Practicing Counselors, Vicarious Trauma, and Subthreshold PTSD: Implications for Counselor Educators

Bethany A. Lanier, Jamie S. Carney

The purpose of this study was to gain an understanding of the relationship between vicarious trauma (VT) symptoms and subthreshold post-traumatic stress disorder (PTSD) symptoms among practicing counselors. The researchers determined the frequency of VT symptoms and subthreshold PTSD symptoms experienced among practicing counselors and common contributing factors that participants felt contributed to the development of VT symptoms. Implications are presented for counselor educators to determine how they best can prepare students.


Keywords: vicarious trauma, subthreshold post-traumatic stress disorder, PTSD, practicing counselors, counselor educators



Most counselors will likely work with clients addressing trauma (Sommer, 2008; Trippany, White Kress, & Wilcoxon, 2004). Thus, it is important for professional counselors to have an understanding of the dynamics of trauma and interventions to use with clients. Additionally, counselors should be educated on the impact that working with clients can potentially have on them, both personally and professionally. For instance, counselors who work with clients addressing trauma might themselves experience emotional and psychological symptoms, or vicarious trauma (VT). VT has been defined as a disruption in schemas and worldview because of chronic empathic engagement with clients. It is often accompanied by symptoms similar to those of post-traumatic stress disorder (PTSD), which occur as a result of secondary exposure to traumatic material that can result in a cognitive shift in the way the therapist experiences self, others, and the world (Jordan, 2010; Michalopoulos & Aparicio, 2012). Although estimates differ, it has been reported that as many as 50% of counselors are at risk of developing VT (National Child Traumatic Stress Network, 2011).


Counseling requires an immense amount of empathetic acceptance on the part of the counselor, which increases the counselor’s vulnerability to taking on their clients’ traumatic experiences (Finklestein, Stein, Greene, Bronstein, & Solomon, 2015). Empathic acceptance and increased vulnerability on the part of the counselor may increase the counselor’s likelihood of developing VT symptoms (Sommer, 2008). VT can have a detrimental effect on all aspects of the counseling process, including both the counselor’s professional and personal life. Practicing counselors experiencing VT have been found to leave the profession early and may also experience emotional and physical disorders, suicidal ideation, strained relationships, increased or continuous burnout, anger, and possible substance abuse (Bergman, Kline, Feeny, & Zoellner, 2015; Keim, Olguin, Marley, & Thieman, 2008). VT is highly detrimental to the counseling process and the care provided to clients. A counselor experiencing VT is more likely to make clinical errors, and VT can negatively impact the counseling relationship (Trippany et al., 2004). The negative implications associated with VT make it imperative that counselors and those who work with them (e.g., supervisors and counselor educators) understand all the factors that lead to the development of VT. This can include recognizing factors that decrease vulnerability, assessing VT, and intervening (Sommer, 2008). One of the initial components to this process is understanding how VT and related symptoms of subthreshold PTSD develop and the variables or experiences that can contribute to higher levels of vulnerability to VT symptoms. Subthreshold PTSD has been defined as the presence of clinically significant PTSD symptoms that fall short of the full Diagnostic and Statistical Manual of Mental Disorders PTSD diagnostic criteria (Bergman et al., 2015).


VT and Subthreshold PTSD


     As noted, VT can have a detrimental impact on all aspects of the counseling process. A counselor experiencing VT can report many of the symptoms associated with both VT and subthreshold PTSD. VT and subthreshold PTSD have been identified as closely related phenomena. Many counselors who experience VT also meet the criteria for subthreshold PTSD and share similar symptoms (Keim et al., 2008). Counselors who experience VT are in essence experiencing post-traumatic stress symptoms in response to hearing and processing the trauma experienced by their clients (Bercier & Maynard, 2015). Common similar symptoms of VT and subthreshold PTSD include experiencing recurring intrusive thoughts about clients or work, numbing of feelings, hypervigilance or increased anxiety, and a decrease in empathy (Howlett & Collins, 2014; Michalopoulos & Aparicio, 2012; Nelson, 2016).


Although there are limitations in the research on the variables that correspond to the development of VT and subthreshold PTSD among counselors, as well as the factors that address these vulnerabilities, the research has highlighted some areas of concern. Understanding these areas is a critical component of addressing the development, assessment, and intervention for VT and subthreshold PTSD, especially for supervisors and counselor educators who train and work with these counselors. One of these variables is years of experience. Although all practicing counselors are at risk for VT and subthreshold PTSD, novice counselors are at an especially elevated risk (Michalopoulos & Aparicio, 2012; Parker & Henfield, 2012). Novice counselors tend to have limited experience with trauma and often have limited training relevant to working with trauma (Newell & MacNeil, 2010; Parker & Henfield, 2012). Further, novice counselors might have trouble establishing boundaries during the early stages of professional identify development, which can contribute to an increase in vulnerability for developing VT and subthreshold PTSD (Howlett & Collins, 2014). Moreover, beginning counselors’ training and personal experiences may not have adequately prepared them for working with individuals dealing with trauma, so in turn they might not have received training on how to address trauma with their clients or identify the development of VT in themselves (Jordan, 2010; Mailloux, 2014; Trippany et al., 2004). It has been recommended that such training should include the key features of trauma, warning signs and symptoms, and strategies to prevent the development of VT and subthreshold PTSD (Newell & MacNeil, 2010).


     An essential element of training counselors on strategies to prevent or address the development of VT and subthreshold PTSD includes increasing awareness of the workplace dynamics that may increase vulnerability. Counselors spend a sizeable amount of their time ensuring that others take care of themselves while potentially neglecting their own personal self-care (Whitfield & Kanter, 2014). Neglecting self-care has been found to correspond to an increased rate for developing the negative effects of VT and subthreshold PTSD symptoms (Mailloux, 2014). In an effort to decrease VT and subthreshold PTSD practicing counselors must ensure they are incorporating various types of self-care on a regular basis. Counselors can incorporate self-care activities, such as adequate sleep, social interaction, exercise, a healthy diet, reading, and journaling, into their routine, but all too often practicing counselors let these activities slip (Jordan, 2010; Nelson, 2016).


Related to self-care is helping counselors to understand the importance of seeking support from peers and supervisors. Collaboration and consultation with peers and supervisors at the workplace are vital to minimize the adverse effects of VT and subthreshold PTSD (Jordan, 2010). To address possible VT and subthreshold PTSD, practicing counselors require support from colleagues in relation to case conceptualization and identification of impairment (Newell & MacNeil, 2010; Parker & Henfield, 2012; Whitfield & Kanter, 2014). Additionally, counselors should seek supervision specific to trauma to ensure they are not developing VT symptoms and subthreshold PTSD symptoms (Whitfield & Kanter, 2014). One of the concerns, however, is that for many counselors working at counseling sites with high caseloads related to trauma, there are often low levels of clinical supervision (O’Neill, 2010). These sites also can link to another variable that corresponds to higher levels of VT: the caseload of the counselor. For example, counselors with large caseloads are at increased risk of developing VT or subthreshold PTSD because the counselor may not be able to spend adequate amounts of time on each case and might overextend their time addressing case needs (Whitfield & Kanter, 2014). In addition, counselors with caseloads that deal primarily with trauma are at an increased risk of developing VT and subthreshold PTSD, especially if they have limited clinical experience (Bercier & Maynard, 2015; Newell & MacNeil, 2010; Trippany et al., 2004). Recognizing and understanding the contributors to VT and subthreshold PTSD are essential for counselor educators and supervisors to be aware of as they prepare new counselors to enter the field.


Counselor Educator and Supervisor Implications


When looking at the risk factors associated with VT and subthreshold PTSD, it is clear that a critical component to decrease risk is the training and support provided to counselors. Thus, it is imperative that counselor educators and supervisors be aware of the symptoms and factors that impact the development of VT and subthreshold PTSD. Keim et al. (2008) found that 12% of counselors-in-training (CITs) qualified for a PTSD diagnosis, highlighting the fact that counselor educators and supervisors need to be aware of and educate counselors to recognize the symptoms of VT and subthreshold PTSD. The Council for Accreditation of Counseling and Related Educational Programs (CACREP; 2015) reinforces the importance of this training by specifically requiring that programs educate CITs on trauma-related counseling skills and also engage students in methods to assess and address VT and subthreshold PTSD symptoms in themselves as practicing counselors. To meet this goal, counselor educators and supervisors must more fully understand the causes of VT and subthreshold PTSD (Keim et al., 2008).


This study was developed to assess the frequency of VT and subthreshold symptoms among practicing counselors. This included variables that correspond to the development of these symptoms. The data can contribute to our understanding of VT and subthreshold PTSD symptoms among counselors and provide a framework for working with counselors during supervision and in preparing CITs.





Two hundred and twenty current practicing counselors completed the nationwide survey. Of the 220 participants, 219 participants reported gender; 23 (10.3%) respondents identified as male and 196 (87.9%) respondents identified as female. Of the participants, 217 (98.6%) reported they were over 19 years of age (range 23–65, M = 39). Two hundred and fifteen respondents indicated holding a master’s degree (97.8%). Thus, exclusion criteria removed five respondents from the data set for not meeting degree requirements—participants must have completed a master’s degree in counseling (i.e., school counseling, clinical mental health counseling, rehabilitation counseling, family and marriage counseling). Current work setting was reported by 207 of the respondents; 137 (62.3%) identified as school counselors, 24 (10.9%) reported working in a community mental health center, 17 (7.7%) reported working in a higher education center, 16 (7.35%) reported working in a private practice, and 13 (5.9%) reported “other,” which included settings such as employee assistance programs and crisis centers.


Six respondents (2.7%) reported less than one year of cumulative counseling experience, 50 (22.7%) reported 1–3 years of cumulative counseling experience, 31 (14.1%) reported 4–5 years of cumulative counseling experience, 47 (21.4%) reported 6–10 years of cumulative counseling experience, and 72 (32.7%) reported 10 years or more of cumulative counseling experience. Of the 220 respondents, 12 (5.5%) did not report how many years they have been in their current position, 8 (3.6%) reported being in their current position less than one year, 103 (10.9%) reported 1–3 years, 31 (14.1%) reported 4–5 years, 30 (13.6%) reported 6–10 years, and 36 (16.4%) reported being in their current position 10 or more years.



Participants were asked to complete a brief demographic questionnaire and two surveys, the PTSD Checklist for the DSM-5 (PCL-5), developed by Blevins, Weathers, Davis, Witte, and Domino (2015), and the Secondary Trauma Stress Scale (STSS), developed by Bride, Robinson, Yegidis, and Figley (2004). The demographic questionnaire sought to understand the impact that years of experience, number of contributing factors, and preventive measures have on VT and subthreshold PTSD symptoms. Participants in this study also completed a series of measures assessing the rate of VT among practicing counselors, the number of participants who meet the criteria for subthreshold PTSD, and the impact of the types and number of professional supports on practicing counselors.


     Demographic measure. A basic demographic survey was developed and utilized to collect data on each respondent’s age, gender, current position, years of counseling experience, primary type of clientele served, and any licenses and credentials. Text entry was utilized to understand the type and number of professional supports respondents identified: supervision, peer support, years of experience, training specific to trauma, caseload size, and self-care implementation. The demographic survey collected basic information related to the participants’ counseling experience and background to gain an understanding of who chose to participate in the study. Further, the information gained was used to assist in developing implications for counselor educators and supervisors in preparing CITs to recognize VT symptoms and identify the types of professional supports needed.


     PTSD Checklist for the DSM-5 (PCL-5). The PCL-5 is a revision of the PTSD Checklist (PCL) that specifically assesses self-report measures of PTSD symptoms as outlined in the DSM-5 (Blevins et al., 2015). The PCL is one of the most widely used measures of PTSD symptoms, and the revised PCL-5 is the only instrument that specifically measures criteria defined in the DSM-5 (Blevins et al., 2015). The PCL-5 is a 20-item survey that corresponds to the 20 PTSD symptoms in the DSM-5 (Bovin et al., 2016). Respondents are asked to rank, from 0–4, how much they have been bothered by the presented symptom within the last month (Bovin et al., 2016). Sample topics include: having difficulty sleeping; feeling jumpy or easily startled; and avoiding memories, thoughts, or feelings related to the stressful event. In a validation study of the PCL-5, Blevins et al. (2015) found high internal consistency (.94), and the measure fell within the recommended range of inter-item correlation of .15 to .50. Test-retest reliability was r = .82 with a 95% confidence interval [.71, .89], and paired t-tests were significant (p < .01) for the PCL-5 between two test validations (Blevins et al., 2015). Cronbach’s alpha for this study indicated high internal consistency (.96) and test-retest reliability of r = .84.


     Secondary Trauma Stress Scale (STSS). The STSS, developed by Bride et al. (2004), was used to understand the number of VT symptoms among practicing counselors as well as to determine the relationship between VT symptoms and subthreshold PTSD symptoms among practicing counselors. The STSS is a 17-item self-report measure designed to assess helping professionals who may have experienced secondary traumatic stress and the frequency of intrusion, avoidance, and arousal symptoms (Bride et al., 2004; Ting, Jacobson, Sanders, Bride, & Harrington, 2005).


The STSS asks that respondents endorse how frequently an item was true for them in the past 7 days (Bride et al., 2004). Responses range from 1 to 5 in Likert form (1 = never and 5 = very often). Psychometric data for the STSS indicates very good internal consistency reliability with coefficient alpha levels of .93 for the total STSS scale, .80 for the Intrusion subscale, .87 for the Avoidance subscale, and .83 for the Arousal subscale (Bride et al., 2004). Ting et al. (2005) determined in their validation study of the STSS that internal consistency reliability for the 17 total STSS items was very high (.94) and was moderately high for the Intrusion subscale (.79), the Avoidance subscale (.85), and the Arousal subscale (.87), and all three factors were highly correlated with each other (intrusion–avoidance, r = .96; intrusion–arousal, r = .96; avoidance–arousal, r = 1.0), as indicated by a confirmatory factor analysis. Cronbach’s alpha for this study confirmed Ting et al.’s findings, as internal consistency reliability for the 17 total STSS items was very high (.94) and was moderately high for the Intrusion subscale (.80), the Avoidance subscale (.86), and the Arousal subscale (.89). Statements on the Intrusion subscale inquire about respondents’ intrusion symptomology on a Likert scale with statements such as “My heart started pounding when I thought about my work with clients” and “I had disturbing dreams about my work with clients.” The Avoidance subscale asks respondents to respond on a Likert scale to statements such as “I felt emotionally numb” and “I had little interest in being around others.” The final subscale, Arousal, asks respondents to respond on a Likert scale to statements such as “I had trouble sleeping” and “I expected something bad to happen.”



Upon Institutional Review Board approval, participants were recruited via email through listserv solicitation that included the Alabama Counseling Association, the American School Counselor Association, the American Counseling Association, and CESNET. Participants were provided a link to an informed consent document and the research surveys in Qualtrics. Participation was restricted to practicing mental health or school counselors who had a master’s degree in counseling and had been a practicing counselor for at least 6 months at the time of the survey.


Design and Statistical Analyses

The purpose of this quantitative study was to investigate the frequency of VT symptoms and subthreshold PTSD symptoms experienced by practicing counselors. This included the relationship of VT symptoms and subthreshold PTSD symptoms with years of experience, work setting and type of clientele, and the number and type of professional supports utilized by practicing counselors. Descriptive analysis was used to determine what symptoms of VT and subthreshold PTSD practicing counselors experience. A linear regression was used to determine the relationship between VT symptoms and subthreshold PTSD symptoms. Linear regressions were utilized to determine the relationship years of experience, work setting and type of clientele, and professional supports have with VT symptoms and subthreshold PTSD symptoms among practicing counselors.




Symptoms of VT and Subthreshold PTSD Experienced by Practicing Counselors

Descriptive statistics based on participants’ responses indicated symptoms of VT and subthreshold PTSD are being experienced by practicing counselors. On the STSS, all symptoms were experienced to some degree by 49.5% of the participants. Symptoms were rated significant if they scored higher than “never” on the STSS, meaning they had experienced the symptom to some degree within the past 7 days.


The most common symptom of VT experienced by participants was thinking about work with clients when not intending to do so (85.5%), as measured by the STSS. Additional symptoms of VT experienced commonly by participants included feeling emotionally numb (80.5%), becoming easily annoyed (79.1%), having difficulty concentrating (75.5%), and feeling discouraged about their future (75.5%). Experiencing disturbing dreams about their clients (49.5%) and feeling jumpy (56.4%) were the least common symptoms experienced by participants, but 49.5% of the participants experienced these symptoms. Table 1 outlines the VT symptoms of participants as measured by the STSS in descending order.



Table 1


STSS Symptom Distribution

Items in Descending Order n (%)
I thought about my work with clients when I didn’t intend to. 188 (85.5%)
I felt emotionally numb. 177 (80.5%)
I was easily annoyed. 174 (79.1%)
I felt discouraged about the future. 166 (75.5%)
I had trouble concentrating. 166 (75.5%)
I had trouble sleeping. 165 (75.0%)
I wanted to avoid working with some clients. 162 (73.6%)
I was less active than usual. 156 (70.9%)
Reminders of my work with clients upset me. 155 (70.5%)
My heart started pounding when I thought about my work with clients. 155 (70.5%)
I had little interest in being around others. 149 (67.6%)
It seemed as if I was reliving the trauma(s) experienced by my client(s). 133 (60.5%)
I expected something bad to happen. 132 (60.0%)
I avoided people, places, or things that reminded me of my work with clients. 126 (57.3%)
I noticed gaps in my memory about client sessions. 126 (57.3%)
I felt jumpy. 124 (56.4%)
I had disturbing dreams about my work with clients. 109 (49.5%)





Participant responses to the PCL-5, utilized to measure subthreshold PTSD symptoms, suggested practicing counselors are experiencing subthreshold PTSD symptoms. Symptoms were rated as significant if they scored higher than “not at all,” indicating they had experienced the symptom to some degree within the past month. The most common symptom reported to have been experienced by all participants (100%) was repeated, disturbing, or unwarranted memories of the stressful experience. Other symptoms that were reported to have been experienced commonly by practicing counselors included having trouble falling or staying asleep (71.4%), having difficulty concentrating (70.9%), feeling distant or cut off from other people (68.2%), and feeling very upset when something reminded them of the stressful experience (66.8%). Taking too many risks or doing things that could cause personal harm (36.8%); feeling or acting as if the stressful experience were actually happening again (42.7%); and experiencing repeated, disturbing dreams of the stressful experience (49.1%) were experienced least commonly by participants. Table 2 outlines the VT symptoms of participants as measured by the PCL-5 in descending order.



Table 2


PCL-5 Symptom Distribution

Items in Descending Order n (%)
Repeated, disturbing, and unwanted memories of the stressful experience? 220 (100%)
Trouble falling or staying asleep? 157 (71.4%)
Having difficulty concentrating? 156 (70.9%)
Feeling distant or cut off from other people? 150 (68.2%)
Feeling very upset when something reminded you of the stressful experience? 147 (66.8%)
Irritable behavior, angry outbursts, or acting aggressively? 139 (63.2%)
Avoiding memories, thoughts, or feelings related to the stressful experience? 139 (63.2%)
Having strong negative feelings such as fear, horror, anger, guilt, or shame? 134 (60.9%)
Having strong physical reactions when something reminded you of the stressful experience
(for example, heart pounding, trouble breathing, sweating)?
130 (59.1%)
Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)? 127 (57.7%)
Being “superalert” or watchful or on guard? 125 (56.8%)
Having strong negative beliefs about yourself, other people, or the world (for example, having thoughts such as: I am bad, there is something seriously wrong with me, no one can be trusted, the world is completely dangerous)? 125 (56.8%)
Loss of interest in activities that you used to enjoy? 123 (55.9%)
Blaming yourself or someone else for the stressful experience or what happened after it? 121 (55.0%)
Trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)? 119 (54.1%)
Feeling jumpy or easily startled? 116 (52.7%)
Trouble remembering important parts of the stressful experience? 113 (51.4%)
Repeated, disturbing dreams of the stressful experience? 108 (49.1%)
Suddenly feeling or acting as if the stressful experience were actually happening again
(as if you were actually back there reliving it)?
  94 (42.7%)
Taking too many risks or doing things that could cause you harm?   81 (36.8%)





Relationship Between VT Symptoms and Subthreshold PTSD Symptoms

     Linear regression models determined the relationship between VT symptoms and subthreshold PTSD symptoms among practicing counselors. In a backward regression, the PCL-5, measuring subthreshold PTSD symptoms, was entered as the dependent variable, and the subscales of the STSS, measuring VT symptoms, were entered as the independent variables. Results indicated that the more VT symptoms were experienced by practicing counselors, the more subthreshold PTSD symptoms were experienced. There was a significant relationship between results from the PCL-5 and all three STSS subscales. The relationship between subthreshold PTSD symptoms and the Intrusion subscale was significant (r = .676, p < .001). There also was a significant relationship between subthreshold PTSD symptoms and avoidance symptoms (r = .759, p < .001), and between subthreshold PTSD symptoms and arousal symptoms (r = .790, p < .001). Avoidance VT symptoms and arousal VT symptoms were the most predictive variables associated with developing subthreshold PTSD symptoms as evidenced in the restricted model regression summary. In the backward regression model, the Intrusion subscale of the STSS was eliminated as the least significant variable, which indicates the more arousal and avoidance symptoms were experienced as VT, the more subthreshold PTSD symptoms were experienced by the practicing counselors. In the full regression model (R2 Full = .656, F = 103.4, p < .001), results suggested a significant relationship, indicating that the more VT symptoms were experienced by practicing counselors, the more subthreshold PTSD symptoms were experienced. Through the restricted regression model (R2 Restricted = .655, F = 155.75, p < .001) and the F change test, results indicated that the restricted model is not worse than the full model because the observed F (.00000892; p = .647) does not exceed the critical F (df = 1,163), which is 3.94.


Relationship Among Demographics and Type of Professional Supports Among Practicing Counselors on VT

A backward linear regression model was utilized to determine the relationship between VT symptoms and years of experience, work setting and type of clientele, and type of professional supports among practicing counselors. There were two significant relationships within this regression in the restricted model of the regression. There was a significant negative correlation between VT symptoms and having a manageable caseload, indicating the more manageable caseload the counselor has, the fewer VT symptoms they have. In addition, there was a significant negative correlation between VT symptoms and having adequate supervision, indicating the more supervision received, the fewer VT symptoms experienced. Overall, the two variables (caseload and supervision) correlate with the dependent variable, VT symptoms (r = .273, R2 = .074). This overall correlation is unlikely due to chance (F = 8.159, p < .001). The F change test indicated the observed F (2.008; p = .158) does not exceed the critical F (df = 1, 202), which is 3.89. The semi-partial correlation between caseload and VT symptoms was -.173, while the semi-partial correlation between supervision and VT symptoms was -.150. The semi-partial correlation indicates the uniqueness of the relationship. The squared semi-partial correlation for supervision was (-.173)2 = .029, and the squared semi-partial correlation for caseload was (-.150)2 = .02., *p < .05.


Relationship Between Demographics and Type of Professional Supports Among Practicing Counselors on Subthreshold PTSD Symptoms

A backward linear regression model was utilized to determine the relationship between subthreshold PTSD symptoms and years of experience, work setting and type of clientele, and the number and type of professional supports among practicing counselors. With subthreshold PTSD symptoms as the dependent variable and years of experience, work setting and type of clientele, and type of professional supports as the independent variables, a backward linear regression was run to understand the relationship between the variables in the restricted model of the regression. Results indicated a significant relationship between subthreshold PTSD symptoms and those counselors who work primarily with adolescents or with sexual assault/domestic violence survivors. Overall, the two variables (adolescents and sexual assault/domestic violence) correlate with our dependent variable, subthreshold PTSD symptoms (r = .242, R2 = .059). This overall correlation is unlikely due to chance (F = 5.080, p = .007). The F change test indicated the observed F (2.255; p = .135) does not exceed the critical F (df = 1,162), which is 3.94. The semi-partial correlation between adolescents and subthreshold PTSD symptoms was .159, while the semi-partial correlation between sexual assault/domestic violence and subthreshold PTSD symptoms was .187. The semi-partial correlation indicates the uniqueness of the relationship. The squared semi-partial correlation for adolescents was (.159)2 = .025, and the squared semi-partial correlation for sexual assault/domestic violence was (.187)2 = .03. This data indicates that work setting and the type of clientele served by the counselor can influence risk for developing subthreshold PTSD symptoms.



     One limitation for this study was the high percentage of participating school counselors (62.3%). This could have possibly skewed results as the type of clientele that the practicing counselors primarily worked with exhibited the most influence on symptoms of VT and subthreshold PTSD (i.e., adolescents). Additionally, this large percentage of school counselors could make the implications suggested in this study not as applicable for counselors in higher education settings.


An additional limitation of this study was the lack of demographics available to identify if counselors were in a rural setting or urban setting. Although the implications suggested are applicable to all counselors, demographic location could serve as an additional barrier to implementing the professional supports suggested.




The purpose of this study was to develop an understanding of the frequency and characteristics of VT symptoms and subthreshold PTSD symptoms among practicing counselors, which was answered by the first research question. The most common VT symptom experienced by participants (85.5%) was thinking about their work with clients when they did not intend to outside of work. This finding is significant for counselor educators and supervisors as it indicates that VT symptoms are being experienced by the majority of the counselors in this study. All VT symptoms, as measured by the STSS, were experienced by 49.5% of the participants, indicating all 17 VT symptoms measured had been experienced to some degree by the counselors that participated in this study. This study adds to the current literature reported by Bride (2007) that 50% of child welfare counselors experience traumatic stress symptoms within the severe range. In addition, Cornille and Meyers (1999) reported 37% of their sample of child protection service workers reported clinical levels of emotional distress associated with secondary trauma, and Conrad and Kellar-Guenther (2006) reported 50% of child protection workers suffered “high” to “very high” levels of compassion fatigue.


In addition to measuring VT symptoms, the first research question was developed to acquire an understanding of the frequency of subthreshold PTSD symptoms experienced by counselors. Subthreshold PTSD symptoms were measured by the PCL-5 and results suggest practicing counselors are experiencing subthreshold PTSD symptoms. Of the 20 items in the PCL-5, all but three were experienced by at least 50% of the participants. All 220 (100%) of participants reported experiencing repeated, disturbing, and unwanted memories of the stressful experience. This finding is similar to that found by the STSS in that over 85% of participants had unwanted thoughts about experiences with clients outside of work. Furthermore, over 70% of participants reported having trouble sleeping and having difficulty concentrating in both the STSS and PCL-5 as symptoms of VT and subthreshold PTSD. Understanding the symptoms of VT and subthreshold PTSD experienced by participants was important, as previous studies have indicated that those who experience VT symptoms also experience subthreshold PTSD symptoms (Jordan, 2010). Additionally, the literature has reported VT symptoms and subthreshold PTSD symptoms as being one and the same (Finklestein et al., 2015).


The second research question was developed to gain an understanding of the relationship between VT symptoms and subthreshold PTSD symptoms. A linear backward regression with the PCL-5 measuring subthreshold PTSD symptoms was entered as the dependent variable, and the subscales of the STSS, measuring VT symptoms, were entered as the independent variables. Results from this regression model indicated that the more VT symptoms were experienced by practicing counselors, the more subthreshold PTSD symptoms were experienced. In the backward regression model, the Intrusion subscale of the STSS was eliminated as the least significant variable, which indicated that the more arousal and avoidance symptoms were experienced as VT, the more subthreshold PTSD symptoms were experienced by the practicing counselors, with the Intrusion scale not being significant. This finding is consistent with the extant literature that has reported VT symptoms being analogous to PTSD symptoms (Keim et al., 2008). Furthermore, this finding also is consistent with prior literature that reported counselors who experience VT symptoms also experience PTSD symptoms (Bercier & Maynard, 2015), as found in Bride’s (2007) study in which 34% of child welfare workers met the PTSD diagnostic criteria because of VT.


In an effort to answer the second research question, which was interested in the relationship between VT symptoms and subthreshold PTSD symptoms and years of experience, work setting and type of clientele, and the number and type of professional supports, two backward linear regression models were established. The first linear regression model was interested in the relationship between VT symptoms and years of experience, work setting and type of clientele, and the number and type of professional supports among practicing counselors. In this backward linear regression model, the STSS served as the dependent variable with years of experience, work setting and type of clientele, and the number and type of professional supports serving as the independent variables. Results indicate a significant relationship between VT symptoms and having a manageable caseload as well as between VT and utilizing supervision. A negative correlation between VT symptoms and having a manageable caseload indicates that the more manageable a counselor’s caseload, the less likely they were to experience VT symptoms. This finding is consistent with prior studies that indicate a manageable caseload as being a protective factor for counselors that can decrease their chance of developing both VT symptoms and subthreshold PTSD symptoms (Trippany et al., 2004). Additionally, there was a negative correlation between supervision as a professional support and the development of VT symptoms among counselors. Adequate supervision has been identified as a protective factor against the development of VT (Harrison & Westwood, 2009). Both of these findings are important implications for counselor educators and supervisors as they can be initiated in the classroom while CITs are preparing for a career in the counseling profession.


The second linear regression model focused on the relationship between subthreshold PTSD symptoms and years of experience, work setting and type of clientele, and the number and type of professional supports among practicing counselors. In this backward linear regression model, the PCL-5 served as the dependent variable with years of experience, work setting and type of clientele, and the number and type of professional supports serving as the independent variables. Results indicated a significant relationship between subthreshold PTSD symptoms and counselors who primarily work with adolescents and sexual assault/domestic violence survivors. These findings are consistent with prior literature that has indicated sexual assault counselors report more VT symptoms and subthreshold PTSD symptoms. For instance, Bride (2007) reported 65% of domestic violence and sexual assault social workers reported at least one symptom of VT, while Lobel (1997) reported over 20 years ago that 70% of sexual assault counselors experienced VT. Additionally, Schauben and Frazier (1995) reported that counselors who work with a higher percentage of sexual assault survivors report more disrupted beliefs about themselves and others, more subthreshold PTSD symptoms, and more VT than counselors who see fewer sexual assault survivors.


Implications for Counselor Educators and Supervisors


     The results of this study provide counselor educators and supervisors with information to prepare CITs to have an increased awareness of VT and subthreshold PTSD symptoms. This study established evidence that practicing counselors are experiencing numerous VT symptoms and subthreshold PTSD symptoms. In fact, this study found that all VT symptoms measured were experienced by 49.5% of the participants, and 17 of the 20 PTSD symptoms measured were experienced by all participants. Further, in an open-ended question in the brief demographic survey, participants provided the researcher with ideas they felt would increase awareness of VT and subthreshold PTSD and decrease VT and subthreshold PTSD symptoms. Over 40% of responses indicated a desire for more education on VT symptoms and subthreshold PTSD symptoms. With 49.5% of participants reporting VT symptoms and subthreshold PTSD symptoms, it is evident that additional education is needed related to these symptoms among practicing counselors. Keim et al. (2008) suggested educational trainings and workshops be provided to CITs proactively to increase awareness of VT and subthreshold PTSD and to decrease VT symptoms and subthreshold PTSD symptoms among practicing counselors. Counselor educators and supervisors can provide trainings on the signs and symptoms of VT and subthreshold PTSD experienced by counselors to raise awareness of these symptoms and ways to recognize and alleviate them before causing harm to the counselor or client.


This study denoted that counselors who work primarily with adolescents and sexual assault/domestic violence survivors are experiencing more subthreshold PTSD symptoms than counselors that do not work specifically with these populations. As counselor educators prepare CITs for practicum, internship, and employment as counselors, it is vital for counselor educators to acknowledge the unique challenges that may stem from working with adolescents and survivors of sexual assault/domestic violence. It is imperative that counselor educators and supervisors integrate specific educational material through coursework related to these populations to best prepare CITs. Evidence-based practices that are effective for counseling these populations should be implemented within counselor education programs, supervision, workshops, and trainings outside of the degree program (e.g., at conferences; Alpert & Paulson, 1990; Mailloux, 2014; Whitfield & Kanter, 2014).


Education on the significance of professional supports, such as adequate supervision and manageable caseloads, is fundamental for CITs to be prepared to lessen the hazard of developing VT symptoms and subthreshold PTSD symptoms. By providing sufficient supervision during practicum and internship, counselor educators and supervisors can prepare CITs for coping with VT symptoms and subthreshold PTSD symptoms should they develop. In addition, through modeling appropriate supervision, CITs will comprehend the supervisory process and seek post-degree supervision.


Directions for Future Research

     Future studies on VT symptoms and subthreshold PTSD symptoms need to focus solely on clinical mental health counselors or school counselors to develop implications specific to counseling sites. Further research devoted to the development of workshops and trainings to educate counselors on VT and subthreshold PTSD is needed.


A future study that compares counselors in rural settings and urban settings will be important to understand barriers to coping with and addressing VT symptoms and subthreshold PTSD symptoms. For example, in a rural setting, the counselor may not have adequate supervision and may be overloaded with cases, which can decrease the amount of self-care they are able to implement. It will be important for future research to explore what barriers to professional supports counselors face in these different demographic communities.

Because of this study’s finding that working primarily with adolescents and individuals who have experienced sexual assault or domestic violence increases counselors’ chances of experiencing VT symptoms and subthreshold PTSD symptoms, a qualitative or mixed-methods study focused on VT among counselors working with these populations is desirable. In an effort to best prepare students who will work with these populations, an understanding of exactly which aspects of working with these clients increase VT symptoms and subthreshold PTSD symptoms is essential.



Conflict of Interest and Funding Disclosure

The authors reported no conflict of interest

or funding contributions for the development

of this manuscript.






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Bethany A. Lanier, NCC, is an assistant professor at the University of West Georgia. Jamie S. Carney is a professor at Auburn University. Correspondence can be addressed to Bethany Lanier, 1601 Maple Street, Carrollton, GA 30116,

Assessment and Treatment of Brain Injury in Women Impacted by Intimate Partner Violence and Post-Traumatic Stress Disorder

Trish J. Smith, Courtney M. Holmes

Intimate partner violence (IPV) is a public health concern that affects millions of people. Physical violence is one type of IPV and has myriad consequences for survivors, including traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD). It is estimated that as many as 23,000,000 women in the United States who have experienced IPV live with brain injury. This article overviews the intersection of TBI and PTSD as a result of IPV. Implications for counselors treating women impacted by IPV suggest counselors incorporate an initial screening for TBI and consider TBI- and PTSD-specific trauma-informed approaches within therapy to ensure best practices. A case study demonstrating the importance of the awareness of the potential for TBI in clients who experience IPV is included.

Keywords: intimate partner violence, traumatic brain injury, post-traumatic stress disorder, PTSD, public health

In 1981, the U.S. Congress declared October as Domestic Violence Awareness Month, marking a celebratory hallmark for advocates and survivors nationwide (National Resource Center on Domestic Violence, 2012). Since this time, similar social and legislative initiatives have increased overall awareness of gender inequality, thus influencing a decline in women’s risk for intimate partner violence (IPV; Powers & Kaukinen, 2012). Recent initiatives, such as a national briefing focused on brain injury and domestic violence hosted by the Congressional Brain Injury Task Force, continue to call increased attention to the various intersections and implications of this national public health epidemic (Brain Injury Association of America, 2017). Unfortunately, despite various social advocacy movements, IPV remains an underrepresented problem in the United States (Chapman & Monk, 2015). As a result, IPV and related mental and physical health consequences continue to exist at alarmingly high rates (Chapman & Monk, 2015).

IPV refers to any act of physical or sexual violence, stalking, or psychological aggression by a current or previous intimate partner. An intimate partner is an individual with whom someone has close relations with, in which relations are characterized by the identity as a couple and emotional connectedness (Breiding, Basile, Smith, Black, & Mahendra, 2015). An intimate partner may include but is not limited to a spouse, boyfriend, girlfriend, or ongoing sexual partner (Breiding et al., 2015). Physical violence is the intentional use of force that can result in death, disability, injury, or harm and can include the threat of using violence (Breiding et al., 2015). Sexual, emotional, and verbal abuse are often perpetrated in conjunction with physical violence in relationships (Krebs, Breiding, Browne, & Warner, 2011).

Heterosexual and same-sex couples experience IPV at similar rates (Association of Women’s Health, Obstetric and Neonatal Nurses, 2015). Researchers estimate that more than one in every three women and at least one in four men have experienced IPV (Sugg, 2015). These rates likely underestimate the true prevalence of IPV, given that populations with traditionally high incidences of abuse (e.g., poor, hospitalized, homeless, and incarcerated women) may not be included in survey samples (Scordato, 2013; Tramayne, 2012).  Additionally, fear and shame often serve as a deterrent to reporting abuse (Scordato, 2013). Although both men and women are victims of IPV, women are abused at a disproportionate rate (Association of Women’s Health, Obstetric and Neonatal Nurses, 2015) and have a greater risk than men of acquiring injury as a result of physical violence (Scordato, 2013; Sillito, 2012). Data have shown that 2–12% of injuries among women brought into U.S. emergency departments are related to IPV (Goldin, Haag, & Trott, 2016), 35% of all homicides against women are IPV-related (Krebs et al., 2011), and approximately 22% of women have experienced physical IPV, averaging 7.1 incidences of violence across their lifespan (Sherrill, Bell, & Wyngarden, 2016). IPV is a pervasive relational problem that creates a myriad of complex mental and physical health issues for female survivors (Sugg, 2015). One health issue commonly experienced by female survivors of IPV is post-traumatic stress disorder (PTSD; Black et al., 2011).


A Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013) diagnosis of PTSD is based on the client’s exposure to a dangerous or life-threatening stressor and consists of the following symptomology: intrusion of thoughts or re-experiencing of the event, including flashbacks; avoidance of experiences or thoughts related to the stressor; negative alterations in cognition and mood; and changes in reactivity, including hypervigilance or hyperarousal. According to Bourne, Mackay, and Holmes (2013), flashbacks are the hallmark symptom of PTSD and involve a process in which the individual dissociates and feels as though they are re-experiencing the traumatic event through involuntary, vivid, and emotional memories. Although PTSD symptoms may occur immediately after a traumatic event, symptoms may have a delayed onset in which the full range of symptoms can manifest even 6 months after the event, showing only partial symptom criteria in the preceding months (Utzon-Frank et al., 2014).

Experiencing IPV increases risk for developing PTSD (National Center on Domestic Violence, Trauma, and Mental Health, 2014). In a national sample of 9,000 women, 62% who experienced some form of IPV reported at least one PTSD symptom (Black et al., 2011). Women who experience IPV are almost three times as likely to meet criteria for PTSD when compared with those who have not had such experiences (Fedovskiy, Higgins, & Paranjape, 2008). Although PTSD is a common manifestation of IPV, another condition, traumatic brain injury (TBI), also is prevalent in survivors (Sherrill et al., 2016). The symptomology of TBI mirrors that of PTSD, rendering the clinical tasks of appropriate diagnosis and treatment planning especially difficult (McFadgion, 2013).


TBI is defined as a change in brain function caused by an external force (e.g., strike to the head or strangulation; Murray, Lundgren, Olson, & Hunnicutt, 2016). Symptoms include headaches, dizziness, fatigue, difficulty concentrating, irritability, and perceptual difficulties with noise and light (Zollman, 2016). Other symptoms can include problems with attention, memory, processing speed, decision making, and mood (Jeter et al., 2013). Professionals can use computerized tomography (CT) scans to find contusions, hematomas, diffuse axonal injury, and secondary brain injuries, which aid in the medical diagnosis of TBI (Currie et al., 2016). Although CT is widely used in assisting with the identification of TBI, a final diagnosis is most often made in a clinical interview with the patient, treating physician, and if feasible, those who observed the violent incident or responded to it (Zollman, 2016). Violence that causes TBI may or may not leave internal or external physical evidence of trauma (e.g., bruising, scarring); thus it is crucial that assessment and screening attempts take place beyond neuroimaging technology and are included as a part of a comprehensive evaluation (Joshi, Thomas, & Sorenson, 2012).

Researchers indicate that over 60% of women, with estimates as high as 96%, who experience IPV sustain injury to the face or head areas, including attempted strangulation (McFadgion, 2013; Sherrill et al., 2016; St. Ivany & Schminkey, 2016). Acquired TBI through IPV can complicate the therapeutic treatment of women (Murray et al., 2016). Brain injury shares similar symptomology with PTSD, increasing likelihood for misdiagnosis, complications with care, and long-term brain damage (McFadgion, 2013). Additionally, TBI and PTSD are often comorbid diagnoses, and those who survive physical trauma and incur a TBI suffer negative mental health impacts such as depression, anxiety, and suicidal ideation (Smith, Mills, & Taliaferro, 2001).

PTSD and TBI have an extensive impact on brain functioning (Boals & Banks, 2012; Saar-Ashkenazy et al., 2016). Individuals with PTSD experience daily cognitive failures in memory, perception, and motor function (Boals & Banks, 2012; Saar-Ashkenazy et al., 2016). Other researchers have shown that PTSD negatively impacts brain functioning on multiple levels, including stimuli recognition, and overall cognitive functioning (Saar-Ashkenazy et al., 2016). Similarly, individuals with TBI may experience physical, sensory, cognitive, and social difficulties as a result of their brain injury (Brain Injury Association of Virginia , 2010). Given the overlapping symptoms of PTSD and TBI, and the overall impact on functioning, it is critical for counselors to consider these factors when diagnosing and treating women who have experienced IPV.

In sum, IPV is a widespread public health issue with a multitude of negative consequences related to human functioning. Incidences of TBI in women who have experienced IPV cannot be overlooked. A framework for mental health counselors that includes awareness of the overlapping symptoms between two likely outcomes of IPV and their manifestation is crucial for successful case conceptualization and treatment.

Counseling Implications

PTSD and TBI have extensive impact on human functioning, and it is critical that counselors examine appropriate responses and considerations for therapeutic treatment of female survivors of physical violence resulting from IPV. Clinical considerations should be incorporated into initial screening, therapeutic approaches, and communication with clients.

Screening and Assessment
McLeod, Hays, and Chang (2010) suggested that counselors universally screen clients for a current or past history of IPV. Based on the literature, survivors of IPV face various challenges when seeking services and either reporting or disclosing abuse, including: self-blame for the abuse; fear of the perpetrator; internalized shame; lack of acknowledgement of the level of danger; perception that community services are not helpful; lack of housing, child care, and transportation; access to money; and lack of educational opportunities (Fúgate, Landis, Riordan, Naureckas, & Engel, 2005; Lutenbacher, Cohen, & Mitzel, 2003; McLeod et al., 2010; Scordato, 2013). Minority populations experience additional challenges, including fear of prejudice and systemic oppression (Scordato, 2013). Thus, counselors carry the responsibility to broach screening with all clients. With an intentional screening for IPV, counselors are able to further identify TBI as a result of physical violence in IPV to ascertain medical and related concerns. Given the statistical probability that a woman who experienced physical IPV sustained past injury to the head or neck, initial screening is critical (Murray et al., 2016). The Pennsylvania Coalition Against Domestic Violence (PCADV; 2011) provides a guide based on a classic TBI screening called HELPS. The guide asks questions in the context of IPV, including if the person has ever been: (a) hit on the head, mouth, or other places on the face; (b) pushed so hard the head strikes a hard or firm surface; (c) shaken violently; (d) injured to the head or neck, including strangulation, choking, or suffocating that restricted breathing; and (e) nearly drowned, electrocuted, or intentionally given something allergic. These questions serve as a guide in detecting if the survivor has acquired TBI; however, they should not be used in place of a medical assessment (PCADV, 2011).

The Brain Injury Association of America (2015) describes symptoms of TBI as including: headaches, dizziness, lack of awareness of surroundings, vomiting, lightheadedness, poor attention and concentration, fatigue, and ringing in the ears. Impairments involving functions related to memory, decision making, and processing speed may be indicators of brain injury (Jeter et al., 2013). Recognizing TBI allows for the appropriate response in treatment, including identifying necessary medical consultations and referrals.

Therapeutic Approaches to IPV

After the brain is injured, a recovery process involving three stages is prompted, including: cell repair, functional cell plasticity, and neuroplasticity (Villamar, Santos Portilla, Fregni, & Zafonte, 2012). Zasler, Katz, Zafonte, and Arciniegas (2007) described neuroplasticity as the process in which spared healthy brain regions compensate for the loss of functioning in damaged regions. Kimberley, Samargia, Moore, Shakya, and Lang (2010) suggested that repetition of activities is required to induce neuroplasticity, or recovery of the brain.

Researchers have shown that certain techniques in talk therapy can aid in the recovery of the brain, serving to benefit both the treatment of PTSD as well as the alleviation of symptoms in TBI (Chard, Schumm, McIlvain, Bailey, & Parkinson, 2011). For example, Chard et al. (2011) compared two therapies: (a) cognitive processing therapy (CPT), a form of cognitive behavioral therapy effective in treating PTSD; and (b) an alternate version of CPT, CPT-cognitive only (CPT-C), which omits the writing and reading of one’s trauma narrative and instead emphasizes cognitive challenging and rehearsal. Both approaches were applied to a sample of 42 male veterans who met criteria for PTSD, had history of TBI, and were compared across four groups based on severity and treatment approach (Chard et al., 2011). In addition to speech therapy two to three times a week and a psychoeducation group 23 hours a week, CPT-C individual sessions and group sessions were each held twice a week as a part of a residential treatment program (Chard et al., 2011). Chard et al. identified a significant main effect across PTSD and depression measures for both groups, indicating CPT-C as a plausible treatment for clients with TBI.

Another therapeutic approach includes CRATER therapy, which is an acronym that encompasses six targets for therapy: catastrophic reaction, regularization, alliance, triangulation, externalization, and resilience (Block & West, 2013). The first target, catastrophic reaction, is based on targeting the explosive reaction that is in response to overwhelming environmental stimuli; regularization is the therapist’s approach to establishing a regular daily routine for the client (e.g., sleep–wake cycle, meal times); alliance is the relationship between the professional and survivor; triangulate is the relationship expanded beyond the client to include a family member or friend; externalize negates self-blame; and resilience promotes the use of effective coping skills (Block & West, 2013). The individual’s family members and friends are specifically targeted in the approach to account for ecological validity and provide support. Block and West (2013) stated, “CRATER therapy targets the formation of a good working alliance, teaches the survivor to perform skills without cues from the provider and integrates both cognitive and therapy interventions” (p. 777). Overall, this theory infuses cognitive restructuring into individual psychotherapy and assists the client in developing effective coping strategies.

In addition to the implementation of specific therapeutic approaches in counseling, the counselor can incorporate management strategies to accommodate survivors’ brain injury symptoms in counseling sessions. For example, a client who takes longer to complete tasks and answer questions because of an impaired information processing speed can be accommodated by the counselor doing the following: (a) allowing extra time for responses, (b) presenting one thing at a time, and (c) not answering for them during the lapse in response time (BIAV, 2010). The PCADV (2011) also recommends speaking in a clear and literal sense as well as providing tasks in short increments. If memory is impaired, the counselor can make it a point to repeat information as necessary, encourage the use of external memory aids (e.g., journals, calendars), and give reminders and prompts to assist with recall (Block & West, 2013). In the case in which the client shows poor self-monitoring skills and lacks adherence to social rules or consistently dominates the dialogue in sessions, the counselor can provide feedback, encourage turn-taking, and gently provide redirection of behavior (BIAV, 2010). Implementing techniques that involve feedback and redirection also can decrease chances of oversharing that might re-traumatize the survivor (Clark, Classen, Fourt, & Shetty, 2014). Utilizing compensatory strategies such as these can ensure the accessibility and efficacy of counseling sessions to survivors with TBI.

Therapeutic Communication With IPV Clients
Aside from specific counseling approaches and management strategies, several considerations can be made by the counselor to ensure an informed response in communication and chosen interventions. Building a therapeutic relationship, including instilling hope for possible change, is especially useful with complex PTSD diagnoses (Marotta, 2000). Additionally, researchers suggest that receiving social support is a resiliency factor in trauma recovery (Shakespeare-Finch, Rees, & Armstrong, 2015; Zhou, Wu, Li, & Zhen, 2016). However, data suggest that women with brain injury, when compared with male counterparts, experience more negative alterations to social and play behavior, including more exclusion and rejection in social situations (Mychasiuk, Hehar, Farran, & Esser, 2014). Mychasiuk et al. (2014) indicated that group therapy or other social types of interventions related to social support building and safety planning may be contraindicated until these specific challenges can be addressed in individual counseling.

Counselors should be aware of the cyclical nature of abusive relationships that can result in multiple brain injuries over time (Murray et al., 2016). Additionally, counselors should understand complex PTSD, which is associated with prolonged exposure to severe trauma; alterations to affect and impulses, self-perception, interactions with others, and increased somatization; and medical problems (Pill, Day, & Mildred, 2017). Consideration of the potential impact that cumulative brain injuries and prolonged trauma have on health outcomes is critical for effective clinical intervention (Kwako et al., 2011), as myriad aspects of a woman’s ability to identify and understand her situation may be negatively impacted. A critical skill for women in violent relationships includes the need to account for, and effectively assess, one’s physical environment at the time of abuse. A client can take the following precautions to protect herself from future violence: (a) making herself a smaller target by curling up into a ball in a corner, (b) avoiding wearing scarves or necklaces that can be used in strangulation attempts, (c) guarding her head with her arms around each side of her head, and
(d) hiding guns or knives (PCADV, 2011). Furthermore, it is imperative that the counselor actively assist in the safety planning process given that head injury and trauma often impair cognitive processes such as a person’s ability to plan and organize (PCADV, 2011). Initiating the safety planning process as a psychoeducational component of treatment could serve to counter shame and self-blame for the survivor, ensuring that a trauma-informed approach and best practices are maintained (Clark et al., 2014).

Ethical Implications
Client cases that include current or past IPV are often fraught with numerous ethical considerations (McLaughlin, 2017). Perhaps the most pervasive ethical issue is the responsibility of mandated reporting. Counselors must be aware of the intricacies of such responsibility and understand the limits of reporting as it pertains to survivors of IPV (American Counseling Association, 2014). Clinicians should become skilled at assessing for violence in relationships so that reporting can occur if one of the following situations arise: abuse of children, older adults, or other vulnerable populations; duty to warn situations; or risk of suicide. The responsibility to report must be discussed with clients during the informed consent process and throughout treatment (American Counseling Association, 2014, B.1.d).

IPV presents additional complications for treatment providers. Researchers suggest that more than 50% of couples in therapy report at least one incident of physical aggression against their partner (O’Leary, Tintle, & Bromet, 2014). Despite this implication, counselors fail to adequately assess for violence or intervene when violence is present. Once a thorough assessment has taken place, clinicians can evaluate the most appropriate and safe course of treatment for each individual and the couple together. Treatment options include continued couples work (when appropriate), separate individual therapy, or group work that may include anger management or other behavioral-change strategies (Lawson, 2003).

Counselors working with survivors of IPV should expect to regularly determine how to “maximize benefit and minimize harm” for each client (McLaughlin, 2017, p. 45). Counselors may find themselves working with clients who want or need to stay in the relationship or those who want or need to leave the relationship. Each situation is complicated with a variety of personal factors such as level of violent threat and access to financial and other types of resources. Individual assessment in collaboration with the client to determine the best therapeutic strategy is necessary (McLaughlin, 2017).

Finally, counselors may hold overt or covert personal biases toward IPV clients and violence against women. Counselors should evaluate personal feelings toward both victims and perpetrators of IPV prior to working with them and throughout the course of treatment. McLeod et al. (2010) developed a competency checklist for counselors to assist in necessary self-reflection and self-evaluation of their level of competency when working with this population. Finally, counselors should understand the critical nature of supervision and consultation and seek it out when necessary (McLaughlin, 2017).

Case Study

The following case study is a hypothetical case based loosely on the first author’s experience as a counselor in a domestic violence shelter. The case and treatment description are meant to provide a general overview of how counselors might implement an overarching lens of screening and treatment when working with survivors of IPV.

A 48-year-old Caucasian woman sat across from her counselor, elated as she described the sense of relief she felt to finally receive counseling support during what she explained to be the worst time of her life. In disclosing several accounts of physical, sexual, and emotional abuse, she described times in which her ex-partner had blackened her eye, broken bones, and strangled her. Knowing the various causes of TBI in IPV, the counselor started a conversation about the possibility of brain injury. The client denied going to the emergency room to be assessed for injuries, a process that would have likely detected contusions or swelling of brain tissue. The absence of medical treatment was not surprising to the counselor, given the numerous barriers that often leave survivors of IPV without medical attention, including fear of further harm. Knowing this, the counselor was careful in her communication so as to not suggest blame or judgement for the client’s decisions to not seek past medical assistance. The counselor proceeded to ask questions related to whether or not the client perceived any changes to physical or cognitive functioning in comparison to life before her abusive relationship, with focus on memory, attention, and learning experiences. The client found it very difficult to answer these questions in detail, indicating that her memory was potentially impaired because of either PTSD or brain injury. A neutral, yet warm and understanding, therapeutic stance was critical for the counselor to keep the client engaged in the therapeutic process.

Following the detection of probable TBI, the counselor provided psychoeducation to promote awareness on the nature of the injury as well as referrals to various local and state resources. The counselor and client then discussed the client’s experience of PTSD symptoms and how these symptoms could mirror the symptoms of brain injury. Education is a recommended strategy when working with clients with PTSD (Marotta, 2000). The counselor knew that helping the client to differentiate between the two would help her monitor and document symptoms for the journaling homework that would eventually be assigned to her. At this time, the counselor provided the client with a handout with a t-chart comparing PTSD and TBI symptoms, knowing that a concrete, visual representation might be a helpful accommodation. For her journaling homework, the counselor instructed the client to record the following: symptom type, duration, intensity, and any contextual details. This recording would benefit the client in multiple ways, including increasing personal awareness and attention to symptoms, indicating the necessity of additional referral sources, and providing a record for discussion with future medical professionals.

At the beginning of the next several sessions, the counselor followed up on the client’s journaling homework. During these check-ins, the client reported times of forgetfulness, difficulty with attention, and problems staying organized and making decisions. One particular incident allowed the counselor and client to actively probe through differences between PTSD and TBI when the client reported a time in which she “zoned out” while running errands. They explored the event, discussing duration and contextual details. It was in this conversation that the client mentioned a glass item having fallen nearby and shattering loudly just moments before she “zoned out.” From this detail, especially noting the infrequency of her zoning out day-to-day, the counselor discussed the likelihood of it being trauma-related, connecting it to the many nights of domestic disturbances with her abuser that ended in various household items being destroyed. On the other hand, the counselor associated her increased forgetfulness, headaches, and a distorted sense of smell with possible manifestations of brain injury. The counselor recommended that the client call the state’s brain injury association to learn about medical providers who had extensive experience treating TBI.

Noting shattering glass as one of her triggers, the counselor and client discussed what she could do after perceiving this stimulus to reorient to the present. Grounding techniques such as deep breathing were discussed. To address forgetfulness, the counselor implemented compensatory strategies that included shorter responses and questions, utilization of the present time frame, and repetition of responses provided by the counselor. To encourage further assessment and treatment, the counselor followed up on the client’s contact with experienced TBI medical professionals.

Clients may be involved in both individual and group counseling simultaneously. However, group counseling may be contraindicated for women who have experienced a TBI until social and relational challenges can be addressed in individual counseling (Mychasiuk et al., 2014). Therefore, before recommending entry into a counseling group, the counselor first assessed the client’s day-to-day interactions with individuals and how her social network changed before and after sustaining TBI. This assessment allowed the counselor an opportunity to both gauge the appropriateness of group therapy and identify possible barriers to group that might be assisted with accommodation. With careful consideration and assessment, counselors can maximize the use of group therapeutic factors such as interpersonal learning, socializing techniques, and imitative behavior.


PV is a prevalent public health issue that impacts the development of a wide range of mental and physical health diagnoses, in which PTSD and TBI are two pervasive complications that often affect survivors of IPV. Recent initiatives, such as the national briefing hosted by the Congressional Brain Injury Task Force, are indicative of the work still needed to properly address this underrepresented national issue (Brain Injury Association of America, 2017). Counselors should understand the intersectionality of PTSD and TBI and how such experiences can complicate treatment. This article has provided several suggestions for counselors to improve their clinical practice to better accommodate survivors of IPV, including screening and assessment techniques, therapeutic approaches, and communication suggestions. Counselors should be aware of the need to adopt specific therapeutic approaches and strategies in counseling that compensate for cognitive impairments so as to avoid gaps in the delivery of services and adhere to best treatment practices. Counselors also are required to abide by ethical codes and guidelines and are urged to continually seek supervision and consultation when working with this population to ensure that the various aspects of this complicated category of violence are thoroughly considered.

Conflict of Interest and Funding Disclosure

The authors reported no conflict of interest or funding contributions for the development of this manuscript.


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Trish J. Smith is a resident in counseling and a senior client services advocate at Safe Harbor Shelter in Richmond, Virginia. Courtney M. Holmes, NCC, is an assistant professor at Virginia Commonwealth University. Correspondence can be addressed to Trish Smith, Safe Harbor Shelter, P.O. Box 17996, Richmond, VA 23226,

PTSD, Optimism, Religious Commitment, and Growth as Post-Trauma Trajectories: A Structural Equation Modeling of Former Refugees

Hannah E. Acquaye

Refugees report several mental health challenges associated with pre-, peri-, and post-flight conditions. Some of these challenges include fear, anxiety, hypervigilance, hyperarousal, and nightmares—symptoms that could meet the diagnostic criteria for post-traumatic stress disorder (PTSD). Despite these challenges, some refugees also report psychological growth with nomenclature like post-traumatic growth, resilience, and benefit-finding. This study examined the directional relationship among war-related events, optimism, PTSD, religious commitment, and growth. Prior studies in traumatized samples have demonstrated that PTSD and growth can occur concurrently, while optimism and religiousness may enhance growth. The hypotheses undergirding this study posited that participants in this non-Western population could demonstrate concurrent PTSD and growth, while those with higher levels of optimism and religiousness would exhibit increased levels of growth compared to those with lower levels. For a sample of 444 former refugees, hypotheses were theoretically modeled to identify whether the data fit the model. Inspection of fit indices provided support for the hypothesized model. Implications for professional counselors are included and recommendations for future research are provided.

Keywords: refugees, post-traumatic growth, PTSD, optimism, religious commitment

Professional counselors who work with refugees, specifically refugees resettled as a result of war or conflict, hear their clients share the harrowing experiences encountered on their journeys toward safety (Clay, 2017; International Counseling and Community Services [ICCS], 2015). War-related internally displaced persons (IDPs) and refugees, more than immigrants or other displaced people, report suffering inhumane acts like ethnic cleansing (United Nations, 2017). Others describe running through forests to avoid warring tribal factions, defending themselves against wild animals and forces of nature, and going without food for days (Betancourt et al., 2015). These experiences can be traced through the precipitating events leading to their flight, the flight progression, and finally the pathways to resettlement. Each of these processes incurs a traumatic adjustment. Clients among this population have reported diverse somatic symptoms and physical challenges (Cline, 2013; Edge, Newbold, & McKeary, 2014), as well as difficulties associated with basic physiological needs (e.g., food, water, shelter; ICCS, 2015; Maslow, 1970). They have described symptoms that meet the criteria for diagnosing post-traumatic stress disorder (PTSD; American Psychiatric Association [APA], 2013; Zerach, Solomon, Cohen, & Ein-Dor, 2013), depression (APA, 2013; Praetorius, Mitschke, Avila, Kelly, & Henderson, 2016), anxiety (APA, 2013; ICCS, 2015; Praetorius et al., 2016), and bereavement (APA, 2013; ICCS, 2015).

Dated research has examined these conditions in refugees through the lens of psychopathology; however, studies spanning the past three decades have emphasized the salutogenic components of post-trauma experience (Antonovsky, 1987). Salutogenesis originates from the Latin salus, meaning “health,” and was developed by Antonovsky (1987), who suggested that when people encounter stress, not all will have negative health outcomes. He therefore entreated researchers to use a strength-based lens instead of a deficit-based one in understanding human reactions to stress (Antonovsky, 1993). Although a strength-based perspective of post-trauma paths was not a new concept (Splevins, Cohen, Bowley, & Joseph, 2010), it had not yet been systematically and scientifically catalogued in the academic literature until the early 1990s. Since then, there has been a plethora of studies addressing people’s strengths and resources despite hardships (Affleck & Tennen, 1996; Bonanno, 2004; Joseph & Linley, 2005; Tedeschi & Calhoun, 1996). Proponents of strength-based post-trauma paths have applied their unique nomenclature to signify the strength and benefit that clients report obtaining despite their encounters with diverse traumatic events. Terminologies such as post-traumatic growth (PTG; Tedeschi & Calhoun, 1996), benefit-finding (Affleck & Tennen, 1996), stress-related growth (Park, Cohen, & Murch, 1996), thriving (O’Leary & Ickoviks, 1995), resilience (Bonanno, 2004; Connor & Davidson, 2003), and adversarial growth (Joseph & Linley, 2005) have been associated with this concept of meaningful positive change from a traumatic experience. The common theme among these writers is that there can be positivity and strength in places in which we expect weakness, illness, and pathology. Subsequent sections of this paper will address various outcomes known to follow a traumatic experience, connect them to theories associated with these experiences, and extract hypotheses to be tested.

Aftermath of Traumatic Experiences

When humans encounter traumatic experiences, they try to make meaning of them by using available resources. While some of these resources can be physical, others are psychological and emotional. Psychological and emotional resources could include inner narratives, religious communities, spirituality, connections with significant others, and nature. Optimism and religious commitment could also be included in the psychological and emotional resources that clients use to make meaning of their war-related traumatic experiences.

Trauma and psychopathology. Trauma is described as challenging experiences that push individuals beyond their normal ability to cope (APA, 2013; Ball & Stein, 2012). Trauma is ubiquitous, with research reporting that 60–80% of adults do experience at least one traumatic event (Simiola, Neilson, Thompson, & Cook, 2015). Traumatic experiences include robbery; terminal illness, for both the sufferer and loved ones; flooding; earthquakes; terrorist attacks; rape; and war-related events, for both civilians and the military. While many people who go through traumatic experiences may not have long-term negative repercussions, between 10–50% report various mental health challenges (Friedman, Resick, & Keane, 2014).

Studies on traumatic experiences in adults have collectively established that after a traumatic encounter, people report and exhibit various symptomatology of PTSD, including avoidance, intrusive thoughts, negative alterations in cognition and mood, and the tendency to live recklessly (APA, 2013). Individuals who experience the direct effects of these traumatic events are not the only ones affected. Research has identified long-lasting effects on significant others (Lahav, Kanat-Maymon, & Solomon, 2016; Zerach, 2015) and helpers (Baum, 2014) because of the regular contact with traumatized individuals. Terms like secondary traumatization, vicarious traumatization, and compassion fatigue (Jenkins & Baird, 2002) have been used to describe the reaction to emotional demands from trauma survivors’ frightening and shocking images. Accordingly, significant others and helpers may sometimes react as if they themselves have gone through the traumatic events.

Based on the literature on war-related military and civilian populations, it is hypothesized that at least 10% of participants in the present study would meet the criteria for PTSD, with a cut-off point of 33 on the PTSD assessment instrument (Weathers et al., 2013).

Trauma and psychological growth. Another aftermath of a traumatic event is PTG (Tedeschi & Calhoun, 1996). The processes of rumination, meaning-making, and growth take place after the perceived shaking of a traumatized person’s worldview (Calhoun & Tedeschi, 2014), and eventually the person is able to put the event into perspective and gain a level of growth from the experience. In the words of the proponents, “PTG involves internal changes that can set the stage for changed behavior. There is variation in the degree to which personal changes can be noticed by others in terms of actions taken” (Tedeschi, Calhoun, & Cann, 2007, p. 399).

As a construct, PTG is seen as a legacy of trauma, containing “at least three broad categories of perceived benefits” identified by individuals and sometimes by the people in their lives (Tedeschi & Calhoun, 1996, p. 456). The three categories include changes in (a) self-perception, (b) interpersonal relationships, and (c) philosophy of life. PTG occurs when a person endures a traumatic event of seismic proportions that destroys some pivotal part of the person’s worldview (Tedeschi & Calhoun, 2004). Theoretically, PTG has been conceptualized as both an outcome and a process (Zoellner & Maercker, 2006). PTG as an outcome represents substantial positive changes in cognitive and emotional life that could be the opposite of PTSD. The constructs are not two ends of the same continuum; PTG does not imply either an increase in well-being or decrease in distress. Although PTG and PTSD are distinct and independent constructs, prior studies suggest that both phenomena can coexist in traumatized individuals (Powell, Rosner, Butollo, Tedeschi, & Calhoun, 2003). These constructs have both been observed to be higher in females than males, even when trauma experiences are greater in males (Ball & Stein, 2012; Friedman et al., 2014).

Based on these findings, it is hypothesized that both male and female participants can exhibit cohabiting symptoms of distress and growth, with females exhibiting higher PTSD and PTG scores. For the sake of this study, PTG is defined as the collective expression of growth and benefit that clients claim to gain after the type of cataclysmic event that challenges their existing worldviews (Calhoun & Tedeschi, 2014; Tedeschi & Calhoun, 1996, 2004).

Optimism. The concept of optimism is grounded in theory and research (Carver, Scheier, & Segerstrom, 2010) that explores what motivates people and how motivation is expressed behaviorally. Optimism is the belief, hope, and confidence that good things will happen in a person’s life instead of bad things (Carver & Scheier, 2002; Rand & Cheavens, 2012). Carver, Scheier, Miller, and Fulford (2009) stated that optimists are not disillusioned, but rather they acknowledge the existence and importance of adversity and choose to identify both internal and external resources that can help them cope.

Relationships between optimism and trauma have been examined in diverse groups of individuals who have encountered adversity. Research has demonstrated that individuals who perceive they are able to cope have a positive outlook on life and expect good things to happen because they can control their environments (Benight & Bandura, 2004). There also is evidence that a person’s disposition to optimism may be attributable to certain environmental factors (Broekhof et al., 2015). In the Broekhof et al. (2015) study, optimism was found to be inversely related with all subtypes of childhood trauma; however, important sociodemographic, clinical, and lifestyle characteristics moderated this inverse relation. Moreover, literature relates optimism to positive mood and good morale (Peterson & Steen, 2012). Positive mood and good morale lead to perseverance and effective problem solving (Fredrickson, 2001), which in turn lead to overcoming negative traumatic symptoms. People who are generally optimistic often explain causes of events that happen to them and use these explanations as a stepping stone toward growth from adversity (Peterson & Steen, 2012).

Additionally, optimistic or hopeful people are able to make informed decisions on their health based on provided information (Rand & Cheavens, 2012; Scheier & Carver, 1985). In a study on health and hope, high-hope women could perform better on a cancer facts test than their low-hope counterparts, even when controlling for previous academic performance. Not surprisingly, hope was inversely related to intentional attempts at self-harm because self-harm efforts are incompatible with the physical health goals that hopeful and optimistic people strive to achieve. Although there are a few scattered studies on Asian populations, there are limited studies within non-Western populations on how optimism and pessimism relate to quality of life (Chang, Sanna, & Yang, 2003); thus, the present study will contribute to the literature by testing the construct of optimism across cultures.

Consequently, it is hypothesized that participants who report higher optimism, despite their shared traumatic experiences with those who report lower optimism, will report higher PTG scores.

Religious commitment. Religiousness, religiosity, and religious commitment are constructs that are often confused and sometimes used interchangeably with spirituality (Brownell, 2015; Pargament & Mahoney, 2012; Pargament & Maton, 2000). Spirituality is a continuous search for the sacred (Batson, Schoenrade, & Ventis, 1993). Religion can also be expressed as human practices and behaviors concerned with a search for the sacred—a search founded on dogma, traditional practices, and institutional regulations (McIntosh, Poulin, Silver, & Holman, 2011; Pargament & Maton, 2000). Spirituality is an individual experience and does not necessarily work in an institutional setup like religion does.

Even though past research has not distinguished between religiosity and spirituality (Pargament & Mahoney, 2012), current researchers are consistently contrasting the two, with some asserting that religion is dogmatic, restrictive, and institutional, whereas spirituality is subjective, personal, and life-enhancing (Brownell, 2015; King & Crowther, 2004; Pargament & Mahoney, 2012; Prati & Pietrantoni, 2009). In many studies, participants often identify themselves as both religious and spiritual, which is not surprising because both religiosity and spirituality can be expressed individually as well as socially, and both can either hinder or foster well-being (Pargament & Mahoney, 2012).

In the discourse on PTG, religious coping is identified as a strong predictor of growth and partially shares the same descriptions as spirituality (McIntosh et al., 2011; Prati & Pietrantoni, 2009). However, Joseph (2011) cautioned against the assumption that higher PTG indicates higher religiosity. His caution has received corroboration from a qualitative study in Australia (Barrington & Shakespeare-Finch, 2013), in which participants in a grounded theory study described a decrease in religious commitment as indicative of psychological growth. The researchers surmised that participants whose trauma was related to their religious faith probably needed a shift in worldview about religion. Such a shift sometimes required lowered religious commitment to ensure psychological growth. This Australian study is in line with Joseph’s (2011) observation that growth could mean a decrease in religious commitment for one person and an increase for another.

In another research study, a sample of 54 students who had experienced major traumatic events took part in a study that examined the association between event-related rumination, pursuit of religion and religious involvement, and PTG (Calhoun, Cann, Tedeschi, & McMillan, 2000). Despite the study’s inability to determine longitudinal direction of effect, results provided evidence that openness to religious change independently predicted the amount of reported growth in the participants. In yet another study on the role of spirituality and religiosity in the physical and mental health after collective trauma, religiosity and spirituality were found to be highly correlated (McIntosh, et al., 2011). Religiosity, like spirituality, predicted higher levels of positive affect. Interestingly, religiosity, but not spirituality, predicted lower incidence of mental ailments.

Overall, with respect to physical health, religiosity was associated with decreased incidence of musculoskeletal ailments three years after the traumatic experience. Psychologically, religiosity was correlated with lower incidence of mental ailments, positive affect, and fewer cognitive intrusions three years after the 9/11 attacks. In sum, religious commitment has been found to enhance psychological growth after a traumatic experience. It is therefore hypothesized that participants in this study who endorse greater levels of religious commitment will have higher PTG scores.

There are contradictory results concerning the relationship between PTSD symptoms and PTG in traumatized populations. While some studies reported a positive relationship between PTG and PTSD (Hussain & Bhushan, 2011), others reported a negative relationship (Kimhi, Eshel, Zysberg, & Hantman, 2010). Proponents of the positive relationship suggested that higher distress symptoms lead to high growth. Contrarily, those who reported the negative relationship reported that distress predicts growth. Other studies have found no relationship between distress and PTG (Widows, Jacobsen, Booth-Jones, & Fields, 2005). Yet, others have identified a curvilinear relationship (Kleim & Ehlers, 2009; Kunst, 2010), in which results have indicated that higher scores of PTG are related to mild PTSD symptoms and vice versa.

Post-traumatic distress and growth need not be mutually exclusive. Results of several studies have indicated that it is possible for both PTSD symptoms and positively perceived effects of the trauma experience to coexist, even in war-related traumatized populations (Powell et al., 2003). In these studies, participants may have experienced the trauma to a greater degree; however, they reported that using their internal resources, like optimism and spirituality, contributed to their positive perception of the experience. Based on the literature reviewed, this study is situated on the following hypotheses:

Between 10–50% of participants will meet the diagnostic criteria for PTSD. Furthermore, both males and females will exhibit co-occurring PTSD and PTG, with females showing higher scores in both PTSD and PTG than males.

Those who report high optimism, despite the war-related experiences, will have higher PTG scores than those with low optimism.

Those with high optimism will also score high on religious commitment.

Those with high religious commitment will score higher on PTG.

In sum, the objective of this paper was to identify post-traumatic trajectories within a sample of former war-related IDPs in a developing country. In the process of assessing the trajectories, the study will also establish reliability of Western-based instruments in a non-Western population.



Participants for the study were adults from the West African country of Liberia who, because of the decade-long civil conflict, became IDPs or refugees. The only West African country not colonized by any of the European colonial masters (i.e., Britain, France, and Portugal), Liberia became a known republic in the 1820s. This occurred when freed slaves were brought from the Americas to the coast of Liberia. The indigenous people inhabiting the land prior to the arrival of the freed slaves were dissatisfied with how the latter, referred to as Americo-Liberians, governed the land (Gerdes, 2013; Verdier et al., 2008). This dissatisfaction festered until its culmination in an over decade-long civil conflict (1989–2003). It is estimated that more than 10% of the population died in the civil conflict (Verdier et al., 2008).

This study used a multi-stage sampling method (Fraenkel, Wallen, & Hyun, 2015). In the initial stage, criterion sampling was used for adult Liberians who were known to be former refugees and IDPs. The number of participants gained after the first sampling stage was less than the expected 500 participants. Snowball sampling was therefore employed to reach the target sample size. Because Liberia has no database of residents, participants had to be contacted face-to-face at community meetings, colleges, churches, and mosques.


All procedures of the university’s institutional review board were followed; informed consent

was provided in both verbal and written form and undertaken via individual and group formats. Additionally, local healers and pastors were introduced to participants in anticipation of traumatic memories culled up from the questions on some of the instruments. The incorporation of local healers and pastors was consistent with research in similar areas and cultural practices (Van Dyk & Nefale, 2005).

Procedural criteria for inclusion were determined prior to data collection. Participants had to be 18 years of age or older, able to read and understand English at the eighth-grade level, and old enough during the war to have remembered the flight. Participants were thereafter given the informed consent and research package, which had been printed and numbered. Participants who preferred to complete the instruments in group format stayed after class or a church service for this activity. Others chose to take it home and bring it back to the researcher at an agreed-upon place. Announcements were made to participants to provide contacts they could recommend who fit the procedural criteria.

When all of the 500 packages had been distributed, data collection stopped. Of packets given, 444 were completed and returned, demonstrating an 88.8% response rate. Statistical power was estimated at .80 for this model using the SAS syntax provided by MacCallum, Browne, and Sugawara (1996). Based on this syntax, a sample size of 200 (df = 179) was considered adequate. Our sample size of 444 was therefore acceptable for an effect size of .80.


Six instruments were given to participants. They were the Post-Traumatic Growth Inventory (PTGI; Tedeschi & Calhoun, 1996), the War Trauma Screening Index (WTSI; Layne, Stuvland, Saltzman, Djapo, & Pynoos, 1999), the Revised Life Orientation Test (LOT-R; Scheier, Carver, & Bridges, 1994), the Religious Commitment Inventory (RCI-10; Worthington et al., 2003), the Post-Traumatic Stress Checklist for DSM-5 (PCL-5; Weathers et al., 2013), and a demographic questionnaire.

PTGI. The PTGI is a 21-item scale that measures positive changes that occur in people’s lives because of crises. The scale comprises five subscales (factors). The subscales and sample questions are: (a) relating to others (e.g., I more clearly see that I can count on people in times of trouble); (b) new possibilities (e.g., I developed new interests); (c) personal strength (e.g., I know better that I can handle difficulties); (d) spiritual change (e.g., I have a stronger religious faith); and (e) appreciation of life (e.g., I can better appreciate each day). Each item is rated on a 6-point Likert-type scale ranging from 0 (I did not experience this change as a result of my crisis) to 5 (I experienced this change to a very great degree as a result of my crisis). The range of possible scores a participant can obtain is from 0 to 105. The PTGI has demonstrated high internal consistency (α = .90; test-retest reliability = .71) and acceptable construct validity (Calhoun et al., 2000). The instrument is not correlated with measures of social desirability (Baker, Kelly, Calhoun, Cann, & Tedeschi, 2008). PTGI scores for the Liberian sample demonstrated high internal consistency (α = .93), providing support for the cross-cultural nature of the instrument in consistently measuring the construct of PTG.

WTSI. The WTSI is a 35-item dichotomously scored self-report instrument. The instrument was used to measure participants’ experiences during the Liberian war, and it was chosen because of its simplicity in assessing what participants saw, touched, or had done to them. Sample questions include, “During the war, did a bullet ever come so close to you that you could have been seriously hurt or killed?” and, “During the war, did you eyewitness someone being killed?” The highest score a person can obtain is 35. There is currently no reported psychometric evaluation of this instrument. On a cursory look, the instrument seems to be divided into broad categories consisting of (a) attack to self; (b) attack to loved one; (c) forced displacement; and (d) witnessing trauma. These four factors were therefore used as part of the structural equation modeling (SEM) procedure. Reliability analysis of the 35 items for the Liberian sample demonstrated high internal consistency (α = .90).

LOT-R. The LOT-R is a 10-item scale that evaluates dispositional optimism. The instrument has four fillers (items 2, 5, 6, and 8), thereby leaving only six items to be used for analysis. Three items are reverse coded (items 3, 7, and 9) before undertaking any analysis. Each item is rated on a 5-point Likert-type scale, ranging from 0 (strongly disagree) to 4 (strongly agree). Sample items include “In uncertain times, I usually expect the best” and “If something can go wrong for me, it will.” The LOT-R has acceptable internal consistency (α = .78), test-retest reliability (α = .60–.79), and discriminant (r =.48–.50) and convergent (r = .95) validity (Scheier et al., 1994). Reliability of the 6-item scale in the Liberian sample was modest (α = .49).

RCI-10. The RCI-10 measures the degree to which a person stands up for his or her religious values. The 10-item scale is measured on a 5-point Likert-type scale, ranging from 1 (not at all true of me) to 5 (totally true of me). The RCI-10 has two factors—intrapersonal and interpersonal religious commitment. The intrapersonal religious commitment assesses an equivalent of personal commitment not related to the social component of religious faith. Interpersonal, on the other hand, measures the social component associated with organized religious faith. Sample items include “Religious beliefs influence all my dealings in life” and “I spend time trying to grow in understanding of my faith.” A cut-off score of 38 and above is needed to identify a highly religious person. Evidence indicates that people who score more than one standard deviation above the mean view the world in terms of their religious worldview (Worthington et al., 2003). Evidence of reliability for the norm groups was high, and both construct and criterion-related validity were similarly high (Worthington et al., 2003). Internal consistency for the Liberian sample in this study was acceptable (α = .84).

PCL-5. The PCL-5 measures distress symptoms after a traumatic experience. The 20-item instrument is ranked on a 5-point Likert-type scale ranging from 0 (not at all) to 4 (extremely). The scale comprises four subscales, consistent with the DSM-5 PTSD Clusters B, C, D, and E. The subscales and sample questions are: Cluster B, or Intrusion (e.g., repeated, disturbing, and unwanted memories of the experience); Cluster C, or Avoidance (e.g., avoid memories, thoughts, or feelings related to the experience); Cluster D, or Negative Alterations in Cognition and Mood (e.g., having strong negative feelings such as fear, horror, anger, guilt, or shame); and Cluster E, or Alterations in Arousal and Reactivity (e.g., taking too many risks or doing things that could cause you harm). Psychometric properties for the instrument demonstrated high internal consistency (α = .91), two-week test-retest reliability (α = .95), and convergent validity (r = .87; Wortmann et al., 2016). Results of reliability analysis for the Liberian sample demonstrated a high internal consistency (α = .92).

Data Analysis

Data were analyzed with three programs. SPSS (version 24; IBM, 2016) was used for descriptive statistics to understand participants’ demographics. SPSS was used to assess reliability of instruments and to answer the first research question. Finally, SPSS was used to extract the correlation matrix that was the foundation of both the confirmatory factor analysis (CFA) and SEM. SAS (SAS Institute, 2015) and AMOS (version 23; Arbuckle, 2014) were used for both the CFA and SEM.

The Hypothesized Model

Figure 1 represents the hypothesized model based on hypotheses extracted from the literature.  It is hypothesized that all participants experienced the 10-year civil war. It is hypothesized that between 10–50% of participants will meet the diagnostic criteria for PTSD. It is also hypothesized that PTSD and PTG can co-occur in participants. It is further hypothesized that those who report higher optimism scores will have higher PTG scores. Finally, it is hypothesized that those who report higher religious commitment scores will have higher PTG scores.



Figure 1. The Hypothesized Model


With SEM, there are two basic variables—unobserved and observed (Schreiber, 2008). Unobserved variables are called latent factors and are graphically depicted with circles or ovals. Observed variables are called manifest variables and are represented graphically with squares or rectangles. Large circles in the graphic represent latent constructs, and small circles represent measurement errors (in observed variables) or disturbances (in equation measurement). Straight, single-headed arrows are indicative of unidirectional paths. The arrow starts from the independent variable and points to the dependent variable. A curved arrow connecting two variables indicates two variables expected to co-vary; however, no hypothesis is made about their causality (O’Rourke & Hatcher, 2013).

Finally, SEM comprises two components: a measurement model, also called CFA, and a theoretical or structural model (Schreiber, 2008). While the measurement model specifies the relationship of the latent to the observed variables, the structural model identifies specific relationships among the latent variables. The objectives of the SEM are to determine whether a theoretical model is supported by the data collected, and to test the hypothesized direct relationships between independent, or exogenous, variables and dependent, or endogenous, variables. The hypotheses testing in SEM consists of several analyses of variances and regressions occurring simultaneously. Through this, researchers also can test mediated relationships between variables and examine the reliability of items to latent variables in a single test.

Several fit indices are reported in SEM as a global examination of how well the collected data fit the hypothesized model (Hu & Bentler, 1998; Schreiber, 2008; Sivo, Fan, Witta, & Willse, 2006). Because of well-known problems of fit estimation using chi square (χ2) in large data sets, the Bentler’s Comparative Fit Index (CFI) was used with values at .95 or higher, indicating a good-fitting model (Hu & Bentler, 1998; O’Rourke & Hatcher, 2013; Sivo et al., 2006). An absolute index, the Standardized Root Mean Square Residual (SRMR), and a parsimony index, the Root Mean Square Error of Approximation (RMSEA), were used as indices assessing the difference between the proposed model and actual variances and covariances in the data. RMSEA values less than or equal to .06 and SRMR values less than or equal to .08 are preferred (Fabrigar, Porter, & Norris, 2010; O’Rourke & Hatcher, 2013; Sivo et al., 2006).


Demography of Participants

Participants’ ages ranged between 28 and 65 years. Many fell within the 31–40 year range (45.7%). More participants were male (70.9%) than female, and many were unemployed (63.7%). Of those who were employed, 34.0% earned less than US$720 a year. Family demographics were varied: 42.3% of participants were single, 30.0% were married, and 23.6% lived with their partners. Many participants (49.3%) had one or two children.

The majority of participants (89.2%) indicated they were displaced during the Liberian civil war. There was no follow-up question to identify how some participants could have stayed in their homes despite the reported rampage that affected the whole country (Verdier et al., 2008), so I can only speculate that they either did not read that question well or had a way to stay safe during the war. Of those who were displaced, 60.4% became internally displaced, while the rest became refugees in and out of Africa. Almost half (48.4%) of the former refugees and IDPs had returned to Liberia since the cessation of the war. Additionally, to assess participants’ reaction to the Ebola epidemic and its possible ability to trigger traumatic experiences (Doucleff, 2015), participants were asked to compare the effect of the epidemic to the effect of the civil war on their mental health. The majority (65.8%) indicated that they linked the epidemic to the war several times a day, a process that could re-traumatize those who may have undisclosed PTSD symptoms.

Results From Hypotheses

The first hypothesis proposed that between 10–50% of participants in the study will meet the diagnostic criteria for PTSD (as measured by PCL-5), as well as co-occurring symptoms of distress and growth based on gender. Results of the descriptive statistics indicated that the majority (351; 79.1%) met the criteria for PTSD. Additionally, results from the one-way multivariate analysis of variance indicated that there was a statistically significant difference in post-trauma pathways based on gender (F[2, 376] = 6.016, p = .005; Wilk’s λ = .972, partial η2 = .028). Gender had a statistically significant effect on PTG (F[1, 377] = 6.354, p = .012, partial η2 = .017), but not on PTSD (F[1, 377] = 3.039, p = .082, partial η2 = .008). The PTG mean score for females (X̅= 84.49, sd = 16.030, n = 109) was higher than for males (X̅= 79.56, sd = 17.663, n = 270). Both males and females demonstrated co-occurring PTG and PTSD. Even though there was a statistically significant difference in PTG scores based on gender, there was no such difference in PTSD scores.

Hypotheses two through four were analyzed with SAS and AMOS to test the confirmatory model and the theoretical model, and to provide graphical representation. Missing data analysis was computed through the relationship between missing values on each variable of the 444 responses. Data were missing completely at random, and no statistically significant relationships were observed among variables. Listwise deletion within the correlation matrix reduced the sample size to 350.

The present analyses followed Anderson and Gerbing’s (1988) two-step procedure. The first step used CFA to develop a measurement model meant to establish an acceptable fit to the data collected. The second step was a theoretical model that was a modification of the measurement model. This modified model is a structural equation model representing the theoretical model of interest. The theoretical model was then tested and revised until a theoretically meaningful and statistically acceptable model was achieved.

The measurement model. A measurement model describes the nature of the relationship between several latent variables and the manifest indicator variables that measure those latent variables. The measurement model investigated in this study consisted of five latent variables corresponding to the five constructs of the post-trauma pathways model: War, PTSD, Optimism, Religious Commitment, and PTG (N = 350). Each of the five latent variables was measured by at least two manifest variables (Figure 2).




Figure 2.  The Confirmatory Factor Analysis (CFA) Model



The maximum likelihood estimation successfully converged in 40 iterations. The correlations table was consulted for multicollinearity; only one relationship was above .90. The relationship between war-related threat to self and intrapersonal religious commitment was .93. The fit indices indicated an acceptable fit of the data to the hypothesized structure. The CFI was .94, SRMR was 0.056, and RMSEA was .050, with a 90% confidence interval of .042–.058. All items loaded statistically significantly (p < .05) on the theorized latent variables and no modifications were warranted based on the values calculated (see Table 1). The squared multiple correlations, an indicator of reliability of items, seemed acceptable, except for some items loading onto the optimism factor. These results were unsurprising considering the low Cronbach’s alpha of the instrument in this sample.

The theoretical model. The 5-factor solution hypothesizing the directional relationship successfully converged in 29 iterations. Using the maximum likelihood estimation, evidence from the model suggested that the data did not fit the model as expected (CFI = .932, SRMR = 0.062, RMSEA = 0.052). Although all parameters within the model indicated statistically significant t-values, one of the paths linking two latent constructs was non-significant. The standardized path coefficient from religious commitment (F3) to growth (F5) was not significant (t = 1.87, se = 0.25, p = 0.06). Further, inspection of the squared multiple correlations table indicated that R-square values relating to the negatively worded optimism items (3, 7, and 9) were weak (< .25).

Revised model. To look for the best fitting model, the Wald test and the Lagrange multiplier tables were consulted. The Wald test provides information on parameters that can be dropped to improve the model. The Lagrange multipliers provide information on parameters to be added. Experts caution researchers to ensure that data-driven model modifications do not capitalize on chance characteristics of the sample data, as they have the tendency to produce a final model that is not generalizable to the population or to other samples (O’Rourke & Hatcher, 2013; Schreiber, 2008). Researchers are therefore encouraged to identify parameters that could be dropped from the model without significantly affecting the model’s fit, as it is generally safer to drop parameters than to add new parameters when modifying models (O’Rourke & Hatcher, 2013). The Wald test suggested the intrapersonal variable within the religious commitment factor be dropped. Even though that suggestion was deemed statistically feasible, it was not theoretically feasible. Furthermore, because of the problems associated with the negatively worded items in the optimism scale, the errors associated with those items were allowed to covary.

When the three errors were covaried, the model was reanalyzed. The maximum likelihood successfully converged in 19 iterations. The revised model fit the data well (CFI = .953; SRMR = 0.049; RMSEA = 0.044). All path coefficients were nontrivial and statistically significant (i.e., t > |1.96|). Figure 3 depicts standardized path coefficients for the revised model.


Table 1

Regression Weights and Squared Multiple Correlations (SMC) of the Measurement Model

Standardized t-value (standard error)
Self 0.37 7.51 (0.05) 0.14
Witness 0.64 17.22 (0.37) 0.41
Displac 0.68 19.48 (0.04) 0.47
Loved1 0.94 34.37 (0.03) 0.88
Avoid 0.49 11.00 (0.04) 0.24
Intrude 0.53 12.50 (0.04) 0.29
NACM 0.91 35.25 (0.03) 0.80
AAR 0.79 26.47 (0.03) 0.61
LOT1 0.49 7.41 (0.07) 0.24
LOT4 0.41 5.95 (0.07) 0.16
LOT10 0.24 3.41 (0.07) 0.06
RLOT3 0.29 4.29 (0.07) 0.09
RLOT7 0.40 6.07 (0.07) 0.16
RLOT9 0.44 6.59 (0.07) 0.20
inTRA 0.94 15.11 (0.06) 0.89
inTER 0.67 12.55 (0.05) 0.44
PTGf1 0.82 40.58 (0.02) 0.68
PTGf2 0.86 48.87 (0.02) 0.74
PTGf3 0.88 56.47 (0.02) 0.78
PTGf4 0.76 30.31 (0.03) 0.58
PTGf5 0.76 29.69 (0.03) 0.57

Note: Statistically significant p < .05 in bold; War = War events; PTSD = Post-Traumatic Stress Disorder; LOT = Optimism; RC = Religious Commitment; Growth = Post-Traumatic Growth




Figure 3. Standardized Estimates of the Final Model



R-square values showed that war accounted for 44% of the variance in PTSD; optimism accounted for 51% of the variance in religious commitment; and PTSD, optimism, and religious commitment accounted for 83% of the variance in PTG. As shown in Table 2, all goodness-of-fit indices for the revised model were in ideal parameters.


Table 2

Fit Indices and Modification of Theoretical Model (N = 350)




Pr > χ2

Δ χ2









< .0001

Measurement  Model (Mm)



< .0001







Theoretical Model (MT)



< .0001





Modified Theoretical Model (MTm)



< .0001







Note: χ2 = chi square; df = degrees of freedom; CFI = Comparative Fit Index; SRMR = Standardized Root Mean Square Residual; RMSEA = Root Mean Square Error of Approximation; RMSEA CL90 = RMSEA 90% Confidence Limits


Discussion and Implications

Because participants were survivors of a 10-year war-related traumatic experience, it was unsurprising that the majority of them met the PTSD diagnosis (APA, 2013). Despite the time lapse, these participants exhibited signs of intrusion, avoidance, reckless behaviors, and hypervigilance. Because the majority of the participants had joint households (married, 30%; lived with partners, 23.6%), it is likely that their loved ones could struggle with secondary traumatization (Jenkins & Baird, 2002; Lahav et al., 2016). Any therapeutic intervention for a group like this must be systemic in nature (Gehart, 2017) to address the mental health issues of not just survivors, but also the significant people in their lives.

Moreover, results of the first hypothesis indicated that there was a statistically significant difference in PTG scores based on gender, with females reporting more growth than males. These results confirm research in both Western and non-Western samples using the PTGI as an instrument to assess psychological growth after a traumatic experience (Baker et al., 2008; Powell et al., 2003). The high Cronbach’s alpha of the PTGI within the sample suggests that the construct of growth is being measured consistently across samples. Thus, interventions used in Western samples to enhance growth, barring any cultural complications, could work in non-Western samples.

In addition, results of the SEM confirm that people with dispositional optimism have a higher chance of gaining growth after a traumatic event than people who are pessimistic (Broekhof et al., 2015; Peterson & Steen, 2012). Readers are cautioned in making this leap because this Western-based instrument used in the non-Western environment was not consistent in measuring the optimism construct (α < .70). It is however possible that had the statements not been negatively worded, participants’ responses would have been different. This assertion is confirmed by the improved theoretical model from covarying the errors of the negatively worded items in the optimism factor.

There is also evidence from the data that participants used their search for the sacred to grow from the war-related traumatic experiences. These results have implications for professional counselors and counselor educators. Counselor educators can train professional counselors to appropriately assess spirituality as part of their multicultural assessment. Because of spirituality’s ability to enhance growth, incorporating spiritual competencies with a therapeutic relationship could enhance post-trauma healing. However, there were no questions assessing participants’ use of religious commitment as a community or whether their use of religious commitment arose from the war-related experiences.

In a related study assessing religious commitment’s moderating effect on the relationship between trauma and growth, the researchers discovered a curvilinear moderating effect (Acquaye, Sivo, & Jones, in press). Thus, the higher participants’ religious commitment, the lower their PTG; at mid-religious commitment, there was increased PTG. These findings were not too far from Joseph’s (2011) supposition that increased religiousness did not automatically lead to increased growth. Therefore, when clients report growth, professional counselors should not assume this growth corresponds to increased religiousness. It may well be that for some clients, decreased religiousness will lead to increased growth (Barrington & Shakespeare-Finch, 2013).

Limitations and Suggestions for Future Research

Because of the group-like nature of data collection, participants communicated among themselves. This kind of communication could skew the results, especially if some participants are providing responses that are consistent with the majority narrative. If possible, future research could be done with more privacy and not in a group format.

On the other hand, this mode of data supports the recommendation that future work take a qualitative approach and identify participants’ perceptions about growth, religious commitment, and optimism. It is possible that even though reliability analyses supported the reliability of these instruments, participants’ opinions without the prompts in such surveys could have shed a new light onto what they perceived to be growth and optimism.

It would be enlightening to conduct a comparative study to examine those who are still living outside Liberia (e.g., in the United States) and those living within Liberia to explore whether optimism and religious commitment before or after the war played a part in PTG, depending on where a person currently resides. This comparative study could identify differences in both religious commitment and optimism scores between gender and family status, depending on current residence. Finally, the comparative study may identify current post-trauma (disorder and growth) scores and how these scores reflect outlook on life.

In sum, the hypothesis that between 10–50% of participants will meet the diagnostic criteria for PTSD was supported; 79.1% of participants met the diagnostic criteria for PTSD. Furthermore, the hypothesis that both males and females will exhibit co-occurring PTSD and PTG was partially supported. Even though there were no differences in PTSD scores between gender, females reported higher PTG scores than their male counterparts. The third hypothesis that those who report high optimism will have higher PTG scores was supported. Finally, the model also supported the hypothesis that people who reported higher religious commitment scores will have higher PTG scores, as well as the hypothesis that optimism, PTSD, and religious commitment could all predict PTG. Most of the instruments used were reliable enough to aver that the measurement of the constructs is cross-cultural.


Conflict of Interest and Funding Disclosure

Data collected in this study was part of a dissertation study. The dissertation was awarded the 2016 Dissertation Excellence Award by the National Board for Certified Counselors.



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Hannah E. Acquaye, NCC, is an assistant professor at Western Seminary. Correspondence can be addressed to Hannah Acquaye, 5511 SE Hawthorne Blvd., Portland, OR 97215,