology doctoral programs still do not have the required training on sexual assault and/or trauma issues more generally (R. Campbell & Raja, 2005). This should be rectified given that many women seeking therapy have histories of sexual trauma. A limitation of this work is that I did not ask therapists about their own history of trauma or their own perceptions of safety in working with survivors of sexual assault, some of whom may be in violent relationships. Three therapists made some mention of this issue spontaneously, with one mentioning her history of domestic violence, another alluding to her history of past trauma, and a third saying she was unsure if she had ever been abused in the past. Several therapists also mentioned having problems with their memories or concerns about abuse, as well as difficulty remembering which clients they had who had sexual victimization histories. One of these therapists had run an incest survivors group and showed me pictures drawn by one of her clients, then asked me what I thought it meant (though I did not respond). She said she felt that her strong aversion to running the group may have meant she had been abused herself, and at the time I thought perhaps her interview with me was partly motivated by wanting to explore this issue further. Because it was not a study focused on interviewing “therapist survivors” about their own victimization experiences though, I did not pursue that when it was mentioned. Such issues as therapist’s own trauma history and fear of victimization in working with clients exposed to violence (e.g., domestic violence) clearly may affect both whether and how they choose to work with sexual assault survivors and their reactions to those clients. Research is mixed but does show that victimization history is related to development of secondary traumatic stress in therapists (Ghahramanlou & Brodbeck, 2000; Jenkins, Mitchell, Baird, Whitfield, & Meyer, 2011). In a recent study of sexual assault and domestic violence, Jenkins et al. (2011) found that counselors motivated by interpersonal trauma report both more PTSD symptoms and more positive changes (including dealing with their own trauma). Those seeking personal meaning report becoming more hypervigilant and self-isolating, whereas those saying they learned from clients reported fewer symptoms, suggesting stress inoculation. They concluded that trauma counselors’ supervisors should facilitate learning from clients separately from processing the counselor’s trauma. I would say this recommendation may apply to trauma researchers as well and such issues need study in sexual assault researchers. Also, the safety of therapists and researchers doing this research is a major issue that was raised by at least one therapist I interviewed who worked with poorer clients whose families had had police and/or criminal justice contact. Psychological self-care

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and supervision may be necessary to process countertransference reactions and to treat vicarious trauma and secondary traumatic stress symptoms (Elwood, Mott, Lohr, & Galovski, 2011), but safety planning in doing this work is also important (see R. Campbell, 2002; Sexual Violence Research Initiative, 2010; Ullman, 2010). Clearly, more research is needed to understand the role of both victimization history and safety in doing this work in researchers and clinicians studying and/or working with sexual assault survivors. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported by a Great Cities Faculty Scholar Award from the University of Illinois at Chicago.

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Author Biography Sarah E. Ullman is a professor of criminology, law, and justice at University of Illinois at Chicago and the director of the Office of Social Science Research. She is a social psychologist whose research concerns the impact of sexual assault and traumatic life events on women’s health and substance abuse outcomes and rape avoidance/prevention. Her book Talking About Sexual Assault: Society’s Response to Survivors was published by the American Psychological Association in 2010 and she is conducting a National Institute on Alcohol Abuse and Alcoholism (NIAAA)–funded longitudinal study of risk and protective factors in sexual assault survivors related to risk of revictimization, mental health, substance abuse, and posttraumatic growth outcomes.