# ind_items

authors_index: stephens, darryl w.
secondary_title_index: religions
title_index: trauma-informed pedagogy for the religious and theological higher education classroom
abstract_index:
       this article promotes a wider understanding of trauma-informed pedagogy for the higher education classroom, whether in-person or virtual, focusing on undergraduate and graduate teaching in religious studies and theological education. trauma is not confined to individual experiences of single horrifying events—trauma can be collective (community-wide, e.g., covid-19), epigenetic (inherited or intergenerational), social-cultural (e.g., racism), or vicarious. drawing on religious education literature and recent insights from psychology, neuroscience, and public health studies, this article provides a shared basis for further development of trauma-informed pedagogy by religious and theological educators. a principle feature of this article is bibliographic, portraying the state of scholarship at the intersection of religious education and trauma and pointing to resources necessary for further development. it offers a brief survey of extant literature, presents a basic definition and description of trauma, introduces the features of a trauma-informed community approach, and discusses the core values guiding trauma-informed pedagogy. the article also explores religious aspects of trauma and discusses care for instructors, who deal with their own traumatic pasts as well as the secondary effects of encountering, teaching, and supporting traumatized individuals in the religious education classroom. this article concludes with a call for further research.     

full_text_index:
       religions article  trauma-informed pedagogy for the religious and theological higher education classroom darryl w. stephens lancaster theological seminary, 555 west james street, lancaster, pa 17603, usa; dstephens@lancasterseminary.edu or dws@darrylwstephens.com received: 12 august 2020; accepted: 29 august 2020; published: 2 september 2020     abstract: this article promotes a wider understanding of trauma-informed pedagogy for the higher education classroom, whether in-person or virtual, focusing on undergraduate and graduate teaching in religious studies and theological education. trauma is not confined to individual experiences of single horrifying events—trauma can be collective (community-wide, e.g., covid-19), epigenetic (inherited or intergenerational), social-cultural (e.g., racism), or vicarious. drawing on religious education literature and recent insights from psychology, neuroscience, and public health studies, this article provides a shared basis for further development of trauma-informed pedagogy by religious and theological educators. a principle feature of this article is bibliographic, portraying the state of scholarship at the intersection of religious education and trauma and pointing to resources necessary for further development. it offers a brief survey of extant literature, presents a basic definition and description of trauma, introduces the features of a trauma-informed community approach, and discusses the core values guiding trauma-informed pedagogy. the article also explores religious aspects of trauma and discusses care for instructors, who deal with their own traumatic pasts as well as the secondary effects of encountering, teaching, and supporting traumatized individuals in the religious education classroom. this article concludes with a call for further research. keywords: psychic trauma; trauma-informed pedagogy; trauma-sensitive pedagogy; trauma-informed education; embodiment; secondary traumatization; vicarious trauma; higher education; religious education; theological education  1. introduction “what’s wrong with you?” when one of my students is habitually distracted, inattentive, or disruptive, this question might surface in my mind. if vocalized, this response to undesired behavior in my classroom, at best, might suppress outward disruption so that class can continue as “normal.” yet, it could perpetuate a cycle of shame and blame, exacerbating the underlying issue and contributing to an ongoing public health crisis. over the past thirty years, our societal understanding of trauma has opened up a different way to address these presenting issues. instead of confrontation, i focus on care. now, i know to ask instead, “what has happened to you?” (salasin 2011, p. 18). this shift from confrontation to care is the crux of a new paradigm in public services, a trauma-informed approach. as educators, we are part of a community of service providers with the power to contribute to or detract from this circle of care. furthermore, our understanding of trauma (or lack thereof) significantly impacts our pedagogical effectiveness and ability to nurture the best learning in our students. we enter the classroom uninformed about trauma at our own peril—and to our students’ detriment. the importance of bringing a trauma-informed approach to undergraduate and graduate teaching in religious studies and theological education cannot be overestimated. this article promotes a wider understanding of trauma-informed pedagogy for the higher education classroom, whether religions 2020, 11, 449; doi:10.3390/rel11090449  www.mdpi.com/journal/religions  
  religions 2020, 11, 449  2 of 14  in-person or virtual. drawing on religious education literature and recent insights from psychology, neuroscience, and public health studies, this article provides a shared basis for further development of trauma-informed pedagogy by religious and theological educators. a principle feature of this article is bibliographic, portraying the state of scholarship at the intersection of religious education and trauma and pointing to resources necessary for further development. it offers a brief survey of extant literature, presents a basic definition and description of trauma, introduces the features of a trauma-informed community approach, and discusses the core values guiding trauma-informed pedagogy. the article explores religious aspects of trauma and concludes with a discussion of care for instructors, who deal with their own traumatic pasts as well as the secondary effects of encountering, teaching, and supporting traumatized individuals in the religious education classroom. 2. new recognition of an existing paradigm trauma-informed practices have become a community standard among many social service providers, and there are many resources and training materials available for early childhood, primary, and secondary education professionals. higher education classroom pedagogy has lagged behind. as recently as 2013, trauma-informed pedagogy was still being “proposed” as essential to higher education classrooms (carello and butler 2014). this “risky teaching” practice, as described by neil harrison and colleagues, is no longer optional; the question is how to engage it effectively (harrison et al. 2020). since the worldwide social and economic disruption of covid-19 and, subsequently, the resurgence of the black lives matter movement in may 2020, the topic of trauma and pedagogy has risen in priority for many instructors in higher education. while higher education resources had previously been available (e.g., carello 2020; davidson 2017; trauma informed oregon 2016), many professors scrambled to understand the paradigm of trauma-informed practices. a blog post by cathy davidson warning, “online learning this fall will be wasted if we do not begin from the premise that our students are learning from a place of dislocation, anxiety, and trauma,” quickly circulated among professors in higher education (davidson 2020). webinars and online resources began to multiply (center for faculty development and excellence, emory university 2020). among these resources, the literature on trauma-informed pedagogy from a religious education perspective is relatively recent in development. over the past 25 years, the concept of trauma has made its way into the discourses of various disciplines of religious instruction, particularly pastoral care, systematic theology, biblical studies, and practical theology. select illustrations establish the growing influence of the paradigm of trauma in multiple disciplines of theological study. scholars addressing sexual violence took an early lead (cooper-white 1995; west 1999). the alban institute published a book by jill hudson for ministerial leaders dealing with congregational trauma (hudson 1998). attention to trauma soon became widespread within the field of pastoral care, for example, cooper-white (2000, 2012) (doehring 2015; hunsinger 2015; mcclintock 2019; sullender 2018; thomas 2020). the imaginatively constructive work of rambo (2010) has been especially influential in several theological disciplines, particularly biblical studies, (e.g., frechette and boase 2017; groenewald 2018). the literature on trauma-informed readings of the bible is now extensive. other theological treatments of trauma include the work of beste (2007), jones (2009), baldwin (2018), and soto albrecht and stephens (2020). in the field of practical theology, works include studies in womanist discourse (wallace 2010), lived religion (ganzevoort and sremac 2018), as well as disaster relief response (brenner et al. 2010; hudson 1998; koenig 2006; warner et al. 2019) (roberts and ashley sr [2008] 2017). however, subject matter expertise does not necessarily equate to pedagogical practice. janice carello, and lisa butler warned, “teaching trauma is not the same as trauma-informed teaching” (carello and butler 2014). what had been seen as a “useful lens for biblical interpretation” (frechette and boase 2017), a contributor to prophetic studies (groenewald 2018), a way of understanding liturgical practices (grundy 2006), and a shaper of theological discourse (rambo 2019) became a tool  
  religions 2020, 11, 449  3 of 14  with much more immediate application for classroom instructors during the multiple, worldwide crises of 2020. building on its 2018 blog series, “teaching and traumatic events,” (e.g., lewis 2018; mcgarrah sharp 2018), the wabash center for teaching and learning in religion and theology featured another timely series of blog posts in 2020, “teaching and learning during crisis,” some of which featured trauma-informed teaching practices (lee 2020; oredein 2020; rideau 2020; silva-mccormick 2020). the publication inside higher ed ran a blog post with twelve principles for “crisis-informed pedagogy” (mintz 2020). resources on teaching holocaust studies through the lens of trauma (gubkin 2015; roth et al. 2001) as well as articles addressing trauma and pedagogy in relation to peace, justice, and conflict studies (stoltzfus 2014), moral injury (antal and winings 2015), sexual trauma (crumpton 2017; procario-foley 2020), and legacies of abuse by noted scholars and public figures guth (2018, 2020) took on new, broader relevance for instructors in religious and theological studies. an edited volume by stephens and ott (2020) combined embodied learning (lelwica 2020), perspective transformation (ott 2020), and trauma-sensitive pedagogy (crumpton 2020) to undergird a trauma-informed approach to many aspects of teaching theology and religion in higher education, including transnational feminist pedagogy (pae 2020) and digital pedagogy (doehring and arjona 2020). the concept of trauma is now recognized as a tool to apply not only within one’s academic discipline but also to one’s everyday, classroom pedagogy—and not just reserved for class sessions discussing trauma or traumatic events. arguing that “this topic should be more than a niche area of interest, becoming a regular part of the reflective lenses of all religious educations scholars and practitioners,” callid keefe-perry and zachary moon proposed a trauma-informed approach to religious education that is not nominally “safe” but courageously risk-taking (keefe-perry and moon 2019, pp. 30–31). they noted an “implicit engagement with trauma already present in existing literature” in religious education and built upon it (keefe-perry and moon 2019, p. 35). while they focused on adult education within congregational contexts, their insights are germane to the higher education classroom. drawing on their insights and the best of existing resources, this article seeks to promote this kind of risk-taking by providing a conceptual basis for trauma-informed pedagogy in religious instruction, based on recent insights from psychology, neuroscience, and public health studies. 3. trauma simply put, psychological trauma is the result of an experience that is too much to handle. judith herman, a pioneering researcher in the modern understanding of trauma, stated that “traumatic events . . . overwhelm the ordinary human adaptations to life” (herman [1992] 2015, p. 33). trauma engages psychic, physiological, and neurological survival mechanisms when a person feels disempowered to respond to a grave threat. trauma involves a loss of agency and a profound sense of powerlessness. yet, a trauma victim is also a survivor,1 coping with overwhelming danger in ways too deep to fathom. the result is often some variant of post-traumatic stress disorder (ptsd). the effects touch the core of being and reside deep in the body. a central feature of trauma is that it disrupts one’s personal narrative, interfering with one’s sense of self and experience of the world. traumatic memories interrupt the present in ways unbounded by chronology. a traumatic memory can be neither coherently articulated nor forgotten. it is an unspeakable response to horror, a response that refuses to be integrated into the past even as it haunts the present2 . besser van der kolk, another pioneering researcher in the field, described it this way: “trauma is not just an event that took place sometime in the past; it is also the imprint left by that  1 2  foregrounding the language of “survivor” over “victim” is an intentional aspect of a trauma-informed response. see glossary of terms in (samhsa 2014b, pp. xvi–xix). herman called this “the dialectic of trauma”: being “caught between the extremes of amnesia or of reliving the trauma” (herman [1992] 2015, p. 47). shelly rambo explored the narrative disruption of trauma as a site for theological exploration and meaning (rambo 2010).  
  religions 2020, 11, 449  4 of 14  experience on mind, brain, and body” (van der kolk 2014, p. 21). a traumatized person relives their terror again and again, triggered involuntarily by sensory reminders. because trauma overwhelms the normal coping mechanisms, the experience is fragmented rather than integrated into a person’s experience. one result is popularly known as a “flashback,” for example, when a war veteran with ptsd responds viscerally to the sound of a car backfiring, as if the noise indicated a mortal danger. for a person with ptsd, the trigger brings the past trauma into the present moment, and they relive the original experience, engaging in survival response to the stimulus. traumatic memories can be triggered by emotions, sights, smells, noises, and many other somatic reminders of the original traumatic experience. the work of recovery involves practices of mind and body designed to empower a person to integrate their traumatic memories into their sense of self, reducing the past’s hold on their present reality. in 2014, the substance abuse and mental health services administration (samhsa) provided the following definition of individual trauma to serve as a common reference point among various sectors of public service provision: individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being. [original emphasis] (samhsa 2014a, p. 7) this definition highlights what samhsa referred to as “the three e’s of trauma”: events, experiences, and effects (samhsa 2014a, p. 8). an event can be traumatic in a single occurrence or over a series of incidents. traumatic life events include military combat, natural disaster, life-threatening accident, sexual assault, abandonment, death of a loved one, and many other psychologically overwhelming situations. trauma can also result from prolonged exposure to threat, including domestic violence, bullying, poverty, abuse, and racism (davidson 2017, p. 4). encountering negative biases through microaggressions based on race, gender, sexual orientation, and other identity markers can also be experienced as traumatic (nadal 2018; see also wallace 2010, p. 49). nevertheless, it is important to remember that trauma is not the event but rather the wound resulting from the event (baldwin 2018, p. 25). thus, trauma can result from a variety of events, depending on how the event is experienced by the individual within their community. the experience of trauma is personal, resting on a combination of factors. not every adverse experience is traumatic; yet, the same event might be experienced as traumatic by one person and not by another. researchers use the term “potentially traumatic event (pte),” since the experience of the event (as traumatizing or not) will vary from person to person (galatzer-levy et al. 2012). personality, social support network, developmental health, previous experiences, and other complex factors shape whether any particular event is experienced as traumatic. these factors contribute to a person’s degree of resilience, defined as “the capacity to bounce back from adversity.” (van der kolk 2014). a landmark study in the late 1990s examined the relationship between “childhood abuse and neglect and household challenges and later-life health and well-being” (centers for disease control and prevention 2020). the adverse childhood experiences (ace) study clearly showed that “adverse childhood experiences are common and they have strong long-term associations with adult health risk behaviors, health status, and diseases” (felitti et al. 1998). more to the present point, “early exposure to aces is associated with traumatic stress reactions and subsequent exposure to trauma in adult years” (samhsa 2014b, p. 47). thus, the experience of trauma varies by person and is shaped by previous social, psychological, developmental, and cultural factors. samhsa’s definition includes single horrifying events as well as a series of events or set of circumstances experience by an individual as traumatic. religious educators keefe-perry and moon described these aspects of trauma as temporal and structural: trauma is an experience that is not readily assimilated or accommodated into a sense of normalcy, overwhelming a person’s beliefs, values, behaviors, and/or meaningful  
  religions 2020, 11, 449  5 of 14  relationships. traumatic experiences have features that are both temporal (occurring in a certain moment of a traumatic event) and structural (occurring as a result of ongoing systemic social and economic inequalities). trauma leaves a person grasping for new, functional coping strategies meant to facilitate survival, including ways in which to re-develop meaningful relationships. (keefe-perry and moon 2019, p. 31) this definition also emphasizes the communal and relational impact of trauma. trauma is a complex and multifaceted concept—it can be collective (community-wide) (institute for collective trauma and growth 2019), epigenetic (inherited or intergenerational) (yehuda and lehrner 2018), social-cultural (e.g., racism), or vicarious. regardless of the type of trauma, its effects on persons and relationships are real and noticeable. in classroom teaching, what is most evident are the effects of trauma. a. hoch and colleagues presented this list of effects observable in postsecondary learners: • • • • • • • •  difficulty focusing, attending, retaining, and recalling tendency to miss a lot of classes challenges with emotional regulation fear of taking risks anxiety about deadlines, exams, group work, or public speaking anger, helplessness, or dissociation when stressed withdrawal and isolation involvement in unhealthy relationships (davidson 2017)  some of these effects were evident in my classroom during the spring 2020 semester, in the first months of societal response to covid-19. many of my students suffered from distraction, inability to concentrate, and short attention spans. they exhibited the effects of trauma (though most of them were unaware of this connection). furthermore, students of color seemed to be the most affected (oredein 2020). the long-term trauma of racism compounds the effects of aces and other potentially traumatic events, contributing, for example, to the well-documented disproportionate impact of covid-19 on black and latinx communities in the u.s. (samhsa 2020).3 furthermore, the resurgence of the black lives matter movement, sparked by the murder of george floyd on may 25, 2020, compounded trauma upon trauma for many students, their families, and communities. in these circumstances, how can we, as instructors in higher education, contribute to the health and success of our students? 4. trauma-informed approach a trauma-informed approach signals a recent culture-shift in public services, of which education is one part (wilson et al. 2013). it is a community-wide effort involving social work, public health, policing, law, education, ministry, and other sectors of public service. while some sectors provide trauma-specific services or interventions, many do not. thus, it is not the responsibility of a classroom instructor to provide mental health services but rather to partner with mental health and other service providers by becoming part of a trauma-informed community (samhsa 2017). becoming a trauma-informed institution is a campus-wide effort, involving student services, academic affairs, administration, athletics, and all areas of the student experience. “samhsa defines any setting as ‘trauma-informed’ if the people there realize how widespread trauma is, recognize signs and symptoms, respond by integrating knowledge into practice, and resist doing further harm” (samhsa 2017; see also samhsa 2014a, p. 9). this four-fold description (realize, recognize, respond, and resist) provides guidance for classroom instructors to contribute to a community of trauma-informed care. realizing the widespread impact of trauma is essential. for example, “by the time they reach college, 66 to 85 percent of youth report lifetime traumatic event exposure, with many reporting  3  for an example analysis of a specific geographic area, see (nowlin et al. 2020).  
  religions 2020, 11, 449  6 of 14  multiple exposures” (davidson 2017, p. 5). this is one of many statistics aggregated by shannon davidson of education northwest on the prevalence of trauma. the aces study revealed that adverse childhood experiences are disturbingly prevalent in u.s. society.4 the point is, trauma is not an unusual experience, and many people bear the effects of trauma in their everyday lives. furthermore, students bring “their whole-messy selves” to the classroom, including past experiences of trauma (lelwica 2020). thus, a trauma-informed approach does not view the student exhibiting the effects of trauma as the exception. rather, “trauma-informed care is initiated by [the] assumption that every person seeking services is a trauma survivor” (salasin 2011, p. 18). a trauma-informed approach to pedagogy is for the benefit of every student. recognizing the signs and symptoms of trauma is essential, as is understanding the causes. common external indications of trauma, listed above, can often be observed in students by classroom teachers. it is important to understand that these behaviors are adaptive. trauma overwhelms a person’s normal stress-response and elicits a survival-based alarm system. the effects of trauma include adaptive behaviors essential to survival, including fight, flight, or freeze responses. however, when traumatic memories are triggered (often with no conscious awareness by the survivor), the body responds as if the original threat were still present. the very behaviors that ensured survival in the first instance become ineffective and inappropriate when triggered at other times and places. the response is individualized: “resilience and recovery look different for each individual. thus, what educators often identify as maladaptive behaviors are really misapplied survival skills” (davidson 2017). the classroom teacher, recognizing the signs of prior trauma in students, can then learn to respond in appropriate and helpful ways. responding as a trauma-informed organization involves more than strategies for immediate intervention. a trauma-informed institution “responds by fully integrating knowledge about trauma into policies, procedures, practices” (samhsa 2014a, p. 9). thus, a set of classroom pedagogical techniques is but one part of an overall, organizational response, the purpose of which is to “promote a culture based on beliefs about resilience, recovery, and healing from trauma” (samhsa 2014a, p. 10). in higher education, it is just as important for administrative assistants, administrators, housing directors, and athletic coaches to become trauma-informed as it is for classroom instructors. for example, the association of title ix administrators identified “failing to understand and use trauma-informed investigations and questioning” as the first of “the seven deadly sins of title ix investigations” (henry et al. 2016).5 for classroom teachers, this means we are partners with all of the other offices on campus contributing to any aspect of the student experience in our institution in responding to the effects of trauma. resisting doing further harm is the fourth aspect of a trauma-informed approach. failing to realize, recognize, and respond appropriately to a survivor of trauma can do harm. re-victimization can easily occur when i fail to shift from an attitude of blame, “what’s wrong with you?” to a stance of care, “what has happened to you?” this shift in perspective, to a trauma-informed approach, allows the classroom instructor to become a partner in recovery and resilience for survivors of trauma. 5. trauma-informed pedagogy a trauma-informed approach requires not only knowledge of trauma but also commitment and action. “the foundation for effective trauma-informed classroom practice is the educator’s grasp of how trauma impacts students’ behavior, development, relationships, and survival strategies” (davidson 2017, p. 17). however, subject matter knowledge is not the essence of trauma-informed pedagogy.  4 5  samhsa cited the aces report as one of two studies significantly influencing the development of the trauma-informed care model (samhsa 2014b, p. 8), the other being (samhsa 2007). according to this 2016 whitepaper, title ix investigations should include four trauma-informed components: understanding the impact of trauma, promoting safety and support, proactively avoiding retraumatization, and promoting choice and empowerment of the trauma survivor (henry et al. 2016).  
  religions 2020, 11, 449  7 of 14  teaching about trauma is not the same thing as using trauma-informed pedagogy and educators should aim to reduce the risk of retraumatization (triggering or reactivating trauma-related symptoms originating from earlier life events) and secondary traumatization (experiencing trauma-related symptoms from learning others’ stories) when exposing students to potentially sensitive material. (davidson 2017, p. 17) i would hasten to add that trauma-informed teaching is not reserved for “potentially sensitive material” but rather recognizes that many of our students arrive in the classroom already dealing with past traumatic experiences (carello and butler 2014, p. 164). a trauma-informed pedagogy is guided by five core values: safety, trustworthiness, choice, collaboration, and empowerment (fallot and harris 2009, p. 3). each of these values can guide classroom pedagogy and practices, allowing classroom instructors to contribute to a community of trauma-informed care. safety is a high priority—not only physical but also psychological. a person dealing with the effects of trauma must feel safe in order to de-escalate their physiological survival-response, allowing them to regain some sense of control in the present. while the need for safety pertains to all aspects of a survivor’s life, in the classroom, safety may involve clearly marked exits, nearby restrooms, and the ability to leave the classroom at any time. the level of commitment to and awareness of safety is communicated from the first contact. trigger warnings are one way to provide classroom safety (crumpton 2020).6 how might a commitment to safety shape the kind of welcome and introduction activity used in one’s classroom? trustworthiness is also necessary for a trauma-informed approach. many traumatic experiences are due to a person in authority abusing their power over someone more vulnerable. re-establishing trust is imperative for many survivors. in order to lessen perceived threats and to provide a conducive environment for recovery, classroom teachers must be clear and transparent about policies, procedures, expectations, professional boundaries, and roles—including self-disclosure in the classroom (crumpton 2017, pp. 142–44). how might a commitment to trustworthiness shape the way one presents the course syllabus and assignments? choice is important for survivors of trauma. trauma robs a person of agency and exposes a deep sense of helplessness. providing adequate information about their rights and responsibilities and offering choices, when appropriate, can help restore a sense of agency to trauma survivors. for example, stephanie m. crumpton developed a classroom “covenant of presence” for this purpose, assuring not only a degree of safety and trust but also choice and control (crumpton 2020, pp. 35–36). how might a commitment to the value of choice change the way one shapes assignments, deadlines, and forms of communication with students? collaboration is essential to becoming a trauma-informed community. resilience from trauma is greatly increased by a social support network, and for this to work to the survivor’s benefit, the survivor must have agency in the process. the event of trauma is something that happens to a person, overwhelming them; healing and recovery is a process that happens with a person, inclusive of them. how might a commitment to the value of collaboration change the way one understands teaching and learning in the classroom? empowerment underlies all of the above values. restoring voice, choice, and agency to a survivor is key to recovery. empowerment means helping the student discover and develop their own capacities. trauma-informed classroom teachers are part of the community that acts on the belief that “trauma-affected students can learn self-efficacy and social-emotional skills” needed to transcend the grip of the past and live fully into their present potential (davidson 2017, p. 13). as classroom instructors, we are in a privileged position to assist trauma-survivors. there are few things more  6  samhsa provides guidance for professionals to help empower survivors to return to the present and to regain focus when such triggering occurs (samhsa 2014b, p. 151). trigger warnings in higher education have prompted no shortage of debate, see for example (siegel 2016).  
  religions 2020, 11, 449  8 of 14  empowering than education. how might a commitment to the value of empowerment change the way one teaches in the classroom? 6. theological implications the above sections on trauma, trauma-informed approach, and trauma-informed pedagogy drew primariy from well-researched, secular resources. what does a faith commitment and religious context contribute to these secular insights? keefe-perry and moon provided five markers of trauma-informed religious education: 1. 2. 3. 4.  5.  actively acknowledge the widespread impact of trauma and recognize potential signs and markers of trauma in congregants, families, staff, and community members; integrate knowledge about trauma into policies, training, and pedagogy; explicitly seek to resist re-traumatization, even while knowing this is a challenge that [religious education offerings] may fail to meet in every case. understand that there are responses that encourage spaces supportive of courageous risk-taking and provide participants with healthy means to consider the potential value of taking a risk on deepening relationships with others and god. incorporate practices that emphasize interpersonal identity, embodiment, and the importance of the imagination for flourishing and healing. (keefe-perry and moon 2019, p. 38).  their first three markers (acknowledge, recognize, integrate, and resist) correspond to samhsa’s fourfold definition of a trauma-informed setting (realize, recognize, respond, and resist). their last two markers are fruitfully compared to (though not identical with) the five core values of trauma-informed pedagogy (safety, trustworthiness, choice, collaboration, and empowerment) presented by fallot and harris (2009, p. 3). keefe-perry and moon intentionally prioritize “a space co-created by those present” over a facilitator-dependent sense of “safe” space (keefe-perry and moon 2019, p. 33). through this approach, they locate trustworthiness as an attribute of the entire classroom community, not just the instructor, and emphasize the value of courageous risk-taking as an expression of choice, collaboration, and empowerment. thus, they claim, “religious education spaces, among others, can support life-giving processing, courageous meaning-making, and trust building” (keefe-perry and moon 2019, p. 34). indeed, this form of courageous risk-taking animates their vision for trauma-informed religious education, with the potential for “deepening relationships with others and god” (keefe-perry and moon 2019, p. 38). regardless of one’s location on the spectrum of classroom safety and risk-taking, it is apparent that trauma-informed pedagogy in religiously affiliated higher education classrooms shares much with secular contexts, drawing on the same insights from psychology, neuroscience, and public health (e.g., carello and butler 2014, pp. 163–64). furthermore, as religious educators, we have the advantage of being equipped to talk about god. for instructors in theological education and religious studies, it is important to remember that trauma is a spiritually disruptive experience. trauma affects mind, body, and soul, causing the survivor to reassess who they are and who god is. trauma disrupts narrative and engages the body in ways too deep for the mind to process. rambo explored this reality through holy saturday, a theology of remaining hovering between life and death, and the witness of the holy spirit in the midst (rambo 2010). jones examined its impact on our understanding of grace and the cross (jones 2009). beste wrestled with its implications for human freedom and divine grace (beste 2007). baldwin reexamined everything she had been taught about god and the human condition (baldwin 2018). whether viewed through the lens of theopoetics (rambo 2010), reformed theology (jones 2009), a revision of rahnerian theology (beste 2007), or the crucible of one’s own faith journey (baldwin 2018), trauma interrupts and reframes faith. it changes the way we think about god, sin, and salvation. previously held theologies of atonement and redemption may prove unhelpful or even false. as classroom instructors, we do not have to become experts on these theological loci—and it is beyond the scope of this article to explore the many and deep theological dimensions of trauma. nor is it our role to provide a therapeutic space or psychological counseling. yet, keefe-perry and moon  
  religions 2020, 11, 449  9 of 14  asserted that religious education can appropriately become a place to “establish a bond” (keefe-perry and moon 2019, p. 33). this is true not only in congregational settings but also undergraduate and graduate classrooms in religious and theological contexts. noting “how trauma can impede the ability of the survivor to develop new relationships with ideas, people, and god,” keefe-perry and moon emphasized the relationship-building potential of religious education (keefe-perry and moon 2019, pp. 32–33). trauma-informed pedagogy contributes to this potential through its core values, which nurture a supportive learning community in which students can risk sharing and hearing experiences that may not make rational sense. thus, keefe-perry and moon also emphasized the affective and embodied experiences of learning as important features of trauma-informed pedagogy: “embodied, aesthetic, and theopoetic knowledges are lifted up as important as rational, propositional discourse” (keefe-perry and moon 2019, p. 37). ott and i emphasized a similar combination of pedagogical lenses through our study of teaching sexuality and religion: perspective transformation draws on affective learning to increase empathy and embodied learning attends to the whole person in the classroom (stephens and ott 2020, p. 2). combined with trauma-sensitive pedagogy, we described our approach as “a holistic endeavor bringing many challenges and potential benefits to classroom pedagogy about religion” (stephens and ott 2020, p. 2). trauma-informed pedagogy is indeed a risky and courageous venture. 7. care for instructors classroom instructors are on the front lines of community support and are potentially exposed to many survivors and their trauma histories. the more one practices trauma-informed pedagogy, the more attuned one becomes to the survivors of trauma who surround us daily, including one’s own self. practicing trauma-sensitive classroom techniques may prompt a more conscious awareness of one’s own unhealed traumatic wounds. furthermore, the more reliably one upholds the core values of trauma-informed pedagogy, the more students will perceive one to be safe, trustworthy, and empowering, thus prompting more frequent divulging of the traumas that are already present within their lives and one’s classroom. trauma is remarkably prevalent, and the increased awareness of and proximity to this reality can itself become traumatic. the experience of vicarious or secondary trauma (sometimes accompanied by compassion fatigue) is a real and present danger. secondary trauma refers to the physiological, emotional, and mental effects of being exposed to the primary trauma of another person, either as a witness to the traumatic event itself or bearing witness to the traumatic effects on that person. it is important that classroom instructors take time to debrief with colleagues, pastors, counselors, and other professionals about the emotional, spiritual, and physical toll that such work demands (davidson 2017, pp. 20–21). being aware of trauma helps us through this journey, but the vicarious effects are no less intense and no less real. it is important to remember that a trauma-informed approach is the work of an entire community of support. 8. conclusions this article has set forth an argument for the importance of trauma-informed pedagogy, particularly for higher education instructors in religious and theological settings. the existing literature at the intersection of religious education and trauma-informed pedagogy is in its infancy. thus, a principle feature of this article was bibliographic, portraying the state of scholarship at the intersection of religious education and trauma and pointing to resources necessary for further development. the article promoted further development of this literature by providing a shared, conceptual basis for trauma-informed pedagogy in religious instruction, based on recent insights from psychology, neuroscience, and public health studies. the article defined and described trauma, introduced the features of a trauma-informed community approach, and discussed the core values guiding trauma-informed pedagogy. the article also explored religious aspects of trauma and the danger of secondary trauma for classroom instructors, especially those with a heightened attunement  
  religions 2020, 11, 449  10 of 14  to the indicators of trauma history. this article raised significant points of debate within the study of trauma-informed pedagogy and implied avenues of further research. significant points of debate within the study of trauma-informed pedagogy include the following. first, trauma-informed pedagogy has been presented as a mode of teaching, yet trauma-informed practices also are used as scholarly tools in specific disciplines as well as a subject of study in their own right, serving as content for classroom discussion. how are these different uses and purposes distinguished in trauma-informed teaching? second, much of the conversation revolves around safety and risk in education. if trauma-informed pedagogy should be seen not as an accommodation to some learners’ needs but rather a standard classroom practice for all learners, how does one negotiate or issue trigger warnings when teaching about trauma or assigning potentially sensitive material in a classroom assignment? third, trauma is present in the classroom whether we address it or not. when practicing trauma-informed pedagogy, how should the instructor navigate between sensitivity to trauma-laden subject matter in the classroom and the pre-existing trauma histories that students (and instructors) bring with them to the classroom? fourth, trauma involves experiences that cannot be adequately shared through words yet manifest themselves in our bodies. how do affect and empathy enter into the perspective transformation we may desire of our students? finally, trauma-informed pedagogy causes us to reevaluate the very nature and goal of religious education. does our pedagogy have mainly to do with content delivery, skills development, relationship-building, or some necessary combination of all of these aspects of learning? this article also implied avenues for further research. more research needs to be done on how this model of pedagogy works in practice, such as the three-year study by harrison et al. (2020). future research should attend to carello and butler’s proposals for trauma-informed teaching (carello and butler 2014, pp. 163–64), particularly in relation to the five markers proposed by keefe-perry and moon (2019, p. 38). furthermore, each of the elements of trauma-sensitive teaching presented in this article need illustration and example in a variety of institutional contexts.7 trauma-informed pedagogy, despite the risk it entails, is no longer an optional means of instruction; it is a necessary and essential tool for religious educators in higher education. furthermore, the analysis of theoretical discourse presented in this article is very important for any kind of education, not limited to religious education. as classroom instructors in higher education, it is imperative that we equip ourselves with the tools of trauma-informed pedagogy and contribute as helping professionals to a trauma-informed community of support. funding: this research received no external funding. acknowledgments: i would like to thank james s. evinger, consultant with the faithtrust institute, for introducing me to the significance of trauma-informed care. thank you, also, to leah r. thomas for her thoughtful feedback on an earlier version of this article and to zeke a. stephens for his bibliographic assistance and technical facility in preparing this manuscript in latex. conflicts of interest: the author declares no conflict of interest.  abbreviations the following abbreviations are used in this manuscript: ace cdc mdpi pte ptsd samhsa  7  adverse childhood experience centers for disease control and prevention multidisciplinary digital publishing institute potentially traumatic event post-traumatic stress disorder substance abuse and mental health services administration  one such effort is an issue of spotlight on teaching in religious studies news, a publication of the american academy of religion, on the topic “trauma-informed pedagogy,” planned for fall 2020. https://rsn.aarweb.org/spotlight-on/teaching.  
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authors_index: greene, talya bloomfield, michael a. p. billings, jo
secondary_title_index: psychological trauma: theory, research, practice, and policy
title_index: psychological trauma and moral injury in religious leaders during covid-19.
abstract_index:
       religious leaders are at risk of psychological trauma and moral injury during the covid-19 pandemic. this article highlights potentially traumatic or morally injurious experiences for religious leaders and provides evidence-based recommendations for mitigating their impact.     

full_text_index:
       psychological trauma: theory, research, practice, and policy  2020 american psychological association issn: 1942-9681  2020, vol. 12, no. s1, s143–s145 http://dx.doi.org/10.1037/tra0000641  psychological trauma and moral injury in religious leaders during covid-19 talya greene  michael a. p. bloomfield  university of haifa and university college london  university college london and camden and islington nhs foundation trust, london, united kingdom  this document is copyrighted by the american psychological association or one of its allied publishers. this article is intended solely for the personal use of the individual user and is not to be disseminated broadly.  jo billings university college london religious leaders are at risk of psychological trauma and moral injury during the covid-19 pandemic. this article highlights potentially traumatic or morally injurious experiences for religious leaders and provides evidence-based recommendations for mitigating their impact. keywords: ptsd, coronavirus, stress, burnout, mental health  material support derived from being part of a community. it is clear, however, that religious leaders are key, because community members may turn to them for comfort and advice in getting through difficult times. although this role can be deeply rewarding, it also comes with risks. previous studies have highlighted the risk of burnout in religious leaders, noting that they tend to not prioritize self-care and often experience work overload, emotional isolation, and the feeling they are permanently on call (jackson-jordan, 2013, lewis et al., 2007). furthermore, religious leaders can suffer distress as result of their exposure to other people’s traumatic experiences, often referred to as secondary or vicarious trauma (hendron, irving, & taylor, 2014). these negative mental health outcomes are likely to occur more frequently during the covid-19 pandemic and may be compounded by the fact that religious leaders and their community have a shared experience of the trauma stressor. in some respects this may be helpful, but it also poses risks because religious leaders have to actively cope with their own experiences while also helping others (baum, 2014). one area that has not yet been addressed in the academic literature, but may be particularly relevant in the covid-19 pandemic, is that of moral injury in religious leaders. moral injury has been defined as the psychological distress caused by actions, or their omission, that violate an individual’s moral code (litz et al., 2009). although moral injury is not in itself a mental disorder, it has been associated with a range of mental health problems, including posttraumatic stress disorder (ptsd), depression, anxiety, and suicidality (griffin et al., 2019; williamson, stevelink, & greenberg, 2018). moral injury has generally been studied in the context of military experiences. although there are studies of moral injury in other occupational groups, such as teachers, journalists, and health care workers (griffin et al., 2019; williamson, murphy, & greenberg, 2020; williamson et al., 2018), there has not yet been any focus on religious leaders. potentially morally injurious events (pmies) refer to acts that an individual has done or failed to do (transgressions of self; nash et  since the outbreak of the covid-19 pandemic, considerable media and academic attention has been directed toward the mental health impact on various high-risk groups, particularly “frontline” workers—those who are key to the treatment of individuals with covid-19 (chen et al., 2020; lai et al., 2020). another group of frontline workers at high risk of psychological distress, but who have largely been overlooked are religious leaders of faith-based communities. although they are not involved in the medical care of people, they play a key role in supporting individuals, families, and communities in coping with the pandemic and especially so for those who are ill or bereaved by covid-19. due to the implementation of quarantine and other social distancing measures, there has been a huge shift in the daily work practices of religious leaders, some of which increase the risk of negative mental health outcomes (lewis, turton, & francis, 2007), and in particular for moral injury. being part of a faith-based community can be a protective factor for mental health following disasters and crises (milstein, 2019). this is partly due to the sense of belonging and the emotional and  editor’s note. this commentary received rapid review due to the timesensitive nature of the content. it was reviewed by the journal editor.— kkt  this article was published online first june 15, 2020. x talya greene, department of community mental health, university of haifa, and division of psychiatry, university college london; x michael a. p. bloomfield, division of psychiatry, university college london, and the traumatic stress clinic, st pancras hospital, camden and islington nhs foundation trust, london, united kingdom; x jo billings, division of psychiatry, university college london. correspondence concerning this article should be addressed to talya greene, department of community mental health, university of haifa, 199 aba houshy avenue, haifa 3498838, israel. e-mail: tgreene@ univ.haifa.ac.il s143  
  greene, bloomfield, and billings  this document is copyrighted by the american psychological association or one of its allied publishers. this article is intended solely for the personal use of the individual user and is not to be disseminated broadly.  s144  al., 2013) or has observed other people do or fail to do (transgressions of others). additionally, people may feel that they have been betrayed by those in positions of authority or even a sense of theological challenge (fontana & rosenheck, 2004; koenig, youssef, & pearce, 2019). in the following text we highlight some pmies for religious leaders that may arise during the covid-19 pandemic. due to restrictions implemented in many countries, religious leaders are not able to conduct in-person meetings or make hospital or home visits and are prohibited from gathering their communities together. in addition, religious leaders are not able to conduct weddings, christenings, and many other joyful lifecycle events, which may feel like a loss and give a sense of “imbalance” in the work they are doing. although the public health reasons for doing so are clear, religious leaders may find themselves struggling with not being able to provide support and comfort to their congregation in the ways that they are accustomed to and feel distressed by this act of omission. in other words, failing to do what they feel morally obliged to do, which may feel like a transgression of self. another area that is likely to be particularly problematic concerns death and mourning. the normal rituals that religious leaders perform are being interfered with. religious leaders are prohibited from visiting those dying from covid-19 and providing direct in-person comfort and end-of-life religious rituals. in many countries, mourners at funerals are limited to immediate family (regardless of the cause of death), and sometimes not even that; if any of the mourners have symptoms of covid-19, they will not be allowed to attend. open-coffin funerals are not allowed for those who died from covid-19, nor is ritual cleaning of the body of the deceased, as undertaken by some religions. religious leaders may find themselves conflicted because they have no choice but to follow these instructions, which are potentially devastating to both the mourners and indeed the religious leaders themselves and may cause a sense of betrayal; leaders may even believe that they themselves have committed a religious transgression.  recommendations given the risks relating to moral injury, and more broadly to burnout, and secondary trauma, what does the literature suggest regarding protective factors? below is a list of recommendations based on existing knowledge regarding psychological stressors for religious leaders, as well as drawing from evidence based on other occupational groups (billings et al., 2020; greenberg, docherty, gnanapragasam, & wessely, 2020; ludick & figley, 2017; williamson et al., 2020, 2018).  self-care it is important for religious leaders to attend to self-care. this means taking regular breaks and trying to schedule time away from professional tasks. try to eat, drink, and sleep properly.  spirituality self-care for religious leaders includes not only physical and mental but also spiritual aspects. this is an unprecedented situation that may be theologically challenging for some. setting aside time to focus on spirituality can help with processing this.  acknowledge moral conflicts it is important to acknowledge the moral conflicts that will likely emerge. discussing them with colleagues and being prepared for some of the possible responses may facilitate coping and acceptance of distress.  purpose religious leaders should try to maintain a strong sense of purpose. although it is difficult to do work in conditions that are far from ideal, it plays a critical role in comforting people in difficult times.  supervision and peer support try to implement supervision, mentoring, and peer-to-peer support. religious leaders can often find themselves isolated and depleted by their role. if such structures already exist, it is not sufficient just to have them but vital to actively make use of them.  social support staying in touch with family and friends is a key buffer of distress and can be a great source of strength.  professional support religious leaders should be aware of the professional support that is available. this can include general psychological support. for some denominational groups, there are bespoke counseling services for their leaders. religious leaders should know how to access this support and be prepared to do so if needed.  conclusion it is important that religious leaders keep in mind that they are doing important work but are also living through difficult times along with everyone else. furthermore, they will experience some stressors unique to their role. attending to self-care, sharing difficult experiences with colleagues, accepting the likelihood of moral conflict, and getting professional help when needed can all facilitate coping with the unique challenges brought by the covid-19 pandemic.  references baum, n. (2014). professionals’ double exposure in the shared traumatic reality of wartime: contributions to professional growth and stress. british journal of social work, 44, 2113–2134. http://dx.doi.org/10 .1093/bjsw/bct085 billings, j., greene, t., kember, t., grey, n., el leithy, s., lee, d., . . . bloomfield, m. (2020). supporting hospital staff during covid-19: early interventions, occupational medicine. occupational medicine. advance online publication. http://dx.doi.org/10.1093/occmed/kqaa098 chen, q., liang, m., li, y., guo, j., fei, d., wang, l., . . . zhang, z. (2020). mental health care for medical staff in china during the covid-19 outbreak. lancet psychiatry, 7(4), e15– e16. http://dx.doi .org/10.1016/s2215-0366(20)30078-x fontana, a., & rosenheck, r. (2004). trauma, change in strength of religious faith, and mental health service use among veterans treated for  
  this document is copyrighted by the american psychological association or one of its allied publishers. this article is intended solely for the personal use of the individual user and is not to be disseminated broadly.  trauma, moral injury, religious leaders and covid-19 ptsd. journal of nervous and mental disease, 192, 579 –584. http:// dx.doi.org/10.1097/01.nmd.0000138224.17375.55 greenberg, n., docherty, m., gnanapragasam, s., & wessely, s. (2020). managing mental health challenges faced by healthcare workers during covid-19 pandemic. british medical journal, 368, m1211. http://dx.doi .org/10.1136/bmj.m1211 griffin, b. j., purcell, n., burkman, k., litz, b. t., bryan, c. j., schmitz, m., . . . maguen, s. (2019). moral injury: an integrative review. journal of traumatic stress, 32, 350 –362. http://dx.doi.org/10.1002/jts.22362 hendron, j. a., irving, p., & taylor, b. j. (2014). clergy stress through working with trauma: a qualitative study of secondary impact. journal of pastoral care & counseling, 68, 1–14. http://dx.doi.org/10.1177/ 154230501406800404 jackson-jordan, e. a. (2013). clergy burnout and resilience: a review of the literature. journal of pastoral care & counseling, 67, 1–5. http:// dx.doi.org/10.1177/154230501306700103 koenig, h. g., youssef, n. a., & pearce, m. (2019). assessment of moral injury in veterans and active duty military personnel with ptsd: a review. frontiers in psychiatry, 10, 443. http://dx.doi.org/10.3389/fpsyt .2019.00443 lai, j., ma, s., wang, y., cai, z., hu, j., wei, n., . . . hu, s. (2020). factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. journal of the american medical association network open, 3, e203976 – e203976. http://dx.doi .org/10.1001/jamanetworkopen.2020.3976 lewis, c. a., turton, d. w., & francis, l. j. (2007). clergy work-related psychological health, stress, and burnout: an introduction to this special  s145  issue of mental health, religion and culture. mental health, religion & culture, 10, 1– 8. http://dx.doi.org/10.1080/13674670601070541 litz, b. t., stein, n., delaney, e., lebowitz, l., nash, w. p., silva, c., & maguen, s. (2009). moral injury and moral repair in war veterans: a preliminary model and intervention strategy. clinical psychology review, 29, 695–706. http://dx.doi.org/10.1016/j.cpr.2009.07.003 ludick, m., & figley, c. r. (2017). toward a mechanism for secondary trauma induction and reduction: reimagining a theory of secondary traumatic stress. traumatology, 23, 112–123. http://dx.doi.org/10.1037/ trm0000096 milstein, g. (2019). disasters, psychological traumas, and religions: resiliencies examined. psychological trauma: theory, research, practice, and policy, 11, 559 –562. http://dx.doi.org/10.1037/tra0000510 nash, w. p., marino carper, t. l., mills, m. a., au, t., goldsmith, a., & litz, b. t. (2013). psychometric evaluation of the moral injury events scale. military medicine, 178, 646 – 652. http://dx.doi.org/10.7205/ milmed-d-13-00017 williamson, v., murphy, d., & greenberg, n. (2020). covid-19 and experiences of moral injury in frontline keyworkers. occupational medicine, 70: kqaa052. http://dx.doi.org/10.1093/occmed/kqaa052 williamson, v., stevelink, s. a. m., & greenberg, n. (2018). occupational moral injury and mental health: systematic review and meta-analysis. british journal of psychiatry, 212, 339 –346. http://dx.doi.org/10.1192/ bjp.2018.55  received april 16, 2020 revision received may 14, 2020 accepted may 18, 2020 䡲  
       


authors_index: downie, alison
secondary_title_index: religions
title_index: christian shame and religious trauma
abstract_index:
       the analysis of religious trauma is enriched by considering how it may be produced by formation in chronic shame. the testimony of those who have experienced religious trauma and severe religious shame is essential to interdisciplinary understanding of and response to this harm. the experiences of those harmed indicates that some traditional christian doctrinal interpretations are shaming. thus, the potential for christian communities to create climates of chronic shame and cause religious trauma is present wherever such theological interpretations dominate. in this way, the religious teachings themselves, especially when communicated in chronically shaming environments, are traumatizing. in this approach, christian religious trauma is not an added element to traumas of domestic, physical, or sexual abuse by a religious person or leader. instead, the source of the trauma is formative experience of participating in christianity. religious trauma merits interdisciplinary study in religious studies and trauma studies, as well as christian theology. theological response to christian religious trauma contributes to this interdisciplinary need.     

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       religions article  christian shame and religious trauma alison downie department of philosophy and religious studies, indiana university of pennsylvania, indiana, pa 15705, usa; adownie@iup.edu  abstract: the analysis of religious trauma is enriched by considering how it may be produced by formation in chronic shame. the testimony of those who have experienced religious trauma and severe religious shame is essential to interdisciplinary understanding of and response to this harm. the experiences of those harmed indicates that some traditional christian doctrinal interpretations are shaming. thus, the potential for christian communities to create climates of chronic shame and cause religious trauma is present wherever such theological interpretations dominate. in this way, the religious teachings themselves, especially when communicated in chronically shaming environments, are traumatizing. in this approach, christian religious trauma is not an added element to traumas of domestic, physical, or sexual abuse by a religious person or leader. instead, the source of the trauma is formative experience of participating in christianity. religious trauma merits interdisciplinary study in religious studies and trauma studies, as well as christian theology. theological response to christian religious trauma contributes to this interdisciplinary need. keywords: shame; christian shame; religious trauma  1. introduction citation: downie, alison. 2022. christian shame and religious trauma. religions 13: 925. https://doi.org/10.3390/ rel13100925 academic editor: dyron b. daughrity received: 4 august 2022 accepted: 29 september 2022 published: 3 october 2022 publisher’s note: mdpi stays neutral with regard to jurisdictional claims in published maps and institutional affil-  scholarship investigating how religious teachings and practices may traumatize remains scant. though the scholarship is sparse, religiously traumatizing experiences are not. psychotherapist dr. alyson m. stone has noted a striking disjunct between the silence of academic literature on the intertwining of religion and trauma and the religious harms evident in her clinical practice. according to stone, “religious trauma is more prevalent than the research suggests and often is a contributing factor to many of the problems that bring people to therapy, including depression, anxiety, and relationship difficulties. for this reason, religious trauma deserves careful attention” (stone 2013, p. 324). nearly a decade after stone called for more study, the need remains. religious trauma merits attention not only from psychologists and therapists but also from religious studies scholars, in both etic and emic approaches., this study employs an emic approach of constructive theology, in which resources inside and outside of the tradition are used to further analysis, develop critique of an identified problem, and suggest further development. after defining religious trauma, i will argue that theologian stephanie arel’s analysis of chronic christian shame elucidates one way in which religious trauma occurs in christian contexts.  iations.  2. defining religious trauma  copyright:   2022 by the author.  licensee mdpi, basel, switzerland. this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license (https:// creativecommons.org/licenses/by/ 4.0/).  terms related to religious trauma, such as spiritual or religious abuse and spiritual violence, appear in related studies.1 i use the term religious trauma for two reasons. firstly, though definitions of and methodologies for studying religion are multiple and contested, in this context, the modifier religious is less definitionally fraught than the term spiritual, though contestation and overlap is inescapable. spiritual harm may occur in any social context, from a workplace to a hospital to a community center. the modifier “spiritual” draws attention to an anthropological view of the human as inherently spiritual in some way and, therefore, potentially vulnerable to harm in that capacity by virtue of being human. in contrast, the term religious trauma is more circumscribed as a functional, descriptive  religions 2022, 13, 925. https://doi.org/10.3390/rel13100925  https://www.mdpi.com/journal/religions  
  religions 2022, 13, 925  2 of 9  term. religious trauma occurs within a religious context. secondly, the term religious trauma clearly situates itself within interdisciplinary trauma studies. the term asserts that a specific form of trauma merits study as tied to a lived experience of a given religion, whether or not this experience also includes abuse or violence. i will highlight three useful definitions of religious trauma, noting their strengths for later reference. psychotherapist marlene winell (2012) coined the term “religious trauma syndrome” and maintains a website devoted to educating and helping people recover from it (https://journeyfree.org/; accessed on 7 july 2022). according to winell, religious trauma syndrome (rts) is explicitly tied to “authoritarianism coupled with toxic theology” in christian contexts, specifically in “doctrines of original sin and eternal damnation” (religious trauma syndrome). i will build upon winell’s linkage of these specifically christian teachings and religious trauma in later discussion of christian shame. stone makes use of winell’s work but decouples religious trauma from a specific religious tradition, defining it as “pervasive psychological damage resulting from religious messages, beliefs, and experiences” (p. 324). in stone’s therapeutic experience, religious trauma often occurs in childhood and youth, during religious formation stone argues that “unlike many forms of trauma that occur through acute incidents, religious trauma generally accrues gradually through long-term exposure to messages that undermine mental health” (p. 325). one of these messages is that emotions exist in a binary of good and bad, acceptable and unacceptable. in such contexts, bad emotions cannot be acknowledged or managed; they can only be condemned. according to stone, “prohibitions against entire categories of emotions can contribute to psychological difficulties, including depression, anxiety, guilt, and addictive or compulsive behaviors. in a similar fashion, the intellectual realm can become restricted, promoting legalistic, black-and-white thinking and difficulty with free association, fantasy, creative thought, and problem solving”. (pp. 325–26) winell and stone both argue that religious trauma occurs within a climate of rigid binaries, absolute judgments, and an atmosphere of fear of condemnation. as trauma, the harm is not resolved simply by leaving a religious group or avoiding the religious tradition because trauma shapes bodies into a “fight/flight/freeze response” (van der kolk 2014, p. 54). as trauma researcher bessel a. van der kolk (2014) puts it, “after trauma the world is experienced with a different nervous system” (p. 53). stone argues that religious trauma produces symptoms of posttraumatic stress disorder (p. 326). these are generally recognized as including “intrusive memories, hyperarousal, hypervigilance, anxiety, depression, numbness, dissociation, compulsion to reenact, restriction of range of affect, and sleep disturbances” (panchuk 2018, p. 509). in addition to ptsd symptoms, stone also notes that those who have experienced religious trauma frequently find participating in religious services and events as intolerably distressful. at the same time, they often also employ “spiritual practices and beliefs to ‘transcend’ or deny problems rather than understand them”, a mechanism called spiritual bypassing in some psychological literature (stone 2013, p. 326). religious trauma thus not only results in potentially lifelong ptsd symptoms, but also frequently shapes a way of being religious in which religious or spiritual teachings and disciplines are used to avoid rather than deepen self-awareness and healing. two essential contributions of stone’s work on religious trauma are the decoupling of its definition from a specific religious group or doctrine and her recognition that it may shape a relationship with religion which is opposite to the generally stated goals of spiritual and religious practices. instead of religious or spiritual practices deepening and developing personal truthfulness, spiritual by-passing employs aspects of a religion to deny or avoid self-knowledge. finally, philosopher of religion michelle panchuk (2018, 2020) argues that the concept of hermeneutical injustice is significant for many experiences of religious trauma. simply put, hermeneutical injustice occurs when oppressive social structures prevent knowledge and thereby diminish agency. panchuk’s argument is not limited to christian contexts,  
  religions 2022, 13, 925  3 of 9  but she cites useful examples from this religious tradition. in one case, a woman raised in a christian context is unable to recognize that she had been abused as a child (panchuk 2020, p. 612). this is not because she does not understand the concept of child abuse in the abstract. instead, it is because religious formation includes norms through which people interpret and understand their experience. a child who understands herself to be a sinner who deserves punishment is formed within a hermeneutic in which those who have authority to punish do so because it is deserved. abuse is not an interpretive option. as an adult, the woman may still be unable to see abuse in her childhood experience, if her childhood religious hermeneutic framework remains intact. as panchuk puts it, “certain theological commitments (for example, original sin or divine justice) can create an epistemic context in which particular instances of abuse cannot be recognized as abuse (220, p. 612). panchuk (2020) also references a published account testifying to religious counsel a christian church official gave to a woman that she ought to endure domestic abuse at the hands of her husband. the rationale of that counsel was that loving and following jesus means to bear this suffering gladly. panchuk argues that both examples demonstrate the usefulness of the analytic lens of hermeneutical injustice for understanding religious trauma. in the first case, a woman is unable to know her own lived experience of abuse as abuse because of the religious context in which her knowledge was formed; in the second case, a religious authority taught a woman that she ought to accept domestic abuse for religious growth. according to panchuk (2020), in both instances, “the victim is harmed as a knower because they are deprived of knowledge that they would otherwise have. they are harmed as an agent because this lack of knowledge prevents them from acting in accordance with their interests, goals, or values. together, these two harms often result in other social and personal harms”. (p. 613) panchuk’s analysis is a significant contribution for understanding how religious trauma occurs. while the important psychological approaches of winell and stone focus upon trauma as individual, interior experience, panchuk’s study examines the larger context in which individual formation occurs, specifically the power of sanctioned knowing within a religious community. panchuk’s study emphasizes how religious trauma deprives persons of knowledge they might otherwise have and thus tends to emphasize harm through lackthrough not being provided what they need to form accurate assessments. building upon these three explorations of religious trauma, i will argue that shamed persons’ bodies are shaped to “know” what is false and, further, that this harm constitutes a form of religious trauma. to support this thesis, i turn to the study of chronic shame in christian formation by stephanie arel (2016, 2019). 3. shame shame, like trauma and like religion, is a multidisciplinary matter of study with vying definitional and methodological approaches. arel employs an understanding of shame developed from within a relational anthropology of humans as bio/psycho/social beings. following several affect theorists, arel regards shame as one of several basic affects; at its core, it is a reflexive bodily response to a perceived social context. in this approach, some experiences of shame are inevitable, because the affect of shame is the flipside of the process of human bonding and forming attachments. acceptance, a sense of belonging and secure connection result in effective bonding. but when an expected, anticipated experience of human connection is blocked, shame occurs. in this way, shame regulates social behavior through the discomfort of disconnection. developmentally, shame is experienced before language is established; some theorists suggest at about eighteen months (arel 2019, p. 50). it is important to note that when shame occurs within a relational context of secure attachment, though always unpleasant, the pain of it may be transitory and not wounding in lasting ways. within contexts of secure attachments, a child is socialized into norms of behavior by experiencing shame.  
  religions 2022, 13, 925  4 of 9  occasionally painful rebuffs do not necessarily jeopardize a positive developing sense of self as valued and accepted if the child experiences these rebuffs within strong enough, positive enough relational context. as an occasional corrective, the discomfort of shame may facilitate connection in that the child learns what is not appropriate and can change behavior to avoid further rebuffs. once verbal ability develops, language entwines with bodily experience. the bodily sensations constituting the physiological response to blocked social connection—the sudden clenching of the gut, the red-hot, burning face-now have names, shame or humiliation. in language, the psychological experience entwines with the bodily experience. in arel’s study, attending to the physiological dimension of shame is essential to understanding its formative power. as explained, in this approach, shame occurs in reflexive bodily processes before language develops; this means it functions in a child’s body before reflective thought about the physiological responses are possible. even after verbal ability develops, however, shame still occurs physiologically before thought in a specific moment is possible. according to this definition, shame happens physiologically and reflexively before a choice about response is possible. as capacity for reflective thought develops, perception of social context already formed in and by shame continues in shame’s complex dynamic. in contexts of insecure attachment and chronic shame, young bodies are shaped into a developing sense of self in deeply wounding patterns. to understand the power of this process of being formed in shame, arel (2016) employs sociologist pierre bordieu’s notion of habitus (p. 9). shame can become more than an occasional response to an external stimulus. it can become a vicious cycle or habitus. in a habitus shame is not only externally imposed but also replicates and perpetuates itself in bodily response through perception, interpretation, and repeated patterns of relation (arel 2016, p. 10). it becomes a bodily hermeneutic. for example, if a toddler is regularly mocked when expressing distress rather than comforted, the child’s whole bio/psycho/social being, including bodily, reflexive responses, social expectation, perception, and developing sense of self will all be shaped in shame. in such a habitus, persons become ashamed of themselves and ashamed of being ashamed. similarly, though theologian stephen pattison (2000) did not incorporate the notion of habitus, he also argued that it is very difficult for people to admit to feeling shame, even to themselves, and, therefore, also difficult to seek healing for it (p. 158). in this way, feeling ashamed of feeling shame blocks healing. in a vicious cycle, chronic shame fuels withdrawal and isolation as well as fearful, protective measures to avoid further exposure to shame, even exposure to self-knowledge of shame. 4. chronic shame and religious trauma using this understanding of what shame is and how chronic shame functions, arel argues that, historically, christian teaching has regularly advocated a religiously appropriate sense of self as one formed by shame. in large measure this is because christian tradition has not distinguished between guilt and shame, even sometimes using the terms synonymously. arel (2016) argues that augustine’s sense of self as “corrupt, immoral and depraved” reflects shame, not guilt (p. 73). a. denise starkey (2009) also argues that augustine’s the confessions, particularly, is permeated by deep sense of shame (p. 101). not only augustine, but much of christian theology, according to arel, has explained human guilt and need for salvation in language which describes and elicits not guilt, but shame. like stephen pattison (2000), arel (2016) argues that shame has not received sufficient theological attention, with the result that theological understandings of the human person have not responded sufficiently to the reality of shame as “visceral, affective and neurological” (p. 11). here is the nexus where shame and religious trauma converge as bodily wound. according to arel (2019), “recent research on shame and trauma has more explicitly linked the two, locating shame at the core of symptomatology of post-traumatic stress disorder” (p. 55). trauma-responsive theologies are a burgeoning area of investigation.2  
  religions 2022, 13, 925  5 of 9  despite many resources in this material, however, these theologies have not addressed religious trauma and its relation to christian formation in chronic shame. as noted earlier, winell’s work emphasizes that in some christian contexts, religious trauma is caused by religious doctrine. testimonies of such childhood experience abound in many formats, though mostly outside scholarly literature. panchuk (2020) brings some online sources into her work, citing a sermon which states “a baby is a ‘viper in [a] diaper, a ‘depraved’, ‘diseased’ beast” (p. 617). the effect of being raised in this type of environment is evident in my own experience. i remember sermons about the indisputable proof of total depravity being children, who are bad in all natural inclinations and behaviors. i specifically remember the congregation’s knowing chuckle in response to the minister’s quip that “no one needs to teach a child how to lie”. i also vividly recall a time of private prayer in which i tried with all my might to cry, to show god how sorry i was for being such a horrible sinner. i could not think of anything particularly bad i had done recently, but i knew without doubt i deserved hell. i was ten years old. tragically, formation in shame is not incompatible with sincerity of religious conviction or feelings of love by those teaching and shaming. in an interdisciplinary study of shame in christian churches, moon and tobin (2018) state that “people often dispense this shame believing it will help their loved ones to conform to god’s will and to spend eternity in heaven” (p. 453). parents who feel love for their children may nevertheless, for many reasons, not create the bonding and secure attachment environment children need. family and religious community dynamics may be structured by chronic shame, even when persons in such communities feel the emotion of love. complicating matters further, systemic shame is often denied at individual, family, and community levels. the mechanism of spiritual by-passing stone noted in the aftermath of an individual’s religious trauma characterizes family and church ways of being religious as well. this dynamic is evident in generalizing statements that may be accurate aspirationally, but when asserted as description become shields of denial. for example, one christian theologian writes that “christians are always aware of the provisional nature of their own judgments about sin and righteousness” (van deusen hunsinger 2001, p. 73). such statements fail to distinguish between what christian communities say they value and harmful behaviors that fall short of or even violate these values. the claim that christians are already “always aware” by virtue of religious identity creates obstacles to becoming more self-aware by listening to those who may have been harmed within and by the community. the most insidious aspect of christian shaming is that it is routinely and consistently presented and justified as love. blogger samantha fields (2021), referencing parental spanking throughout her childhood, writes, “i was taught that the people who hurt you, violently hurt you, every day, for years, are doing it because they love you”. the significance of panchuk’s analytic of hermeneutical injustice in religious trauma becomes evident in fields’ statement. when children are taught that their experience of harm is not harm but an expression of love, hermeneutical injustice is clear. those formed to believe that violent harm is an expression of love are thereby prevented from the possibility of considering their harm as abuse. they already “know” it is a demonstration of love. shame can also be understood through a lens of hermeneutical injustice. in chronic christian shame, those experiencing the pain of shame are also taught not to know what their bodies tell them, the truth of their own experience. this harm must be understood not only as deprivation of knowledge but as formation in a hermeneutical habitus of shame as a way of knowing encompassing all relation to self, others, world, and god. chronic shame shapes body-knowing. this sort of knowing is not that of concepts in the mind. it is a visceral knowledge, the knowledge of physical reflexes acting before the mind has time to suggest or consider alternatives. this knowing is a bio/psycho/social way of experiencing any and all aspects of life. chronic shame shapes religiously traumatized body-selves to “know” they are utterly wrong, a wrongness which is not guilt or regret for a specific decision or behavior. instead, it is an ontological wrongness of identity, the wrongness of self as self. the self shaped in and by shame thus knows itself not as subject  
  religions 2022, 13, 925  6 of 9  but as an object of condemnation (pattison 2000, p. 72). tobin and moon (2019) develop a similar analysis in what they call “dispositional shame” in their ethnographic study of lgbt experiences in conservative christian communities. they argue that “when shame becomes a person’s habitual way of navigating the world, it violates the self and can harm . . . ability to cultivate virtues that support healthy relationships and moral action” (p. 113). theologically, formation in severe shame shapes a false knowing which prevents persons from knowing what christian tradition generally purports to teach. theologically, the religious trauma of chronic christian shame is the harm of being prevented from knowing the truth of one’s identity as being born beloved, loved into existence and sustained by creator spirit. formation in shame prevents or obstructs persons from perceiving or listening to their own depths, to their own inner truth as relational subjects, not objects. theologically, formation in chronic shame thus obstructs relationship to the spirit by inculcating a way of being religious dependent upon fear and lack of genuine self-knowledge. in its most severe outcomes, the only knowledge of self permitted in chronic christian shame is that which conforms to the religious authority which establishes truth. all else is condemned as either sinful or false. in such contexts, truth is always and only external. truth is received by submission to authority, by conformity. it is not known from within. knowledge of self as subject in the sense of becoming aware of emotions, interests, desires, capacities, and aspirations that do not adhere to the religious norms is forbidden and obstructed not only externally but also internally through formation in a shame habitus. because it is such a painfully powerful affect, shame is an effective tool of control, a tool enforcing social conformity (pattison 2000, p. 135). in a study of shame in the united states, myra mendible (2016) argues that “historically the moral function of shame has tended to serve power rather than to challenge it” (p. 6). shame functions this way in religious contexts as well as elsewhere. those who would speak in religious settings about experiencing chronic christian shame as religious trauma do not only risk encountering disagreement in the sense of a disputed thesis. those speaking up within religious communities can expect the truth of their experience to be minimized or denied; they can also expect to be shamed back into silence in countless ways. their character and religious commitments may be questioned, with implied or outright accusations that if their faith were stronger, their prayer more devout, or their understanding more spiritually mature, they would not have the experiences they describe. they may be accused of disloyalty, of betraying and harming family, community, or the larger religious tradition in sinful ways. in an ethnographic study of a large protestant group in the united states, jessica johnson (2018) documents multiple such shaming strategies. johnson’s analysis of one megachurch studies what she refers to, following theorist sara ahmed, as an “affective economy” in the church (p. 17). johnson observes and analyzes the power of emotion at work in the community during services and events, one of which is shame. in one example, a leadership training program within the church was “conducted in the manner of bullying harassment” (p. 173). when one of the trainees expressed concern about the process, he was asked to have an interview in which church leaders told him his real problem was pride. he was grilled and told he had failed the interviewers. johnson quotes the trainee’s account at length, a portion of which states, “i started to feel like i was suffocating or like a giant weight was crushing me. i finally broke. the tears start running and at once my wife and i and everyone else in the room was relieved that i had admitted my sin. we were convinced that my concerns were irrelevant because i was prideful” (p. 174). only after the session was the church member able to conclude that it had been “a manipulative experience”. (p. 174) cashwell and swindle (2018) refer to public shaming in religious contexts as “religious abuse”, which they analyze as a form of “betrayal trauma” (p. 187). their clinical perspective resonates with panchuk’s analysis of hermeneutical injustice when they state that those harmed may not “recognize the experience as abusive and traumatic” (p. 196).  
  religions 2022, 13, 925  7 of 9  their clinical study also draws attention to the power dynamics at work in what they refer to as religious abuse and trauma (p. 189). precisely because shame is such a powerful tool of control, it is exceedingly difficult to bring it out into the open. as popular shame researcher brene brown (2012) puts it, “shame derives its power from being unspeakable” (p. 67). this makes theological naming and study of chronic christian shame and religious trauma an urgent matter. tobin and moon (2019) study survivor accounts of clergy sexual abuse, one of whom is ann hagan webb. tobin and moon write, “as horrific as the abuse was, webb claims that the experience of being silenced, ignored, and even censured by members of the catholic hierarchy when she came forward to testify to the abuse was equally if not more spiritually damaging” (p. 11). panchuk (2018) has argued that “in order to pursue recovery, the survivor must be in a position to identify their experience for what it is—that is, they need access to the hermeneutical resources necessary to interpret their experience as trauma” (p. 523). the responsibility for naming such experience and changing power structures which not only harm but also protect those who harm others from accountability lies with the entire religious community, not with those who have been harmed. theology has a place in this work to become a hermeneutical resource for new knowing, to counter formation in shame and religious trauma, to listen to witness and name the wounds, to speak against shame’s fierce silencing. theologian hilary jerome scarsella (2018) argues that theologies responding to trauma, particularly those by womanist, mujerista, and feminist writers, do not use the term recovery to discuss living in the aftermath of trauma. in this scholarship, what may be possible in trauma’s aftermath is not recovery, but, instead, a new creation: “a process of making something new in the place of that which has been lost” (p. 269). for those formed in chronic shame, the process entails not recovery of a lost way of being self but forging a new way of being self-as-subject, rather than object, learning to discover what is within as worthy of being felt, acknowledged, considered, and perhaps followed. theologically, this process entails openness to the movement and prompting of the spirit arising within. though it may involve concepts, this is not primarily an intellectual process but about felt experience in the body. as marcia mount shoop (2018) writes, the truth of embodied trauma is that safety evaporates as a familiar sensation, but trust and openness do not have to disappear. they can be cultivated, they can be relearned, but the body must be the primal site of the learning. these are not simply ideas; they are visceral sensations that require cellular address. (“body-wise”, p. 246) for bodies shaped in a hermeneutic of shame, recognizing harm as harm, not as expression of love, either human or divine, may be a most difficult but essential first step in this learning. though this learning is not primarily intellectual, theologies which “reimagine the sacred as a dynamic power, rather than an ageless being—a power that that [sic] dwells in earthly bodies (human and nonhuman) and makes itself known in the truths of our diverse, ever-evolving experiences” offer a promising frame for such reforming (lelwica 2017, p. 211). the christian claim that god is love needs to be explored in the light of shame and trauma which prevent persons from experiencing love, from themselves, others, and god. 5. conclusions theological response to chronic christian shame and religious trauma is necessary for at least three reasons. firstly, these wounds have not received the serious and sustained interdisciplinary and theological attention they merit. these wounds are not only individual, interpersonal matters, but also systemic, social, and structural issues requiring analysis from many quarters. secondly, integrating chronic christian shame and religious trauma opens avenues for further discussion on intersections of similarity in shame-injury across difference. people are shamed within christian contexts for a host of reasons beyond those mentioned here. in  
  religions 2022, 13, 925  8 of 9  addition, religious shaming may well intersect with broader cultural shaming of aspects of identity, as, for example michelle mary lelwica (2017) argues in shameful bodies. christian theological work testifying to and examining religious shaming may, in addition to breaking silence, open possibilities for interdisciplinary dialogue and deeper understanding of shame and trauma. finally, just as interdisciplinary study of trauma deepens understanding of how chronic shame and religious traumaharm, continuing empirical studies of bodily practices which help traumatized persons manage or reduce ptsd symptoms may also yield theologically significant insight. christian theological understanding of the human must continually be shaped by and respond to developing interdisciplinary knowledge regarding chronic shame and religious trauma. for all these reasons, at least, theology has a place in and must engage with interdisciplinary response to chronic shame and religious trauma. funding: this research received no external funding. data availability statement: not applicable. acknowledgments: i thank kevin timpe for making me aware of michelle panchuk’s work and i thank michelle panchuk for making me aware of blogger samantha fields. conflicts of interest: the author declares no conflict of interest.  notes 1  2  (cashwell and swindle 2018; fernandez 2022; johnson and vanvonderen 2005; pasquale 2015; pisila 2022; tobin 2019; tobin 2016). (arel and shelly 2016; baldwin 2018; beste 2007; hess 2009; jones 2009; rambo 2010; rambo 2017; shoop 2010).  references arel, stephanie n., and rambo shelly, eds. 2016. post-traumatic public theology. chaim: palgrave mcmillan. arel, stephanie. 2016. affect theory, shame, and christian formation. cham: palgrave mcmillan. arel, stephanie. 2019. disgust, shame, and trauma: the visceral and visual impact of touch. in trauma and lived religion: transcending the ordinary. edited by r. ruard ganzevoort and srdjan sremac. cham: palgrave mcmillan, pp. 45–70. baldwin, jennifer. 2018. trauma-sensitive theology: thinking theologically in the era of trauma. eugene: cascade books. beste, jennifer erin. 2007. god and the victim: traumatic intrusions on grace and freedom. new york: oxford university press. brown, brene. 2012. daring greatly: how the courage to be vulnerable transforms the way we live, love, parent, and lead. new york: avery. cashwell, craig s., and paul j. swindle. 2018. when religion hurts: supervising cases of religious abuse. the clinical supervisor 37: 182–203. [crossref] fernandez, samuel. 2022. victims are not guilty! spiritual abuse and ecclesiastical responsibility. religions 13: 427. [crossref] fields, samantha. 2021. the best way out is through. october 6. available online: http://samanthapfield.com (accessed on 18 july 2022). hess, cynthia. 2009. sites of violence, sites of grace: christian nonviolence and the traumatized self. lanham: lexington books. johnson, david w., and jeff vanvonderen. 2005. the subtle power of spiritual abuse. minneapolis: bethany house. johnson, jessica. 2018. biblical porn: affect, labor, and pastor mark driscoll’s evangelical empire. durham: duke university press. jones, serene. 2009. trauma and grace: theology in a ruptured world. louisville: westminister johnknox press. lelwica, michelle mary. 2017. shameful bodies: religion and the culture of physical improvement. london: bloomsbury. mendible, myra. 2016. american shame and the boundaries of belonging. american shame: stigma and the body politic. edited by myra mendible. bloomington: indian university press, pp. 1–23. moon, dawne, and theresa w. tobin. 2018. sunsets and solidarity: overcoming sacramental shame in conservative christian churches to forge a queer vision of love and justice. hypatia 33: 451–68. [crossref] panchuk, michelle. 2018. the shattered spiritual self: a philosophical exploration of religious trauma. res philosophica 95: 505–30. [crossref] panchuk, michelle. 2020. distorting concepts, obscured experiences: hermeneutical injustice in religious trauma and spiritual violence. hypatia 35: 607–25. [crossref] pasquale, teresa b. 2015. sacred wounds: a path to healing from spiritual trauma. st. louis: chalice press. pattison, stephen. 2000. shame: theory, therapy, theology. cambridge: cambridge university press. pisila, mikko. 2022. supernatural punishment, spiritual violence and the gospel of matthew. approaching religion 12: 18–35. [crossref] rambo, shelly. 2010. spirit and trauma: a theology of remaining. louisville: westminster johnknox press. rambo, shelly. 2017. resurrecting wounds: living in the afterlife of trauma. waco: baylor university press.  
  religions 2022, 13, 925  9 of 9  scarsella, hilary jerome. 2018. trauma and theology: prospects and limits in light of the cross. in trauma and transcendence: suffering and the limits of theory. edited by eric boynton and peter capretto. new york: fordham university press, pp. 256–82. shoop, marcia mount. 2018. body-wise: re-fleshing christian spiritual practice in trauma’s wake. in trauma and transcendence: suffering and the limits of theory. edited by eric boynton and peter capretto. new york: fordham university press, pp. 240–55. shoop, marcia w. mount. 2010. let the bones dance: embodiment and the body of christ. louisville: westminister johnknox press. starkey, a. denise. 2009. the shame that lingers: a survivor-centered critique of catholic sin-talk. new york: peter lang publishing. stone, alyson m. 2013. thou shalt not: treating religious trauma and spiritual harm with combined therapy. eastern group psychotherapy society 37: 323–37. tobin, teresa. 2016. spiritual violence, gender, and sexuality: implications for seeking and dwelling among some catholic women and lgbt catholics. in seekers and dwellers: plurality and wholeness in a time of secularity. edited by philip j. rossi. washington, dc: the council of research in values and philosophy, pp. 133–66. tobin, theresa w. 2019. religious faith in the unjust meantime: the spiritual violence of clergy sexual abuse. feminist philosophy quarterly 5: 1–29. [crossref] tobin, theresa w., and dawne moon. 2019. the politics of shame in the motivation to virtue: lessons from the shame, pride, and humility experiences of lgbt conservative christians and their allies. journal of moral education 48: 109–25. [crossref] van der kolk, bessell a. 2014. the body keeps the score: brain, mind, and body in the healing of trauma. new york: viking. van deusen hunsinger, deborah. 2001. forgiving abusive parents: psychological and theological considerations. forgiveness and truth. edited by alistair mcfayden and marcel sarot. edinburgh: t & t clark, pp. 71–98. winell, marlene. 2012. religious trauma syndrome. available online: https://journeyfree.org/rts/ (accessed on 10 may 2022).  
       


secondary_title_index: professional psychology: research and practice
abstract_index:
       for many individuals, religious and spiritual (r/s) beliefs are a central part of their worldview and provide substantial support when adapting to and coping with life’s challenges. as mental health professionals provide supportive services, they must carefully consider ways to incorporate clients’ r/s beliefs into culturally sensitive and responsive interventions. to gain insight into clients’ adaptive coping when relying on r/s beliefs, this research explored the experiences of 39 women from christian, islamic, and jewish traditions. each of these individuals accessed their r/s beliefs to adaptively cope following a severe life event. individual interviews (90–120 min) were conducted with each participant. employing interpretative phenomenological analysis (ipa), a systematic review of interview transcripts revealed four common themes of reliance on r/s coping: (a) engaging in important relationships with others who also shared a strong r/s core belief system (cbs), (b) integrating r/s practices with psychological strategies, (c) experiencing and acknowledging divine intervention, and (d) reframing experiences through the use of r/s-oriented thoughts and beliefs. regardless of religious denomination, participants reported similar r/s coping processes. participants’ reliance on r/s coping and a strong cbs in a supreme being were powerful, stabilizing, and beneficial forces. these findings suggest the importance of mental health professionals understanding, validating, and drawing upon clients’ r/s beliefs, practices, and experiences. this article emphasizes the critical need to better prepare mental health professionals, who may feel insufficiently prepared, to incorporate r/s issues in therapy.     

authors_index:
       jerome, annette     allen heath, melissa     williams, marleen     winters, rebecca     cutrer-parraga, elizabeth a.     

title_index:
       traversing trauma: resilient women’s religious and spiritual stories of hope and strength.     

full_text_index:
       professional psychology: research and practice  2022 american psychological association issn: 0735-7028  2023, vol. 54, no. 2, 177–187 https://doi.org/10.1037/pro0000491  traversing trauma: resilient women’s religious and spiritual stories of hope and strength annette jerome1, melissa allen heath2, marleen williams3, rebecca winters4, and elizabeth a. cutrer-parraga4  this document is copyrighted by the american psychological association or one of its allied publishers. this article is intended solely for the personal use of the individual user and is not to be disseminated broadly.  1  licensed psychologist, private practice, grapevine, texas, united states 2 licensed psychologist, mckinney, texas, united states 3 licensed psychologist, orem, utah, united states 4 department of counseling psychology and special education, brigham young university for many individuals, religious and spiritual (r/s) beliefs are a central part of their worldview and provide substantial support when adapting to and coping with life’s challenges. as mental health professionals provide supportive services, they must carefully consider ways to incorporate clients’ r/s beliefs into culturally sensitive and responsive interventions. to gain insight into clients’ adaptive coping when relying on r/s beliefs, this research explored the experiences of 39 women from christian, islamic, and jewish traditions. each of these individuals accessed their r/s beliefs to adaptively cope following a severe life event. individual interviews (90–120 min) were conducted with each participant. employing interpretative phenomenological analysis (ipa), a systematic review of interview transcripts revealed four common themes of reliance on r/s coping: (a) engaging in important relationships with others who also shared a strong r/s core belief system (cbs), (b) integrating r/s practices with psychological strategies, (c) experiencing and acknowledging divine intervention, and (d) reframing experiences through the use of r/s-oriented thoughts and beliefs. regardless of religious denomination, participants reported similar r/s coping processes. participants’ reliance on r/s coping and a strong cbs in a supreme being were powerful, stabilizing, and beneficial forces. these findings suggest the importance of mental health professionals understanding, validating, and drawing upon clients’ r/s beliefs, practices, and experiences. this article emphasizes the critical need to better prepare mental health professionals, who may feel insufficiently prepared, to incorporate r/s issues in therapy.  public significance statement to adaptively cope following severe life events, christian, islamic, and jewish women reported their reliance on religious and spiritual beliefs. their beliefs in a supreme being were powerful, stabilizing, and beneficial forces. because many women who experience trauma rely on their religious and spiritual beliefs, mental health professionals need to consider coping strategies that incorporate culturally sensitive religious and spiritual beliefs. keywords: qualitative interview, religious coping, spiritual coping, trauma, women  this article was published online first november 7, 2022. https://orcid.org/0000-0003-0259-3244 annette jerome annette jerome, phd, bcba, graduated with a doctorate in counseling psychology from brigham young university, with a dual emphasis in the areas of counseling psychology and school psychology. she is currently a licensed psychologist, in private practice. she works in the dallas fort worth, tx area, specializing in emergency response and assessment and treatment planning for trauma/posttraumatic stress disorder, autism, and obsessive-compulsive disorder. she has extensive experience providing individuals with interventions sensitive to their cultural background and their spiritual/religious core belief systems. melissa allen heath, phd, ncsp, graduated from texas a&m university’s school psychology program. she is a retired professor of school psychology. her research interests include children’s grief, suicide, and using children’s literature to support children’s social–emotional learning. marleen williams, phd, is a retired clinical professor. she received her phd in clinical psychology from brigham young university. her research interests include eating disorders, women’s issues, and spirituality and mental health.  rebecca winters, phd, is an assistant professor in brigham young university’s department of counseling psychology and special education. she received her doctoral degree in school psychology from texas a&m university. her areas of expertise include emergency response and crisis intervention. she also specializes in the assessment and treatment of children’s behavioral and mental health challenges. elizabeth a. cutrer-parraga, phd, is an assistant professor in brigham young university’s department of counseling psychology and special education. she received her doctoral degree in early childhood, intervention, and literacy from the university of north carolina, chapel hill. her areas of expertise include qualitative research methods, literacy training, and coaching of preservice teachers, early/emergent literacy instruction with struggling readers, and bibliotherapy to support children’s social–emotional learning. the authors want to express our gratitude to the resilient women who participated in the interviews and to the student researchers who assisted with data analysis. gratitude to dr. clavenna for health and healing. correspondence concerning this article should be addressed to annette jerome, 312 west northwest highway, grapevine, tx 76051, united states. email: annette.jerome@gmail.com 177  
  this document is copyrighted by the american psychological association or one of its allied publishers. this article is intended solely for the personal use of the individual user and is not to be disseminated broadly.  178  jerome et al.  for many, trauma and adversity are part of the human experience. these challenges cause distress and suffering and may trigger lifealtering consequences that negatively impact the quality of life (aten et al., 2019). during stressful times when personal resources are overburdened, coping strategies help individuals manage external and internal demands (boss et al., 2017). positive adaptive coping involves flexibility in perspective-taking and allows individuals to identify and exercise purposeful and deliberate personal choices (cheng et al., 2014). effective coping is influenced by an individual’s core belief system (cbs) and helps the individual find meaning and purpose in life experiences (lewis hall & hill, 2019). how an individual copes with stress, not the source of the stress, influences health and well-being (pargament et al., 1992). although some are paralyzed by despair, losing motivation during and following extreme circumstances, many successfully navigate challenges associated with adverse events (lewis hall & hill, 2019). those who cope and transition effectively often emerge with increased resilience and renewed life meaning (prati & pietrantoni, 2009), encouraging posttraumatic growth (tedeschi & calhoun, 1995).  religious and spiritual (r/s) coping some researchers differentiate religious and spiritual practices (zwingmann et al., 2011). many individuals associate religion with a structured set of beliefs and customs (richards & bergin, 2014). somewhat similar, the definition of spirituality has gradually developed and expanded over time (koenig et al., 2012). according to walsh (2009), “spirituality is a powerful dimension of human experience involving transcendent beliefs and practices that foster meaning, well-being, and connectedness” (p. xi). hill and pargament (2003) report that most individuals use the terms religious and spiritual interchangeably. both terms are associated with honoring what is sacred and holy (richards & bergin, 2014) with expressions embedded in social and cultural norms (aten et al., 2019). in this article, we refer to the combination of religious and spiritual, denoted as r/s. many individuals value r/s ceremonies and rituals to honor and/or acknowledge major life events, such as birth, transition to adulthood, marriage, and death (plante, 2014). over the past 20 years, gallup polls indicate that 80% of americans view religion as important in daily living (newport, 2016). in a more recent gallup poll, 72% of americans view religion as important in their daily life (brenan, 2018) and more than half the world’s adult population were unified in praying to end covid-19 (bentzen, 2021). mental health professionals work to promote survivors’ well-being with an emphasis on supporting clients’ adaptive coping (howell, 2017). however, in a counseling relationship, there is often a mismatch between clients’ natural coping strategies and counseling interventions (gladding & crockett, 2019). while many clients rely on r/s coping strategies (lancaster & palframan, 2009; plante, 2014), professionals may not affirm these strategies (gladding & crockett, 2019; vieten & lukoff, 2022), may not be religious nor inclined to promote these strategies (magyar-russell, 2020), or may feel ill-equipped to incorporate clients’ r/s cbs into the counseling process (henriksen et al., 2015; vieten & lukoff, 2022). vieten and lukoff (2022) and bryant-davis and wong (2013) stress the importance of considering religion and spirituality as  critical components of cultural diversity. preservice training and continuing education must build on multicultural counseling competencies to prepare professionals who value and sensitively include clients’ r/s core beliefs in treatment planning (bryant-davis & wong, 2013; vieten et al., 2013, 2016; vieten & lukoff, 2022). additionally, r/s strategies address the feeling/thought/behavior paradigm and thus, fit nicely with and augment “third wave” behavior strategies such as cognitive behavioral therapy, acceptance and commitment therapy, and mindfulness (binensztok et al., 2018; hayes et al., 2012). however, differences are noted. r/s strategies align feelings, thoughts, and behaviors with an individual’s personal cbs. this culturally sensitive approach integrates spiritual devotions into daily life. r/s strategies sensitively acknowledge an individual’s divine locus of control. an r/s cbs provides context and perspective, supporting an individual in reframing and finding new meaning in life experiences.  women’s r/s-oriented coping women more consistently utilize religious coping strategies than men (bjorck & cohen, 1993; pew research center, 2022) and are more inclined to acknowledge benefits when relying on r/s strategies during times of crisis (tedeschi & calhoun, 1995). women’s r/s expressions differ from men’s in distinctive ways, such as forms of communication, types of life experiences with god, and frequency and style of prayers (ochs, 1997; pew research center, 2022). because of these differences, investigations of women’s r/s coping should focus on how they experience and process traumatic experiences through a female r/s perspective (hickson & phelps, 1998).  rationale for present study in a counseling relationship, there is often a mismatch between an individual’s r/s coping style and the manner in which professionals offer intervention (gladding & crockett, 2019). although many women naturally rely on their r/s beliefs when facing challenges (plante, 2014), professionals may not utilize r/s coping strategies with their clients (vieten & lukoff, 2022), may not profess religious beliefs nor feel inclined to discuss or encourage r/s strategies (magyar-russell, 2020), or may feel unprepared or ill-equipped to incorporate clients’ r/s cbs into the counseling process (bryantdavis & wong, 2013). in particular, women may report significant benefits when relying on their r/s beliefs and coping strategies (pew research center, 2022; tedeschi & calhoun, 1995). as such, examining how women access and utilize these beliefs and strategies during difficult times will increase our understanding of adaptive coping and posttraumatic growth. following traumatic events, data gleaned from quantitative measures have historically demonstrated a positive relationship between r/s beliefs and practices and positive posttraumatic growth (davis et al., 2016; prati & pietrantoni, 2009). prati and pietrantoni (2009) compiled data from 103 quantitative studies that investigated the effects of three systems of variables as related to positive coping: optimism, social support, and various types of coping strategies. age and gender were significant demographic predictors of utilizing religious coping. older individuals and women were more likely to rely on religious coping associated with positive  
  this document is copyrighted by the american psychological association or one of its allied publishers. this article is intended solely for the personal use of the individual user and is not to be disseminated broadly.  spiritual stories  posttraumatic growth. overall, the largest effect sizes of coping strategies related to positive posttraumatic growth were positive appraisal coping and religious coping. though informative, quantitative studies lack important descriptions of the actual process of relying on one’s r/s cbs to strengthen resilience (winkeljohn black et al., 2021). tennen et al. (2000) recommend studying coping mechanisms from a within-person, process-oriented approach. data gathered from in-depth interviews with women who espouse an r/s cbs will provide a rich and expanded perspective of their adaptive r/s coping. additionally, women’s spiritual experiences during severe life events will offer insights into how they utilize their r/s cbs to attain and maintain well-being.  method this research was approved by the sponsoring university’s institutional review board. all participants signed informed consent. this qualitative study relied on an interpretative phenomenological analysis of participants’ stories (ipa; smith, 2007). with this approach, researchers gained insights into how women relied on their r/s cbs to make sense of and effectively cope with trauma. each person’s trauma was a major life event of personal significance. the lead researcher, a female licensed psychologist experienced in trauma response, conducted one-on-one interviews (90–120 min) with each participant. for their convenience, participants were given options of quiet/private locations for interviews (e.g., church, home, work, library). most participants (85%) preferred to interview in their homes. the following prompt initiated each interview: every life is vastly complex and there are always important differences between one person and another. i do not think that i can know what your experiences are before we start. you are the expert about your life. i am here to learn from you and to arrive at some general understanding of your experiences. i want you to tell me anything that you think is important in your experiences, especially anything that you think will help me understand your life experiences better. now, as i’ve mentioned, i know you’ve been experiencing great adversity. tell me about your experiences.  participants to solicit participation, invitation letters were shared with faith leaders from churches, mosques, and temples who then referred potential participants from their congregations. by word of mouth, participants and professional colleagues also referred participants. to protect confidentiality, names were replaced with pseudonyms. participants were a self-selected convenience sample who (a) identified as female and were older than 18; (b) currently or recently experienced severe adversity/trauma; (c) self-reported and demonstrated effective coping; and (d) self-identified as religious and espoused theistic beliefs from christian, jewish, or muslim religious traditions. this study focused on a population of women who were demonstrating psychological resilience despite their experiences with extreme trauma. the lead researcher evaluated whether participants demonstrated effective coping according to (a) the referral source’s subjective opinion, (b) participant’s self-reported well-being, and (c) an objective measure of well-being based on the standardized  179  outcome questionnaire-45.2 (oq-45.2; lambert et al., 1996). the oq-45.2 questionnaire includes 45 items (0–4 likert-scale responses) and demonstrates strong psychometric properties (lambert et al., 1996). scores on the oq-45.2 range from 0 to 180. for this study, as recommended in the test manual, a total score of 64 was identified as the cutoff. refer to the test website for additional information [https://www.oqmeasures.com/oq-45-2/]. although we did not specifically exclude individuals with a mental health diagnosis, nor did we use the oq-45.2 to diagnose mental health conditions, we simply used the overall cutoff score to exclude those individuals who reported high levels of subjective discomfort, described insufficient interpersonal relations, and reported an inability to function in social roles and daily routines. of the 44 women who initially volunteered for participation, only two participants received a total oq-45.2 score that exceeded the cutoff. of these two women, one was excluded from the study. although the other woman’s score exceeded the cutoff by one point, because the higher score was related to her medical condition, she was included in the study. prior to the interview, one participant rescinded her consent to participate. three others failed to complete questionnaires and therefore were not included. ultimately, this study included 39 women. the participants identified as christian (n 28), jewish (n 5), and muslim (n 6). participants ages ranged from 20 to 71 years. participants identified as asian, black, hispanic, native american, pacific islander, and caucasian. thirteen of the caucasian women were of middle eastern descent and were born and raised in the middle east. in terms of schooling, participants ranged from high school graduates to advanced college degrees. one participant did not report her education. see table 1, for a summary of demographic information.  training and data analysis to enhance the trustworthiness and credibility of thematic analysis, procedures recommended by lincoln and guba were utilized (1985). these procedures involved training six reviewers in ipa thematic data analysis (smith, 2007). each reviewer read an article describing the research model, participated in qualitative data analysis training, and practiced in group data analyses supervised by the trainer. reviewers’ biases and assumptions were discussed during training and throughout the data analysis. initially, six reviewers met to develop a uniform system for analyzing transcripts and establishing reliability in identifying themes. the research team members also identified associated quotes to support or refute established themes. after analyzing six transcripts, reviewers established uniformity in analyzing the themes. at this point, the primary researcher determined that sufficient integrity/reliability of thematic analysis was established. data analysis involved four steps: (a) prior to team meetings, each reviewer read assigned transcripts and independently identified major themes and associated quotes. (b) reviewers met in their team meeting to discuss transcripts and identify themes. in collaboration, reviewers compared and grouped statements into clusters of meaning (themes), noting unique ideas and contradictory statements. (c) the team compared/contrasted across stories to support or disprove identified themes and reach a consensus (all members  
  180  jerome et al.  table 1 study 1: demographic characteristics of participants (n 39)  this document is copyrighted by the american psychological association or one of its allied publishers. this article is intended solely for the personal use of the individual user and is not to be disseminated broadly.  demographic characteristics age: 20–29 30–39 40–49 50–59 60–69 70–71 marital status single married separated/divorced widowed education  high school high school diploma some college college graduate advanced degree did not respond race asian black caucasianc hispanic native american pacific islander other  christiana (n 28) mage 44  jewishb (n 5) mage 56  muslim (n 6) mage 32  3 7 7 9 2 0  0 1 0 2 1 1  4 1 1 0 0 0  1 19 6 2  1 3 0 1  1 5 0 0  0 1 10 10 6 1  0 — 1 1 4 —  0 — 1 3 1 —  1 1 23 1 1 1 —  0 0 5 — — — —  0 0 3 — — — 3  divine intervention; and (d) reframing experiences through the use of r/s-oriented thoughts and beliefs. a summary of religious and spiritual (r/s) themes expressed during participant interviews is included in table 2.  relationships  a  christian denominations represented in the sample included: baptist, catholic, christian not affiliated with a specific denomination, first baptist, four square, church of jesus christ of latter-day saints, methodist, nazarene, nondenominational christian, presbyterian, seventhday adventist. b jewish women represented conservative, orthodox, and reformed traditions. c thirty-one of the participants were caucasian, however, one was moroccan and 13 were of middle eastern descent, including indian, israeli kurdish, pakistani, palestinian, syrian, and turk.  were in agreement). (d) as needed, the teams collaborated to resolve questions and consider new emerging themes. an expert outside reviewer independently conducted a final check of data analyses. this involved reading transcripts; examining the process of inquiry; and reviewing, evaluating, and endorsing the interpretation and coherence of the thematic analyses and associated quotes. three auditors, doctoral-level psychologists (one christian, one jewish, and one muslim), further established trustworthiness by conducting a final check (lincoln & guba, 1985) that supported the list of themes; acknowledged the consistency of the selected quotes; and ensured against inconsistencies, biases, omissions, and other threats to trustworthiness (hill et al., 1997).  results each woman endorsed a strong personal, r/s cbs and described reliance on her beliefs to cope and adapt after traumatic life events. four major themes emerged from their stories: (a) identifying the importance of relationships with others who also shared a strong r/s cbs; (b) integrating psychological practices with r/s practices; (c) experiencing and acknowledging  participating women sought and developed relationships with others who shared a strong personal r/s cbs. relationships were enhanced by forgiveness, gratitude, and sacrifice. these relationships seemed to create an interpersonal context for coping. this general category reflected evidence of complex psychological interconnectedness that positively influenced the coping process. interpersonal relationships seemed to play five major roles. relationships provided (a) an important and alternative focus that countered the constricting stronghold of adversity; (b) an opportunity to share and thus find meaning in their life experience; (c) an opportunity to reach out and form unique connections with others; (d) important role models to provide inspiration; and (e) a similitude of a personal relationship with god. reaching out to family, friends, and community members was more than support seeking. participants reported sharing close emotional intimacy with a few trusted individuals who had a personal r/s cbs, even when not sharing similar denominational backgrounds. the initial focus on adversity shifted to these important relationships that became a central focus in their lives. molly’s story exemplified how important relationships became a primary focus. molly saw her terminal brain cancer as only one aspect of life. “in my case, it [the cancer] was never all-consuming. my husband, my children, and church were all more important. i just kept living despite the limitations of my cancer.” molly’s script aligned with a common mantra of survivors: don’t allow your adversity to be the center of your life; if you do, it will consume you. molly coped by keeping her important relationships, her life work, and her faith at the center of her life. as more time and thoughts were dedicated to interpersonal relationships, less time was spent perseverating on adversity. sonia described the spiritual alliance shared with her husband and how this alliance distracted her focus away from the adversity. in their first year of marriage, her husband was diagnosed with huntington’s disease. he lost his ability to speak and had limited motor control. he became dependent on his wife for all self-care. sonia described her experience: “it wasn’t the disease that frustrated me, but the way we were responding to it. i realized this adversity was going to perfect us. we depended on our spiritual understanding, our heavenly father, and each other.” the early onset of this adversity barely allowed time and resources for them to develop an identity as a couple. however, sonia described the spiritual development of their relationship: “at times like this you dig deep down inside yourself to truly define the relationship. i’d describe our communication as ‘spirit-tospirit.’ the spirit is a huge conduit.” in their relationships, participants created opportunities to share and find meaning. this offered a broader perspective that facilitated adaptive coping. for example, anna’s daughter was murdered and her granddaughter was abducted and murdered. anna described the value of sharing her experience with others who also relied on r/s beliefs.  
  181  spiritual stories  table 2 summary of religious and spiritual (r/s) themes expressed during participant interviews  this document is copyrighted by the american psychological association or one of its allied publishers. this article is intended solely for the personal use of the individual user and is not to be disseminated broadly.  themes 1. interpersonal relationships family/friends/community upbringing personal intimate relationship w/god enhancing relationships through: sacrifice forgiveness gratitude 2. integrating r/s practices with psychological strategies public worship private devotion psychological coping communion with nature performing charitable acts (includes sacrifice, forgiveness, gratitude) 3. experiencing and acknowledging divine intervention divine presence/intervention influence of divine examples signs and symbols 4. reframing experiences through r/s-oriented thoughts and beliefs divine locus of control personal spiritual beliefs perspective change/adjustment  christian (n 28)  jewish (n 5)  muslim (n 6)  all participants (n 39)  28 28 28 28  5 5 4 3  6 6 6 6  39 39 38 37  25 11 24 28  5 1 3 5  6 6 6 6  36 18 33 39  27 28 28 8 28  5 5 5 2 5  6 6 6 2 5  38 39 39 12 38  28  4  6  38  15 25 23 28  4 4 4 5  5 6 6 6  24 35 33 39  28 28 28 28  3 5 5 5  6 6 6 6  37 39 39 39  note. numbers represent how many participants in the sample reported a particular theme. we cannot do it on our own. ... [to] walk a path that is not only filled with grief, but absolute horror, you get through it by talking to others. ... losing a parent who is elderly is a different kind of grief than losing a child and your grandchild in such a horrendous act. ... you need to talk about the spiritual parts. ... this is where you go [the support group] to cry. that’s where you go to learn to say the word murder, because that is difficult to say. ... some of us broke off into another smaller group where we [could] talk about the spiritual aspects of “how are we healing?” ... we all know that without talking about the spiritual side of life, it’s very difficult.  connecting with friends and congregation members for spiritual support was another way important relationships facilitated coping. ruby described the network of friends who provided spiritual support during her time of need. they were a young family of 2 years with a 1-year-old son. on a business trip, her husband had a seizure and collapsed. testing and scans indicated a brain tumor. unable to be with her husband, congregational members reached out providing spiritual support. ruby described her situation. i immediately called my parents, but no one was home. it was wednesday night and i realized they were at church, so i just called the church. the service had just let out ... my dad immediately told the preacher. ... they had a prayer circle and it started right then. over the next few days, our friends and congregation members began to call their friends and family. ... we were receiving letters from all over the united states that people were praying for us.  after contracting a rare and lethal form of meningitis, bobbie described the spiritual support she received from three continuous  care nurses who shared her faith. although she survived, complications of the illness resulted in the amputation of both legs and all her fingers. bobbie described her situation: i was admitted into the continuous care ward of the hospital. three of my nurses were adventists. this was a blessing to me. there is a bond and a connection when you are of similar faith. i think the lord wanted them there. one stayed with me through the 10-hour amputation surgery.  another theme emphasized the importance of relationships with individuals who served as inspirational role models. these role models were not necessarily present during the time of adversity. reflection on these relationships continued to promote positive coping. examples of participants’ role models included parents, religious teachers, and spiritual leaders from their youth or cultural ancestry. participants fondly referred to their role models and drew upon these memories with great conviction. one woman offered: my father was a deeply spiritual man. i can remember as a child, getting up early and finding him in the den reading his bible before he began the day. ... i think having that kind of model helped a lot.  another example, ezra described the influence of a religious teacher from her youth: i feel this woman was paramount to my coming to know god in a personal way. i wonder what it would be like [going through adversity] had i not had the opportunity to learn that important lesson from that woman.  
  182  jerome et al.  finally, many of the women described the significance of an intimate and personal relationship with god. participants stated, “i involve myself with god.” “allah is always there and i’m never alone.” “god is good. i’m just pleased to know him and that he’s with me.” “i’m happy because i know that no matter what trial comes my way, he is going to take care of me.” rachel’s story aptly reflects this theme:  this document is copyrighted by the american psychological association or one of its allied publishers. this article is intended solely for the personal use of the individual user and is not to be disseminated broadly.  i don’t know how it happened, but from the time i was a teeny girl i always had a personal relationship to god. that god figure ... has never been clearly defined to me, but i always felt that relationship even though i’ve gone in and out of being what i call a “jewish follower.”  her husband and one son were killed, several of her seven surviving children were critically injured, and she became paralyzed from her chest down. she describes her experience: am i really capable of forgiving? i think so. the first thing i had to do was to forgive myself. depression, anger, and bitterness could only taint the soul and make life more difficult than it already was. ... i have forgiven my husband for leaving me. i don’t hold the lord responsible. i don’t hold myself accountable. if i did, i would draw others into my suffering and despair. i will not let my children suffer more because i am not willing to forgive myself and get on with life.  in their relationship with the divine, women referred to the importance of companionship and partnership. molly reported an experience she had before being diagnosed with terminal brain cancer:  chelsea used forgiveness to reclaim her life and was able to cope more effectively with her ongoing physical challenges. for chelsea, forgiveness was the spiritual tool that allowed her life to be beautiful, even though not as perfect as she originally planned. after sustaining prolonged abuse, ayesha described how forgiveness worked to mitigate suicidal ideation and gesturing:  it was as if he were saying, “molly, you’re about to go through something that you don’t want to go through ... ” i just knew christ was going to walk through this with me. at this point i had no earthly idea what this was about because this was before the diagnosis.  ... the most important thing i’ve learned is forgiveness. forgiving someone isn’t saying “it’s okay that you did that to me.” it’s letting go of being the victim. forgiveness allowed me to take power and control of my own life ...  trusting in god, molly approached death with a feeling of support that fostered courage and a positive attitude. her perception that god was aware of and caring for her gave her confidence throughout her struggle with cancer. her faith strengthened her motivation to thrive. participants reported that these important r/s relationships were magnified through sacrifice, forgiveness, and gratitude. relationships were strengthened as participants thought of others, rather than focusing on their own adversity. acts of personal sacrifice strengthened relationships and fortified coping. participants described this sacrifice as “serving and reaching out to others,” and “focusing on others.” jordyn described her desire to reach out to others in compassion: “i think of how vulnerable every person is. because i was hurting, i could sense other people’s needs. it just gave me a desire, even though i was struggling, to help fill the needs that i saw.” many women expressed a desire to be a role model to their children. they were willing to inhibit expressions of disappointment, anger, and sadness to provide an example to their children. sacrifice and service seemed to help the women control emotions, resulting in a change in attitude which ultimately facilitated coping. denise described the process this way: “i am always aware of what i say and do because my kids are watching me go through this. i am a role model showing them how to deal with adversity.” amira, a jewish follower, said, “i have a family and i can’t say, “i’m not going to deal with this.” i have to show them that they can deal with it when they have to.” another aspect of strengthening relations is related to the practice of forgiveness. several participants experienced personal violation and significant loss. across time, the forgiveness of self and others played a healing role. forgiveness was associated with letting go of personal burdens, strong feelings of responsibility, and self-blame. “letting go” allowed room for gratitude and other positive feelings. forgiveness served to mediate strong emotions for the women who experienced abuse, murder of a loved one, and loss due to a car accident. chelsea’s family was involved in a catastrophic accident one night when she fell asleep while driving. as a result of the accident,  another theme expressed in the women’s stories was gratitude to god and others. gratitude was especially prominent in the stories shared by both muslim and christian women. for example, after an automobile accident, hanna found that gratitude allowed her to accept the death of her youngest son and the permanent disability of her oldest son. no matter how hard i tried to be angry, i was given this peace of being thankful. i wasn’t thanking god for the accident, but i was thanking him because i was given to be this boy’s mother. ... this feeling of gratitude was just a gift that was given to me ... that has helped me a lot.  peace replaced hanna’s anger and facilitated her ability to cope.  integrating r/s practices with psychological strategies through public and private r/s practices, each woman reported integrating traditional psychological strategies with r/s coping. public r/s practices included participating in sacred ordinances, attending worship services, and participating in rituals such as alms or sacraments. regardless of r/s orientation, all participants described r/s activities that were personal and practiced individually in private settings. private r/s practices included praying, meditating, reading holy books, engaging in personal study, and reciting sacred text and set prayers. chava described how her jewish worship practices assisted her: “... my only true involvement in the temple now is that i go to a tuesday study class with this 90-year-old rabbi. ... this, above anything i do during the week, brings me peace.” sieni talked about the power of engaging in private r/s practices. she came to accept the anticipated death of her husband. married 3 years, with a 2-year-old and infant twins, her husband was diagnosed with terminal cancer. her story exemplifies reliance on prayer. the most powerful thing a woman can do is pray. we get so busy ... taking care of our husbands, taking care of our families, work, and church responsibilities. we are always so busy that we forget the most  
  spiritual stories  this document is copyrighted by the american psychological association or one of its allied publishers. this article is intended solely for the personal use of the individual user and is not to be disseminated broadly.  basic of all these things is to get on your knees and pray. i feel that if you have an intimate relationship with heavenly father ... that will get you through the deepest, darkest moments. i think we develop that relationship through prayer. ... one day my husband told me he wanted to see snow before he died. we’re from tonga, and he had never seen snow. it was september and i didn’t think that would be possible. we had his bed by the glass doors in the living room. he was very weak. ... one afternoon, that september, it began to snow for about an hour. we rolled his bed out, and he was able to touch the snow. it was a selfish thing to ask, but this was just one of those times where you know for sure that he hears you and he listens to your prayers.  psychological and spiritual coping practices were utilized in tandem. many of the women adopted a cognitive set that included humor, positive thinking, and journal writing in conjunction with their r/s coping practices. many sought refuge in nature and music. jordyn explained that listening to religious music helped her cope: ... spiritual music has been soothing. i’ve used it as a coping mechanism. ... it’s been an expression of praise, even when i’m feeling pain or that awful kind of grieving. because i feel so low, i’m also feeling especially sensitive, and somehow the praise and closeness i feel to god through music has helped me. it’s just made it bearable in a very tender and loving way in spite of the hurt.  experiencing and acknowledging divine intervention all participants reported experiencing forms of divine intervention, such as r/s premonitions, symbols/signs, and personal communication with deity. prior to and throughout their adversity, participants described “spiritual occurrences” that they attributed to divine intervention and changed how they perceived and responded to challenges. prior to her diagnosis, molly described a spiritual thought that provided direction, peace, and comfort. she explained, “i kept coming back to the fact that i was forewarned. knowing that i was forewarned gives me confidence to persevere and cope.” this peace helped her accept her terminal illness. another example, hanna reported experiencing thoughts and dreams that provided spiritual warnings prior to the car accident that killed her youngest son and permanently injured her oldest son. she stated: “somehow my spirit knew. ... i think all the thoughts and feelings and dreams i had were god’s way of preparing me and letting me know it’s going to be okay if my life takes this path.” several women reported “miraculous” experiences. they considered these experiences as divine communication, expressed through visions, spiritual dreams, or spiritual manifestations. women drew strength from these experiences to persist despite their adversity. anna’s spiritual dream helped her cope with the murder of her daughter and granddaughter: i had a dream on the night that she died. of course, i did not know that she had died at that time. in my dream, my daughter came into my room and laid along-side me. i felt her, i held her. i pulled the covers up and held her. she was dressed in white and she was ice cold. and everything around her was white.  approximately a month later the police were able to piece together the events leading up to the murders. as she referred to her journal account detailing her dream, she realized her dream occurred on the actual night of her daughter’s death. others felt divine intervention as they studied holy writ. divine examples in scripture influenced these women’s thoughts, feelings, and behaviors. examples included scriptural figures, prophets, holy  183  men and women, and scriptural messages. ellie reported, “you grow up with torah values and with the values from the bible. i found that the more i got into it, the more inner peace i experienced. i was able to draw on those stories.” other women interpreted meaning drawn from very personal and private r/s symbols and signs. participants acknowledged that others might not understand the meaning of these experiences. jill, whose family struggled in the aftermath of incest, noted: ... i was so weary and tired. i thought i was going to break down and i just couldn’t keep going. i prayed and prayed that he would please give me a sign that everything was going to be okay. he did. there were some big bushes outside my window, and two doves would come and sing at night. birds don’t sing at night. birds sleep at night. but these birds sang all night long. ... the birds stayed for 2–3 months. ... i felt like that was god’s sign that he was going to take care of us.  rachel described a sign that helped her cope with her teenage son’s sudden and unanticipated death. following her son’s seizure, and her application of cardiopulmonary resuscitation, she helplessly stood by after the medics took over and her son died. you know the [graveyard] plot number has to be a number eight, because when he played football, he was number eight. ... and the only plot left was number eight. the only one at that time. and i said, “ok, god.” he’s hiking [lifting] my spirit.  visual r/s symbols stimulated thoughts and feelings that directed participants to a place of peace. gracie remembered holding her small daughter, born with brain cancer. she was feeling exhausted as she walked the halls of the hospital trying to calm her crying baby. then she came to a statue of the virgin mary holding baby jesus. she reported, that image of mary holding the christ child stayed with me. every time i felt like i could not go on ... that image would come to my mind and bring me peace.  reframing experiences through the use of r/s-oriented thoughts and beliefs participants reported adopting empowering thoughts and beliefs (e.g., trust in divine locus of control, a spiritual perspective, and development of a personal r/s belief system) that changed perspectives and promoted adaptive coping. women’s belief systems centered on a divine locus of control, a belief that god is in charge. for example, women reported, “he has a plan for me;” or “i trust and will submit to his will.” participants reported trusting that a loving and all-wise god/allah had a personal plan for them. because they acknowledged that adversity was accounted for in god’s/allah’s plan, this reduced the anxiety associated with the “out-of-control” situation thrust upon them. it was comforting to know that god was in control. belief in a divine locus of control encouraged the women to reframe their adversity, provided an alternate perspective, and offered a new meaning for life’s events. belief in a divine locus of control did not result in passivity. each woman expressed her belief of partnership with the divine, that the supreme being (savior, god, or allah) expected her to do all she could to cope and manage during adversity. sarik stated, “that it is very important in islam, to take action, to do what is right.” as she coped with her husband’s terminal illness, sonia described her spiritual partnership with the savior: “... i had this feeling  
  this document is copyrighted by the american psychological association or one of its allied publishers. this article is intended solely for the personal use of the individual user and is not to be disseminated broadly.  184  jerome et al.  that ‘this is not about me.’ it is about what we are doing with the savior. it’s about the savior’s healing and that he is not a band-aid, he is the physician.” sonia explained that the reason she nurtured her marriage in the midst of adversity was because “... it is an eternal marriage, and because the lord has sanctioned it.” spiritual thoughts and beliefs contributed to a broadened perspective that promoted coping. in an eternal perspective, each woman considered her earthly adversity as temporary and transitory. husna described her experience of coping with abuse, “the qur’an tells us that god will not give you what you cannot bear. it may sound a little odd, but just knowing that allowed me to bear it.” for these women, loved ones died, children suffered due to abuse, physical ailments resulted in amputations, and expectations and dreams were unrealized. however, when coping with extreme adversity, participants, such as celeste, reported positive change and adjustment. celeste described the process of changing her perspective in this way: “spirituality is embracing the adversity so you can cope through those hard moments—that’s really where you’re coping. the spiritual part is what keeps you loving it [your life] instead of just living it.” after going through adversity, sarik reflected on her perspective. “you do benefit from adversity, you just take awhile to see it. ... you can receive tragedy as an opportunity.” personal r/s beliefs empowered the coping process. even though several participants did not attend or affiliate with an organized congregation, all espoused intrinsic, personalized core beliefs that influenced their thoughts, feelings, and actions. each participant identified her personal spiritual capacity as a sustaining force. this notion is exemplified in bobbie’s story. she described her personal beliefs as distinct from her “adventist heritage.” she explained, “i don’t think i am an extremely religious person outwardly, but i do consider myself a spiritual person. although i recognize how my adventist heritage influences me, it is my own personal spiritual belief system that sustains me.”  discussion the majority of prior research has examined the influence of multiple variables on r/s coping behavior (prati & pietrantoni, 2009). few studies have conducted in-depth interviews following a variety of traumatic life events (prati & pietrantoni, 2009), and even fewer studies have investigated perceptions of women from various theistic traditions (kennedy et al., 2015). abu-raiya and pargament (2015) note, “there is much to learn about the differences and similarities among and within religious traditions regarding the form, function, and effectiveness of religious coping” (p. 31). this study explored how women within and across various religious traditions relied on their r/s cbs to cope with a variety of severe life events.  major findings and implications for practice as we consider this study’s findings, the most striking is that while participants represented a diverse group in terms of age, race/ ethnicity, religious tradition, education, and type of trauma, they shared common r/s experiences and they utilized similar r/s coping strategies. however, this research does not suggest a single best way to traverse trauma. each participant’s coping was unique  to their personal r/s cbs. though public r/s practices were influenced by familial expressions of faith and religious denominational traditions, each woman’s personal r/s cbs provided an anchor of hope and strength. in order to best support women who rely on r/s coping strategies, psychologists need to understand the individual’s r/s cbs and their expression of those core beliefs. this understanding will assist psychologists in better supporting women who face adversity. in summarizing this research, four major themes of reliance on r/s coping emerged from participants’ stories. in the following paragraphs, we identify implications for practice.  encouraging therapeutic relationships a predominant theme included engaging in relationships with others who shared a strong personal r/s cbs. sharing spiritual experiences provided a venue to not only tell their story but to elicit support and provide support to others. this sharing ultimately resulted in enhanced r/s coping. broadened perspectives facilitated the individual’s adaptive coping. stories shared by the women in this study revealed a depth and breadth of cumulative life experiences bolstered by spiritually oriented coping. analyses revealed insight into the interpersonal context within which spiritually oriented coping occurred. findings also highlight the importance of engaging in spiritually grounded relationships enhanced through participation in acts of sacrifice, forgiveness, and gratitude. additionally, participants recounted the importance of developing a personal intimate relationship with a divine being, their god. when facing extreme challenges, each woman expressed a preference for r/s coping and benefitted from sharing these experiences with others who also relied on similar coping strategies. psychologists might help individuals clarify their r/s cbs, by asking, “do you have a specific belief system that guides your perspective?” “i want to hear your thoughts and practices that have helped you.” it is important for psychologists to listen carefully to identify r/s coping and practices. after clarifying the r/s cbs, it is important to emphasize: “i value your beliefs.” further implications for counseling might include encouraging and facilitating interpersonal connections with others who accept and share r/s core beliefs. this reduces isolation and expands shared life experiences. psychologists might pose a challenge, “how could you reach out to others who also have a strong r/s belief system?”  encouraging integration of r/s practices with psychological strategies this study suggests the advantages of integrating r/s practices with psychological strategies. spiritually significant practices regulated mood and stimulated thoughts that led to a changed perspective about the role of adversity. these practices promoted a contemplative state that brought harmony with god. many reported that “just being still” allowed them to recognize divine intervention. participants’ spiritual mindfulness guided their thoughts, feelings, and actions. when feeling anxious and overwhelmed, r/s mindfulness brought peace and healing. this allowed participants to focus on the present moment, prioritizing attention to small and simple joys, the “tender mercies” of deity.  
  this document is copyrighted by the american psychological association or one of its allied publishers. this article is intended solely for the personal use of the individual user and is not to be disseminated broadly.  spiritual stories  practitioners may validate clients who are mindful of spiritual metaphors and symbols in daily life. listen carefully to clients, accepting and acknowledging their perceptions of dreams and spiritual premonitions. rather than questioning their experiences, validate and encourage the client to find meaning in these experiences. for example, after a client talks about a specific religious verse, practitioners might prompt, “tell me about the importance of this scripture.” “how does this religious verse guide you in coping with your challenges?” “how does this scripture offer you hope/ peace?” some clients may benefit from a tangible list of r/s coping and insightful mantras derived from clients’ words during the session. others who are inspired by r/s art (such as the statue of the mother mary holding the christ child), could be asked, “tell me about your impressions.” “how does this art influence your feelings and thoughts?”  acknowledging and affirming experiences with divine intervention divine intervention was experienced in the form of signs/symbols, premonitions, and dreams. practitioners may ask questions to promote thoughtful consideration of god’s/allah’s intervention. after her son was killed in an automobile accident, hanna described a dream in which a heavenly being brought baby eric to her. after holding and playing with the baby, she realized she had to give the baby back to the heavenly being. at the conclusion of the dream, she reported feeling perfect peace. she wrote in her personal journal, somehow i knew it was time for me to turn him back to her [the heavenly being]. and i willingly did that ... i had the hardest time separating from her. i could feel her holding my hand. ... i felt tremendous love from this spirit woman. in fact, when i woke up, i had my hand out. ... and if i look back now, that was really my spiritual turning point. ... i knew eric was fine, because this beautiful woman held him, and i trust her immensely ...  in such a case, a practitioner may ask one or more of the following questions to elucidate personal meaning: “how does your dream resonate with your r/s beliefs?” “describe your feelings as you consider that god is aware of you. he is with you on this journey.” “i am wondering, how does this give perspective on what you are going through?” experiencing divine events confirmed the presence, involvement, and omnipotence of god. women reported feeling strength from these spiritual experiences. one muslim woman, asyre, said, “knowing that this adversity was part of god’s plan, made it bearable.” hanna, molly, and anna reported spiritual experiences that foreshadowed events and provided comfort after experiencing the adversity. these experiences promoted acceptance of their challenges and strengthened adaptive coping. these events were interpreted as evidence of god’s involvement in their lives, which allowed them to reframe adversity as an opportunity for growth under god’s watchful eye. allow the client to take the lead as the expert of their core beliefs. help the client utilize their core r/s belief system to give context and meaning to divine intervention. this empowers the individual and fosters posttraumatic growth (sen et al., 2022; shaw et al., 2005).  185  helping clients reframe experiences the belief in a divine locus of control empowered participants to reframe adversity. this perspective gave new meaning to life’s challenges and facilitated adaptive coping. as sonia described the challenges of coping with her husband’s terminal illness, she also talked about her r/s beliefs and how those beliefs helped her reframe her thought process. she further explained that she nurtured her marriage in the midst of adversity because “it is an eternal marriage, and because the lord has sanctioned it.” she depended on her belief in a divine locus of control as an anchor during this traumatic experience. if presented with a similar situation, practitioners could expand on the client’s r/s perspective by asking one or more of the following prompts and utilizing the client’s language and beliefs: “how has this knowledge empowered you to cope with your adversity?” “how does your belief in an ‘eternal marriage’ give you hope and help you persevere?” “you said that ‘god sanctioned your marriage,’ how does putting your circumstance in god’s hands give you strength and comfort?” these questions are intended to assist the client in applying their core belief that stems from a divine locus of control. this divine locus of control encourages the client to reframe their adversity. when clients draw upon r/s thoughts and beliefs, their new perspective promotes posttraumatic growth (prati & pietrantoni, 2009).  limitations of study and recommendations for future research our sample included a convenience sample of women who were adaptively coping with extreme trauma. these women espoused a theistic belief system. because of our study’s focus on adaptive coping, participants also met several other criteria to ensure psychological health. we acknowledge that the strategies of psychologically healthy women may not be effective for all women. therefore, this sample is not representative of all women who have experienced trauma or those who do not hold a theistic belief system. however, mental health professionals need to be aware of women’s r/s beliefs as a potential basis for adaptive coping strategies. furthermore, this research did not consider women who rely on a theistic belief system, yet continue to experience psychological distress, impaired interpersonal relationships, and diminished capacity in daily functioning. we also acknowledge the potential negative effects of maladaptive r/s beliefs, or trauma stemming from r/s experiences (ano & vasconcelles, 2005; kennedy et al., 2015). these limitations suggest a need for further investigation in future research. while religion may contribute to maladaptive coping and exacerbate negative outcomes, the evidence is mixed (kucharska, 2020). additionally, the positive role of r/s coping reported in counseling sessions is often overlooked by mental health professionals and not researched adequately from the viewpoint of practitioners (gladding & crockett, 2019). additionally, future research needs to consider a wider range of trauma and possibly investigate comparisons across groups. future research employing qualitative interviews must more deeply investigate r/s coping strategies and how these strategies may or may not impact mental health across time. future studies may also investigate how other gender-specific populations  
  186  jerome et al.  employ or fail to employ r/s strategies when coping with severe adversity.  this document is copyrighted by the american psychological association or one of its allied publishers. this article is intended solely for the personal use of the individual user and is not to be disseminated broadly.  conclusion participants in this study represented a wide range of ages, r/s beliefs, religious and cultural backgrounds, and traumatic experiences. this sample’s demographics make this study unique in comparison to the majority of existing qualitative research studies that investigate posttraumatic coping (davis et al., 2016). this research supports the practice of incorporating r/s strategies in therapy for women who espouse an r/s cbs. practitioners need to carefully listen to clients’ r/s stories shared in therapy, validate those experiences, and understand how the experiences are related to the client’s r/s cbs. once identified and understood, r/s strategies can be incorporated into effective and personalized interventions. similar to aten et al. (2019), we found that the perceived positive benefits of r/s coping are associated with active coping strategies such as engaging in one’s faith and seeking connection with and support from others who share similar core r/s beliefs. after reflecting on these brave women’s stories, we surmise that r/s coping is an active, rather than passive process. this process involves reframing one’s situation to align with r/s beliefs, adapting oneself to accept the human condition while acknowledging divine communication and support, and increasing one’s hope for a growth-oriented outcome.  references abu-raiya, h., & pargament, k. i. (2015). religious coping among diverse religions: commonalities and divergences. psychology of religion and spirituality, 7(1), 24–33. https://doi.org/10.1037/a0037652 ano, g. g., & vasconcelles, e. b. 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(2018). spiritual and religious interventions in “third wave” cognitive behavioral therapies. in c. s. gill & r. r. freund (eds.), spirituality and religion in counseling: competency-based strategies for ethical practice (pp. 132–146). routledge. https://doi.org/10.4324/9781315211046-9 bjorck, j. p., & cohen, l. h. (1993). coping with threats, losses, and challenges. journal of social and clinical psychology, 12(1), 56–72. https://doi.org/10.1521/jscp.1993.12.1.56 boss, p., bryant, c. m., & mancini, j. a. (2017). family stress management: a contextual approach (3rd ed.). sage publications. https://doi.org/10 .4135/9781506352206 brenan, m. (2018, december 24). religion considered important to 72% of americans. gallup. https://news.gallup.com/poll/245651/religion-conside red-important-americans.aspx bryant-davis, t., & wong, e. c. 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title_index: religious trauma syndrome articles – journey free
full_text_index:
       home  about us  religious trauma syndrome subscribe to newsletter  services resources faqs  religious trauma syndrome articles   winell, m. (2011) religious trauma syndrome (series of 3 articles), cognitive behavioural therapy today, vol. 39, issue 2, may 2011, vol. 39, issue 3, september 2011, vol. 39, issue 4, november 2011. british association of behavioural and cognitive therapies, london. reprinted at journey free website: https://journeyfree.org/rts/rts-itstime-to-recognize-it/   winell, m. (2011) religious trauma syndrome (series of 3 articles), cognitive behavioural therapy today, vol. 39, issue 2, may 2011, vol. 39, issue 3, september 2011, vol. 39, issue 4, november 2011. british association of behavioural and cognitive therapies, london. reprinted at journey free website: https://journeyfree.org/rts/rts-itstime-to-recognize-it/   winell, m. (2011) religious trauma syndrome (series of 3 articles), cognitive behavioural therapy today, vol. 39, issue 2, may 2011, vol. 39, issue 3, september 2011, vol. 39, issue 4, november 2011. british association of behavioural and cognitive therapies, london. reprinted at journey free website: https://journeyfree.org/rts/rts-itstime-to-recognize-it/  book a consultation  donate  newsletter  
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secondary_title_index: spirituality in clinical practice
title_index: religious/spiritual abuse and trauma: a systematic review of the empirical literature.
abstract_index:
       religion and spirituality (r/s) play an important role in the lives of many. although r/s can be a resource when coping with stress, it can also be a source of stress or trauma. we sought to review the extant empirical research on r/s abuse and trauma. our systematic review identified 25 studies that met the inclusion criteria. the empirical findings of the studies are organized into eight sections: (a) definitions of r/s abuse and trauma, (b) prevalence of r/s abuse and trauma, (c) entering/exiting abusive religious communities, (d) the intersection of r/s abuse and trauma and domestic violence, (e) the role of the r/s community in the abuse, (f) negative outcomes associated with r/s abuse and trauma, (g) identity changes associated with r/s abuse and trauma, and (h) prevention and clinical treatment of r/s abuse and trauma. we conclude by discussing limitations of the review, areas for future research, and implications for clinical practice.     

authors_index:
       ellis, heidi m.     hook, joshua n.     zuniga, sabrina     hodge, adam s.     ford, kristy m.     davis, don e.     van tongeren, daryl r.     

full_text_index:
       spirituality in clinical practice  2022 american psychological association issn: 2326-4500  2022, vol. 9, no. 4, 213–231 https://doi.org/10.1037/scp0000301  religious/spiritual abuse and trauma: a systematic review of the empirical literature  this document is copyrighted by the american psychological association or one of its allied publishers. this article is intended solely for the personal use of the individual user and is not to be disseminated broadly.  heidi m. ellis1, joshua n. hook1, sabrina zuniga1, adam s. hodge1, kristy m. ford2, don e. davis3, and daryl r. van tongeren4 1  department of psychology, university of north texas department of counselor education and family studies, liberty university 3 department of counseling and psychological services, georgia state university 4 department of psychology, hope college 2  religion and spirituality (r/s) play an important role in the lives of many. although r/s can be a resource when coping with stress, it can also be a source of stress or trauma. we sought to review the extant empirical research on r/s abuse and trauma. our systematic review identified 25 studies that met the inclusion criteria. the empirical findings of the studies are organized into eight sections: (a) definitions of r/s abuse and trauma, (b) prevalence of r/s abuse and trauma, (c) entering/exiting abusive religious communities, (d) the intersection of r/s abuse and trauma and domestic violence, (e) the role of the r/s community in the abuse, (f) negative outcomes associated with r/s abuse and trauma, (g) identity changes associated with r/s abuse and trauma, and (h) prevention and clinical treatment of r/s abuse and trauma. we conclude by discussing limitations of the review, areas for future research, and implications for clinical practice. keywords: religion, spirituality, trauma, religious abuse, spiritual abuse  religion provides a strong social identity and a coherent meaning system through which people make sense of the world. a majority of the world’s population report being religious and/or spiritual (r/s). across the world, eight out of 10 individuals endorse an r/s identity (pew research center, 2012). specifically, in america, 48% of the population identify as “religious and spiritual,” with 27% identifying as “spiritual but not religious” (pew research center, 2017). because most individuals endorse an r/s identity, understanding how various r/s identities impact people in both positive and negative ways is imperative for providing holistic and culturally competent care. although there is still debate on how to define “religion” and “spirituality” (oman, 2014), this article was published online first august 18, 2022. heidi m. ellis https://orcid.org/0000-0002-8335-1038 correspondence concerning this article should be addressed to heidi m. ellis, department of psychology, university of north texas, 1155 union circle no. 311280, denton, tx 76203, united states. email: heidiellis@my.unt.edu 213  zinnbauer and pargament (2005) defined spirituality as the “search for the sacred,” (p. 35) and religiosity as the search for the sacred within communities and institutions with established ways of engaging the divine. researchers have also begun to explore “relational spirituality,” defined as the relational aspects of a person’s relationship with their god or higher power, rather than focusing on traditional behaviors associated with religiosity (e.g., church attendance, financial giving; tomlinson et al., 2016, p. 55). over the past 30 years, considerable research has accumulated on r/s and health and mental health. initial work in this field focused especially on r/s as a source of coping and resilience (bonelli & koenig, 2013). more recently, researchers have also explored ways that r/s may cause or amplify stress (stone, 2013). r/s abuse and trauma a particularly damaging form of an r/s stressor involves r/s abuse or r/s trauma (johnson & vanvonderen, 1991). definitions of r/s abuse  
  this document is copyrighted by the american psychological association or one of its allied publishers. this article is intended solely for the personal use of the individual user and is not to be disseminated broadly.  214  ellis et al.  vary (a review of the variety of definitions follows in the results section), but johnson and vanvonderen (1991) define r/s abuse as “the mistreatment of a person who is in need of help, support, or greater spiritual empowerment, with the result of weakening, undermining, or decreasing that person’s spiritual empowerment” (p. 23). they elaborate that this kind of abuse can be through the abuse of one’s spiritual position or in requiring a certain “spiritual performance” (p. 23). within an abusive r/s system, (a) leaders typically focus on making their power and position known, (b) there is a preoccupation with member performance and obedience/submission, (c) members must follow unspoken rules, (d) there is either extreme religious objectivism or extreme subjectivism, (e) the members must be loyal to the church over god, and (f) there is a sense of paranoia/secretiveness within the r/s community (johnson & vanvonderen, 1991). when defining r/s abuse and trauma, it is important to distinguish r/s abuse and trauma from other forms of abuse such as sexual abuse and physical abuse. for example, most cases of sexual abuse perpetrated by religious authority meet the criteria of r/s abuse, but many cases of r/s abuse or trauma do not involve sexual abuse. also, child abuse linked to faith or belief likely meets the criteria of r/s abuse and can result in various forms of physical, sexual, and psychological trauma (simon et al., 2012); however, r/s abuse can also be subtle and not readily recognized by mental health professionals if the abuse is not accompanied by other forms of abuse and trauma. the effects of r/s abuse and trauma can include (a) distorting one’s image of god or a higher power, (b) distorting one’s spiritual selfidentity, (c) barriers to accepting grace, (d) barriers to setting healthy boundaries, and (e) barriers to establishing trusting relationships in the future (johnson & vanvonderen, 1991). additionally, revictimization can often occur in the r/s community by misusing religious texts to keep people in abusive situations through teaching unhealthy submission, forgiveness, and forgetting of past wrongs (johnson & vanvonderen, 1991). the perpetrators of r/s abuse and trauma often have a sense of false authority, are image-focused, and misuse trust through lying, double-talk, and hypocrisy (johnson & vanvonderen, 1991). although many assume that only r/s leaders perpetrate r/s abuse and r/s adherents are victimized  by r/s abuse, it is important to understand that r/s abuse can also be perpetrated to leaders by other leaders and that one can be both abused and abuser (johnson & vanvonderen, 1991). additionally, r/s abuse and trauma may or may not be intentionally inflicted. there is much nuance and subtlety involved in r/s abuse and trauma, and although researchers have begun to explore this dark side of r/s through theoretical and theological writings (johnson & vanvonderen, 1991), there is a need for more empirical research to more deeply explore this phenomenon. purpose of review the purpose of this literature review is to provide an overview of the extant empirical research that has been conducted on r/s abuse or trauma. after reviewing the key findings, we provide guidance and insight for future research and practical implications for clinical work with individuals who have experienced r/s abuse or trauma. method inclusion and exclusion criteria in this literature review, we included all empirical studies that examined the constructs of r/s abuse or trauma. theoretical papers and case studies were not included. studies that did not qualitatively or quantitatively assess r/s abuse or trauma were excluded. to reduce the impact of publication bias, both published and unpublished studies (i.e., theses, dissertations) were included. finally, studies not written in english were excluded from the review. literature search we followed the preferred reporting items for systematic reviews and meta-analyses (prisma) statement guidelines to identify, screen, and select studies reviewed in this systematic review (page et al., 2021). the literature search included three main steps. first, we searched the following databases as of february 22, 2022: psycinfo, proquest dissertations and theses global, and google scholar. the searches included the key terms “religious abuse,” “religious trauma,” “spiritual abuse,” or “spiritual trauma.” second, once the studies were  
  this document is copyrighted by the american psychological association or one of its allied publishers. this article is intended solely for the personal use of the individual user and is not to be disseminated broadly.  religious and spiritual abuse  collected, the reference section for each study was reviewed to search for missing studies that should be included. third, the corresponding authors for the included studies were contacted and asked to send any related research that might have been missed or may be unpublished. to determine whether studies met inclusion criteria, the titles and abstracts of all identified studies were screened by the first author. additionally, the first author independently coded all data from the studies that met inclusion criteria and organized this information in table 1. the coding of studies included citation, email of corresponding author, publication status, research design, sample size, demographic information of the participants, measurement of r/s abuse or trauma, and main findings. results we identified 25 empirical studies that met the inclusion criteria. first, we reviewed the methods utilized by the included studies. second, we reviewed the empirical findings reported by the included studies. review of methodology research design of the 25 empirical studies reviewed, 12 were quantitative, 11 were qualitative, and two utilized a mixed-methods design. twenty-two of the quantitative studies utilized cross-sectional research designs, two utilized experimental designs, and one utilized a nonexperimental longitudinal design. each quantitative study utilized surveys measuring at least one aspect of r/s abuse and/or trauma. the qualitative studies utilized a variety of qualitative approaches, including phenomenological approaches (n 6), thematic analysis (n 1), grounded theory data analysis (n 1), consensual qualitative research (n 1), interpretive content analysis and thematic analysis (n 1), and heuristic and interpretive phenomenological analysis (n 1). both mixedmethod studies utilized a survey and qualitative analysis. participants most studies reported sample size (missing 1). of the 24 studies that reported sample size, the total number of participants included in this review was  215  5,300. fifteen studies were conducted in the united states, four in the united kingdom, two in canada, two in nigeria, one in australia, and one study was an online survey distributed through the united states, canada, europe, africa, south africa, south america, and australia. all studies provided some basic demographic information for the participants. twenty-three studies reported participants’ gender with over half of the participants identifying as female (74%; 25% male, 1% other, 1% transgender). twenty-two studies reported the age of the participants. fifteen studies reported the average age of the sample, whereas seven studies reported frequencies of age ranges. the overall mean age for the 16 studies that provided average age was 43.27 years. the six studies reporting age range frequencies reported that 10% of participants were between the ages of 18–29; 11% were between 30 and 39 years; 13% were between 40 and 49 years; 17% were between 50 and 59 years; and 18% were 60 years. sixteen studies reported race/ethnicity with most participants identifying as white/european american (73%; 9% black/african american, 6% hispanic/latinx, 6% other, 3% indigenous/native persons, 1% asian/pacific islander, 1% bi/multiracial). fifteen studies reported religious affiliation, with most participants identifying as christian (i.e., roman catholic and protestant, 83%; 9% other, 4% agnostic, 3% jewish, 3% not religious, 2% spiritual, 2% atheist, 1% buddhist, 1% muslim,  1% hindu). five studies reported participants’ sexual orientation with most participants identifying as heterosexual (70%), 17% lesbian/gay, 8% bisexual, 3% other, 1% questioning, 1% unknown, 1% queer. measures of r/s abuse or trauma the 14 quantitative/mixed-method studies utilized various means of assessing aspects of r/s trauma and/or abuse. seven studies utilized specific measures of r/s trauma and/or abuse, including the religious/spiritual abuse and neglect of children scale (rsanc; kvarfordt, 2010; kvarfordt & herba, 2018; kvarfordt & sheridan, 2007; n 3), the 21-item spiritual trauma measure (simmons, 2017; n 1), the spiritual abuse questionnaire (saq; lawson, 2016; n 1), and the saq (keller, 2016; n 1). the remaining seven quantitative studies utilized survey questions designed by the respective  
  quantitative, experimental  research design n 88 adults who were/had been married and participated on the whatsapp application; 50% f, 50% m; age n/a  sample  r/s trauma/abuse measure  summary of findings  (table continues)  researchers created a pre/post- social media interventions resulted in significant experiment survey questions increase in participants’ understanding and to assess participants’ awareness of domestic violence, including spiritual knowledge/experience of and emotional abuse, when compared to the r/s abuse and trauma. control group that did not receive intervention. adekoya et al. (2019) quantitative, n 88 adults who were/had been married researchers created a pre/post- social media interventions resulted in significant experimental and participated on the whatsapp experiment survey questions increase in participants’ understanding and application; 50% f, 50% m; age n/a to assess participants’ awareness of domestic violence, including spiritual knowledge/experiences of and emotional abuse, when compared to the r/s abuse and trauma. control group that did not receive intervention. bagwell-gray et al. quantitative, crossn 660 adult women endorsing experiences researchers created a single 135 of the 660 participants endorsed experiencing (2021) sectional of domestic violence; 100% f, 0% m; m item to assess religious religious abuse (20.5%). women who experienced age 37 abuse. religious abuse were 4.13 times more likely to experience reproductive coercion. bent-goodley and qualitative, thematic n 122 african american adults who qualitative interview (a) participants voiced concern about defining fowler (2006) analysis believe in a higher power; 62% f, 38% spiritual abuse, (b) spiritual abuse can be m; age range: 18 to 60 perpetuated in a variety of ways that impact meaning-making and coping in cases of domestic violence, (c) clergy often either ignored or perpetuated domestic violence, and (d) faith-based communities should address how abuse impacts the spirituality of survivors of domestic violence. researchers created a survey (a) in the pretest, students reported increased berry (2010) mixed-method, n 23 protestant leaders and seminary to assess participants’ knowledge and experiences of spiritual abuse than quantitative survey, students; 61% f, 29% m; m age 37 knowledge/experiences of protestant leaders (students: 59% knowledge; 30% spiritual abuse r/s abuse and trauma prior experience; leaders: 17% knowledge; 0% curriculum, and to exposure to the spiritual experience). (b) exposure to the spiritual abuse qualitative abuse curriculum curriculum resulted in self-reported increased interview understanding and awareness of spiritual abuse. bilsky (2013) qualitative, grounded n 17 adults endorsing qualitative interview (a) participants reported initially they perceived their theory data analysis experiences of religious/spiritual abuse; religious group where abuse of religious authority 53% f, 46.9% m, 0.1% other/unknown; (ara) was perpetrated positively, (b) these initial m age 45 positive perceptions resulted in increased engagement in the religious community, (c) eventually participants began having more negative than positive experiences, (d) the negative experiences resulted in eventual disengagement from the religious group, i leaving the religious group resulted in a variety of impacts and consequences over time  adebayo and evbuoma (2021)  study  table 1 religious/spiritual trauma and abuse: empirical studies included in literature review  this document is copyrighted by the american psychological association or one of its allied publishers. this article is intended solely for the personal use of the individual user and is not to be disseminated broadly.  216 ellis et al.  
  qualitative, phenomenological analysis  qualitative, phenomenological analysis  glasscock (2019)  gomez (2004)  n 7 christian adults endorsing qualitative interview experiences of interpersonal trauma either perpetuated by the church or invalidated/ unsupported by the church following their trauma; 86% f, 14% m; m age 40  n 7 adults who are ex-cult members; 71% qualitative interview f, 28% m; age range: 30 to 60  qualitative interview  qualitative, n 13 african american clergy members; interpretive content 69% f, 31% m; m age 55 analysis and thematic analysis  davis and johnson (2021)  r/s trauma/abuse measure qualitative interview  sample  qualitative, n 10 adults endorsing past religious consensual experiences related to their sexual qualitative research orientation or sexual identity; 30% f, 70% m; age range: 18—39  research design  crocker (2021)  study  table 1 (continued)  (table continues)  (a) participants endorsed negative impacts on their psychological health (e.g., anxiety, depression, trauma symptoms), physical health (e.g., sleep, risky behaviors), and spiritual well-being (e.g., more distant from god or increased closeness to him) due to their past religious abuse. (b) participants identified that they did experience some positive impacts including stronger faith, increased empathy and value of social support, and greater involvement in advocacy due to their religious abuse. (c) participants identified social support, educational resources, changes in theological beliefs, religious attitudes and beliefs, spiritual practices, and value-driven behaviors as factors that maintained their faith after the religious abuse. (a) participants considered r/s abuse to be a spiritual problem or sin, primarily characterized by misinterpretation of religious texts. (b) participants highlighted the importance for victims to understand religious texts, and (c) the need for clergy to be trained on r/s abuse. (d) participants reported increased difficulty addressing r/s abuse when perpetrated by a fellow clergy member. 16 themes were identified describing the lived experience of the participants beginning with their experiences prior to joining the cult (e.g., precult vulnerability), factors that maintained cult membership (e.g., fears and phobias instilled by group or leader), and their experience leaving the group (e.g., coping with painful aftermath). 13 themes were identified describing the impact of interpersonal trauma being perpetrated and/or denied by church communities. results suggest denial of the trauma results in isolation and marginalization resulting in secondary traumatization.  summary of findings  this document is copyrighted by the american psychological association or one of its allied publishers. this article is intended solely for the personal use of the individual user and is not to be disseminated broadly.  religious and spiritual abuse 217  
  quantitative, crosssectional  quantitative, crosssectional quantitative, crosssectional, exploratory factor analysis  johnston (2021)  kamminga (2018)  keller (2016)  qualitative, heuristic and interpretative phenomenological analysis  research design  gubi and jacobs (2009)  study  table 1 (continued) r/s trauma/abuse measure  (a) participants described the spiritual abuse as involving manipulation, control, and power (b) endorsed feelings of anger toward the church and a desire to justify their own spirituality, (c) reported feeling personally impacted by working with spiritually abused clients as impacting their mood and emotions, and (d) described very limited training and mixed experiences utilizing supervision in working with religious/spiritual trauma/abuse. (a) religious trauma was positively correlated with the presence of meaning and the search for meaning. (b) spiritual abuse was also associated with the presence of meaning but not the search for meaning. (c) both religious trauma and spiritual abuse were positively associated with depression. (d) neither religious trauma nor spiritual abuse was associated with meaningmaking or trust.  summary of findings  spiritual abuse: the religious and spirituals struggle scale (exline et al., 2014) religious trauma: the composite score of the structured trauma-related experiences and symptoms screener for adults (grasso et al., 2019), the attitudes toward god scale (wood et al., 2010), and the measures of betrayal, powerlessness and stigma scale (gibson & leitenberg, 2001) n 33 adults; 73% f, 27% m; m age 33 saq (lawson, 2016) endorsement of spiritual abuse was positively correlated with opioid usage. saq (keller, 2016) outlines the development of and provides study 1: n 535 adults endorsing psychometric support for the 17-item saq. two experiences with a christian or bibleunderlying factors of the measure are power-based based church group for at least 1 year; affective wounding and conditionality. 81% f, 19% m, 1% transgender/other; m age 42 study 2: n 271 adults endorsing experiences with a christian or bible-based church group for at least 1 year; 78% f, 22% m, 1% transgender/ other; m age 40 (table continues)  n 69 adults endorsing past traumatic religious experiences; gender identities n/a; m age: n/a  n 5 adult counselors endorsing experience qualitative interview of working with spiritually abused children; 100% f, 0% m; age range: 30 to 60  sample  this document is copyrighted by the american psychological association or one of its allied publishers. this article is intended solely for the personal use of the individual user and is not to be disseminated broadly.  218 ellis et al.  
  qualitative, phenomenological analysis  quantitative, crosssectional  quantitative, crosssectional  quantitative, crosssectional  kvarfordt and herba (2018)  kvarfordt (2010)  kvarfordt and sheridan (2007)  research design  krueger (2018)  study  table 1 (continued)  qualitative interview  r/s trauma/abuse measure  summary of findings  (table continues)  results are presented by (a) core dimensions of nonsexual clergy misconduct (e.g., abuse of power, harmful boundary violations), (b) church congregations’ involvement in nonsexual clergy misconduct (e.g., shifting blame, remaining loyal to clergy), and (c) impact of nonsexual clergy misconduct on those who experience it (e.g., hurt, anger, betrayal, powerlessness). n 307 registered members of the ontario religious/spiritual abuse and participants reported somewhat frequent encounters college of social workers and social neglect of children with religious and spiritual abuse/neglect. the service workers who work with children (kvarfordt & sheridan, three most frequently observed types of abuse and and/or adolescents; m age 44 2007) neglect that were “sometimes” or “often” seen by at least 65% of respondents were youth’s spiritual health being impacted by experiencing or witness violence, lack of religious or spiritual guidance, and aspects of modern culture that are detrimental to youth’s spiritual development. n 283 adult board certified diplomates of religious/spiritual abuse and 65–82% of social work practitioners reported that the american board of examiners in neglect of children they “sometimes” or “often” encounter seven of clinical social work who work with (kvarfordt & sheridan, the 10 listed examples of spiritual abuse or neglect children and/or adolescents; 65% f, 35% 2007) in their clinical work with youth with the two most m; m age 56 common being (a) aspects of modern culture being detrimental to youth’s spiritual/religious development and (b) the misuse of religious teachings that scare, frighten, or place unrealistic demands on youth. n 283 adult board certified diplomates of religious/spiritual abuse and in addition to 65% of participants reporting they the american board of examiners in neglect of children either “sometimes” or “often” saw 7/10 of the clinical social work who work with (kvarfordt & sheridan, listed examples of spiritual abuse or neglect in children and/or adolescents; 65% f, 35% 2007) and an open-ended their clinical work, they also identified rigid m; m age 56 question prompting adherence to religious/spiritual beliefs (e.g., forced participants to list any religious observance, not allowing youths to additional types of religious/ question religious teachings) and excessive lack of spiritual abuse observed in attention or sensitivity to youth’s spiritual health their clinical work. (e.g., caregiver criticizing a child’s spiritual journey, a child not being provided any spiritual guidance).  n 148 adults endorsing experiences of nonsexual clergy misconduct; 84% f, 16% m; age range: 18 to 60  sample  this document is copyrighted by the american psychological association or one of its allied publishers. this article is intended solely for the personal use of the individual user and is not to be disseminated broadly.  religious and spiritual abuse 219  
  r/s trauma/abuse measure  mixed-method, n 1,298 adults endorsing prior knowledge survey designed to assess descriptive statistics of the term spiritual abuse and who are a understanding of spiritual and inductive member or attend a christian religious abuse and safeguarding thematic and organization; 69% f, 31% m, age range: practices against spiritual content analysis 18 to 60 abuse  oakley et al. (2018).  church experiences survey  n 502 adults; 62% f, 38% m; age n/a  quantitative, crosssectional  oakley and kinmond (2014)  qualitative interview  n 10 adults endorsing experiences of spiritual abuse; 80% f, 20% m; age n/a  qualitative, phenomenological analysis  oakley (2009)  n 230 american indian and white adult experiences of adopted and participants who experienced foster care fostered individuals project and/or adoption during childhood; 82% f, survey 18% m; m age 49  sample  quantitative, crosssectional  research design  landers et al. (2021)  study  table 1 (continued)  49.5% of native american children in foster care reported experiences of spiritual abuse, higher rates than their white counterparts. native americans were more likely to be victims of polyvictimization (spiritual, sexual, emotional abuse). two primary themes were identified: (a) the first primary theme of power was identified with subthemes capturing aspects or elements of power abused in the religious setting such as coercion/ control and divine position being leveraged to abuse others. (c) the second primary theme was “spiritual abuse as abuse,” meaning participants felt their experiences should be validated as a true form of abuse and described that it had felt like the core of who they were was attacked. (a) only 50% of participants felt able to raise questions and issues with their churches, and over 70% of participants endorsed feeling manipulated at their current church and 84% at a prior church. (b) 45% of participants endorsed that scripture was used to control behavior and 56% of participants endorsed distrust of the church, but only 15% endorsed no longer trusting god. 74% of participants endorsed feeling damaged by a church experience. (c) 63% of participants endorsed they had heard of spiritual abuse prior to participation in the study, and 105 participants provided definitions of spiritual abuse with key factors being manipulation, use of scripture, misuse of power by church leadership, and control. (d) only 34% reported knowing where to go for help and support if they were to experience spiritual abuse. (a) participants provided their own definitions of spiritual abuse characterized by religious or spiritual beliefs being a central component to the abuse, coercion/control, manipulation, using religious texts to control, and “divine rationale.” (b) participants also endorsed a need for policy changes to protect individuals from spiritual abuse, describing the impact of spiritual abuse as damaging and harmful and highlighted the need for greater awareness. (table continues)  summary of findings  this document is copyrighted by the american psychological association or one of its allied publishers. this article is intended solely for the personal use of the individual user and is not to be disseminated broadly.  220 ellis et al.  
  qualitative, phenomenological analysis  qualitative, interpretive phenomenological analysis  swindle (2017)  ward (2011)  r/s trauma/abuse measure  n 6 adults endorsing experiences of spiritual abuse in bible-based christian settings; 67% f, 33% m, m age 56 qualitative interview  n 7 adults endorsing experiences of qualitative interview religious abuse; 100% f, 0% m, m age 40  n 278 adults who were a current or 21-item spiritual trauma former member of the church of jesus measure (simmons, 2017) christ of latter-day saints, and identifying as lgbtq ; 39% f, 45% m, 15% transgender/other; m age 33  sample  95% of participants endorsed experiencing at least one instance of spiritual abuse, with 86% of participants likely meeting criteria for ptsd relating to their religious experiences. when controlling for intrinsic, social extrinsic, and quest orientation, spiritual trauma had a significant effect on ptsd. spiritual trauma explained approximately 18% of the variance in ptsd scores. 10 themes were identified describing participants’ experiences of religious abuse: (a) emotional trauma, (b) betrayal, (c) rules prioritized over people/devalued, (d) abuse of power/use of the sacred to control or manipulate, (e) spiritual transformation, (f) isolation, (g) healing, (h) gender bias/discrimination, (i) stigma, and (j) victim blaming. 6 themes were identified describing participants’ experiences of spiritual abuse: (a) leadership representing god/powerful symbolic authority, (b) spiritual bullying/manipulative behavior of the leadership, (c) acceptance via performance/ approval based on obedience, (d) spiritual neglect/ detrimental acts of omission by the leadership, (e) expanding external/internal tension/dissonance between one’s inner and outer worlds, and (f) manifestation of internal states/bio/psycho/spiritual repercussions of the abuse  summary of findings  note. saq spiritual abuse questionnaire; ptsd posttraumatic stress disorder; lgbtq lesbian, gay, bisexual, transgender, queer, or questioning.  quantitative, crosssectional  research design  simmons (2017)  study  table 1 (continued)  this document is copyrighted by the american psychological association or one of its allied publishers. this article is intended solely for the personal use of the individual user and is not to be disseminated broadly.  religious and spiritual abuse 221  
  this document is copyrighted by the american psychological association or one of its allied publishers. this article is intended solely for the personal use of the individual user and is not to be disseminated broadly.  222  ellis et al.  author(s) to assess r/s abuse (e.g., “did you experience spiritual abuse in any foster home?” landers et al., 2021; “has your partner used religious teachings or traditions as a reason to control your daily activities?” bagwell-gray et al., 2021). the saq (lawson, 2016) is a 78-item dichotomous survey assessing the following domains: (a) church or religious group’s leaders; (b) your group and its teachings; (c) your group or church’s policies; (d) your group’s literature and multimedia; (e) morals and ethics, (f) health and conscience; (g) making personal choices, (h) registered sex-offenders being allowed around children; finances; and (i) a domain titled “a few more questions” which asks about social experiences within the religious setting. no research on the psychometric properties of this measure was able to be located for this review. included in the current review is a study on the development of a different saq (keller, 2016). keller (2016) developed a 17-item measure in which participants are asked to reflect on their current/past experiences in a christian or biblebased religious setting and respond to questions based on a two-factor structure: (a) power-based affective wounding and (b) conditionality. power-based affective wounding examines the power dynamics and negative emotional impact experienced in spiritual abuse. questions on this factor include, “at times, i was scolded by my leader and made to feel ashamed and helpless” and “i now feel cynical about church/religious groups.” conditionality refers to performance-based, transactional nature of relationships when spiritual abuse is occurring. questions on this factor include, “i believed i could be totally surrendered to god if i did everything perfectly according to the church/group’s instructions,” and “i believed god would punish me if i didn’t do what my church/ group encouraged me to do.” the saq demonstrated evidence of convergent and divergent validity, and a cronbach’s α of .98 (keller, 2016). additionally, simmons (2017) developed the 21-item spiritual trauma measure to assess spiritual trauma regarding the experiences of lesbian, gay, bisexual, transgender, queer, or questioning (lgbtq ) individuals within the church of jesus christ of latter-day saints (lds) assessing the domains of (a) ecclesiastical spiritual trauma and (b) punitive or traumatic teaching and beliefs. ecclesiastical spiritual trauma refers to experiences such as being advised to not openly share one’s sexual and/or gender identity or being  threatened due to one’s sexual and/or gender identity. questions assessing this domain include, “how often did lds leaders associate your sexual or gender identity with pedophilia” and “how often did lds leaders encourage you to seek professional treatment to change your sexual or gender identity?” in this measure, punitive or traumatic teaching and beliefs refer to experiences such as labeling homosexuality a sin or teaching that one will be punished by god due to their sexual attractions. questions assessing this domain include “god would punish me for my sexual attractions,” and “i would be eternally separated from my family for my same-sex sexual behaviors.” the 21-item spiritual trauma measure yielded a cronbach’s α of .95 (simmons, 2017). three studies utilized the religious/spiritual abuse and neglect of children (rsanc; kvarfordt & sheridan, 2007), which consists of 22 items designed to assess practitioners’ frequency of encounters with various types of spiritual and religious abuse that may be reported in clinical work with children/adolescents. the rsanc yielded a cronbach’s α of .94 (kvarfordt & herba, 2018). finally, johnston (2021) utilized the religious and spiritual struggles scale (rss scale; exline et al., 2014) to assess spiritual abuse and the composite scores of the structured traumarelated experiences and symptoms screener for adults (grasso et al., 2019), the attitudes toward god scale (wood et al., 2010), and the measures of betrayal, powerlessness and stigma scale (gibson & leitenberg, 2001) to assess religious abuse. although these scales can provide helpful information, they are not designed to specifically assess the r/s abuse and trauma. the rss scale is designed to assess the six domains of spiritual struggle such as “divine struggle” (e.g., negative emotions toward god or one’s relationship with god) and “moral struggle” (e.g., worries about one’s moral offenses, concern regarding following moral principles). although experiences of r/s abuse and trauma could potentially be associated with r/s struggles, the rss scale was not designed to specifically assess spiritual abuse. additionally, utilizing the composite of several scales to assess religious abuse has not been empirically tested and may not be a reliable measure of religious abuse as the measures were not intended to be utilized in that manner. from the review of measures used to assess r/s abuse and trauma, it is clear that work on developing psychometrically sound measures is in the beginning stages. most of the studies in the review  
  religious and spiritual abuse  used measures of r/s abuse and trauma that were created for the present study. thus, there is a little evidence of reliability and validity for these measures in diverse populations, and more work is needed to develop and test assessment instruments.  this document is copyrighted by the american psychological association or one of its allied publishers. this article is intended solely for the personal use of the individual user and is not to be disseminated broadly.  review of empirical findings overall, 25 studies were included in the review (see table 1). the empirical findings of the studies are organized into eight sections: (a) definitions of r/s abuse and trauma, (b) prevalence of r/s abuse and trauma, (c) entering/exiting abusive religious communities, (d) intersection of r/s abuse/trauma and domestic violence, (e) the role of the religious community in the abuse, (f) negative outcomes associated with r/s abuse and trauma, (g) identity changes associated with r/s abuse and trauma, and (h) prevention and clinical treatment of r/s abuse and trauma. definitions of r/s abuse/trauma r/s abuse and trauma was defined in a variety of ways across the studies reviewed. however, three core elements in defining r/s abuse and trauma emerged from the studies. misuse of power. several studies suggested that r/s abuse and trauma involves a misuse or abuse of power occurring within a relationship. for example, kamminga (2018) stated that r/s abuse involves a misuse of power or using a god or higher power to control or induce fear in others. oakley (2009) explained that in r/s abuse, “the abuser uses power to control others : : : ” (p. 193). this misuse or abuse of power is typically defined as having the goal of coercing, controlling, or exploiting another person. simmons (2017) noted that r/s abuse could be either intentional or unintentional. most of the studies examined the relationship between r/s leaders and their followers, but several studies specifically examined how spouses/romantic partners can leverage r/s teachings in an abusive manner. additionally, when qualitatively exploring how victims described r/s abuse and trauma, a primary theme of abuse of power was present across studies (krueger, 2018; oakley, 2009; oakley et al., 2018; swindle, 2017; ward, 2011). psychological harm. in addition to the misuse or abuse of power, many definitions of r/s abuse and trauma included negative psychological impacts. glasscock (2019) cited childers’ (2012, p. 3) definition, including that r/s abuse results in a  223  “diminishing sense of self.” ward (2011) also described r/s abuse as negatively “influencing one’s inner and outer worlds” (p. 913). swindle (2017) applied finkelhor’s (1987) traumagenic dynamic, applying a model of childhood sexual abuse to r/s abuse, defining it as “an experience that alters : : : cognitive or emotional orientation to the world and causes trauma by distorting : : : selfconcept, worldview, or affective capacities” (p. 354). additionally, oakley (2009) noted that r/s abuse is often experienced as “an attack on self” (p. 193). spiritual harm. finally, many of the definitions also acknowledged the negative impact on one’s spiritual health. for example, three studies utilized johnson and vanvonderen’s (1991) definition of r/s abuse, noting that it involves “the mistreatment of a person who is in need of help, support, or greater spiritual empowerment, with the result of weakening, undermining, or decreasing that person’s spiritual empowerment” (p. 23). kvarfordt (2010) also noted that r/s abuse of children/adolescents involves a “detrimental impact on youth’s spiritual development, which can include adverse effects in multiple areas generally addressed by spirituality (meaning, purpose, connection/belonging, faith, moral or ethical guidelines)” (pp. 144–145). prevalence of r/s abuse/trauma six studies assessed the prevalence of r/s abuse and trauma. overall, these studies suggest a high prevalence rate of r/s abuse and trauma. oakley and kinmond (2014) reported that over 70% of their participants, adults in the united kingdom, reported feeling manipulated at their current church, and 84% endorsed feeling manipulated at a prior church. additionally, 45% of their participants endorsed that scripture was used to control behavior, and 56% of participants endorsed distrust of the church. however, only 15% endorsed no longer trusting god. only 34% of participants reported knowing where they could receive help and support if they were to experience r/s abuse. within specific populations, these rates may be even higher. for example, simmons (2017) found that 95% of participants, adults who were a current or former member of the church of jesus christ of lds and identifying as lgbtq , endorsed experiencing at least one instance of r/s abuse, and 86% likely met criteria for posttraumatic  
  this document is copyrighted by the american psychological association or one of its allied publishers. this article is intended solely for the personal use of the individual user and is not to be disseminated broadly.  224  ellis et al.  stress disorder (ptsd) relating to their religious experiences. additionally, landers et al. (2021) found that 49.5% of native american children in foster care reported experiences of r/s abuse—rates higher than their white counterparts. additionally, native americans were more likely to experience polyvictimization, or multiple forms of abuse (landers et al., 2021). when examining on the prevalence of r/s abuse and trauma as a presenting concern in children/ adolescent clinical populations, kvarfordt and herba (2018), kvarfordt (2010), and kvarfordt and sheridan (2007) reported that 65%–82% of surveyed social workers reported that they “sometimes” or “often” encounter seven of the 10 examples of r/s abuse or neglect in their clinical work with children/adolescents. the three most frequently observed types of abuse and neglect were youth’s spiritual well-being shaken by experiencing or witnessing violence, lack of r/s guidance, and aspects of modern culture (e.g., materialism, technology, messages from media) that were detrimental to children’s and youth’s spiritual and religious development. these studies highlight the relevance of research on r/s abuse and trauma and the increased risk in vulnerable populations for experiencing this type of abuse and trauma.  intersection of r/s abuse/trauma and domestic violence  entering/exiting abusive religious communities  four studies specifically highlighted the role of the members of the religious community in the abuse, with the primary theme being victim blaming and minimization of the abuse, as well as isolation and marginalization resulting in secondary traumatization. for example, krueger (2018) found that church congregations often play a role in the abuse by shifting blame from the r/s leader to the victim or remaining loyal to the r/s leader despite the perpetrated abuse. similarly, swindle (2017) noted that victim blaming, isolation from the community, and gender bias and discrimination were key themes reported by participants. davis and johnson (2021) reported that clergy members interviewed in their study reported increased difficulty addressing r/s abuse and trauma when it is being perpetrated by a fellow clergy member.  two studies examined participants’ experiences of entering or exiting r/s abusive religious communities. first, bilsky (2013) qualitatively explored the transition into and out of abusive religious communities. bilsky found that participants initially perceived their religious groups in a positive light, resulting in increased engagement and commitment to the religious community. however, participants reported eventually encountering more negative than positive experiences within the community, leading to disengagement and ultimately, leaving the group (bilsky, 2013). second, glasscock (2019) qualitatively explored the experiences of ex-cult members and found that participants were typically vulnerable prior to joining the cult, but upon joining maintained their membership due to scare tactics and fear. the participants in both studies endorsed negative consequences and impacts upon leaving the religious community or cult.  five studies highlighted the need to consider the role of r/s abuse and trauma within the context of domestic violence. for example, bagwell-gray et al. (2021) reported that 135 of their 660 participants (20.5%), adult women who reported experiences of domestic violence, also reported experiences of r/s abuse and were 4.13 times more likely to have experienced reproductive coercion. additionally, bent-goodley and fowler (2006) found in their qualitative analysis of african american adults who believe in a higher power that r/s methods of abuse were present in domestic violence through means such as manipulating victims to remain in the abusive relationship due to r/s beliefs or by denying the victim the ability to be a part of their r/s community. they also found that the church often serves as a mechanism for revictimization of victims of domestic abuse when met with sexism or maladaptive sex role perceptions (bent-goodley & fowler, 2006). these studies highlight the intersection of r/s abuse and trauma and domestic violence. the role of the religious community in the abuse  negative outcomes associated with r/s abuse and trauma ten studies described significant, negative emotional and psychological impacts of r/s trauma.  
  this document is copyrighted by the american psychological association or one of its allied publishers. this article is intended solely for the personal use of the individual user and is not to be disseminated broadly.  religious and spiritual abuse  qualitatively, oakley (2009) found that participants highlighted r/s trauma as a true form of abuse, indicating that it felt like an attack on their core self. participants also described feeling blame, distrust, and fear (oakley, 2009). swindle (2017) noted that participants identified r/s abuse as a form of emotional trauma and betrayal. additionally, crocker (2021) explored participants’ symptomology in relation to r/s trauma and reported that 60% of participants endorsed a mental health diagnosis they believe was connected to or exacerbated by their r/s trauma, with participants endorsing symptoms of depression, anxiety, and trauma-related symptoms. additionally, participants endorsed forms of negative coping with the r/s trauma such as risky sexual behavior, disordered eating, self-conforming behaviors, or self-injurious behaviors (crocker, 2021). quantitatively, johnston (2021) found that r/s abuse and trauma were positively associated with symptoms of depression, and kamminga (2018) found that the endorsement of r/s abuse was positively associated with opioid usage. endorsement of fear and abuse of power within an r/s setting and secrecy were significant factors in the positive correlation between r/s abuse and opioid usage (kamminga, 2018). in addition to psychological effects, crocker’s (2021) participants reported effects to their physical health and spiritual well-being due to r/s abuse/trauma. physical effects included disordered eating, engaging in risky behaviors, and changes in sleep. spiritual effects included feeling more distant from god, skeptical of religion, and distrustful of religious communities. identity changes associated with r/s abuse and trauma other work noted survivors’ resilience following r/s abuse. two studies highlighted the potential identity changes associated with r/s abuse and trauma. crocker (2021) noted that some participants experienced identity-related changes, such as taking personal ownership of their faith and or later reporting a stronger relationship with god, increased empathy and open-mindedness, created belonging and vulnerability with others, increased identity development, increased advocacy and education for lgbtq community and making positive life choices such as what school to attend or career to pursue. swindle (2017) reported participants’ descriptions of their  225  experiences of healing and “spiritual transformation” after their traumatic r/s experiences (p. 94). for some, this spiritual transformation involved adopting a completely new r/s identity (e.g., identifying as atheist now instead of catholic), although for others, it involved reconciling their traumatic experiences with their desire to maintain their r/s identity, sometimes leaning into their r/s identity as a source of strength and resilience (swindle, 2017). for example, one participant described their view of god during the healing process stating, he’s bigger than ever. i really don’t think i would have made it without him. i refuse, and i guess this is the stubborn woman they hate, i refuse to let the devil take away the only real father i ever had. (swindle, 2017, p. 97)  future work could explore how people make sense of their traumatic experiences of r/s abuse. prevention and treatment of r/s abuse and trauma regarding prevention of r/s abuse and trauma, two studies experimentally tested a social media intervention for increasing knowledge of r/s abuse within the context of domestic violence by providing information on the whatsapp application (adekoya et al., 2019; adebayo & evbuoma, 2021). additionally, one study utilized an r/s abuse curriculum with christian leaders and seminary students, qualitatively assessing whether the curriculum impacted their awareness of r/s abuse (berry, 2010). in all three studies, the researchers found significant increases in knowledge and understanding of r/s abuse following the interventions. adebayo and evbuoma (2021) and adekoya et al. (2019) noted that the increase in knowledge regarding r/s abuse within the context of domestic violence was associated with a decrease in r/s abusive behaviors exhibited by men in the experimental group, but the women in the experimental group did not demonstrate a decrease in r/s abuse behaviors. however, berry (2010) found that participants endorsed increased awareness but not a change in behaviors. this could be in part to the social media intervention primarily portraying men as the perpetrator of r/s abuse within the context of domestic violence, and the christian leaders and seminary students not perceiving themselves as perpetrating r/s abuse. in addition, oakley et al. (2018) found that participants endorsed a need for policy changes to assist in  
  this document is copyrighted by the american psychological association or one of its allied publishers. this article is intended solely for the personal use of the individual user and is not to be disseminated broadly.  226  ellis et al.  protecting individuals from r/s abuse, alongside raising awareness of the prevalence of r/s abuse. regarding the treatment of r/s abuse and trauma, swindle (2017) noted that participants identified counseling as a helpful factor in promoting healing following r/s abuse, and crocker (2021) found that factors that helped victims of r/s abuse and trauma maintain their faith included social support, educational resources, changes in theological beliefs, religious attitudes and beliefs, spiritual practices, and value-driven behaviors. additionally, one study specifically explored the impact that addressing r/s abuse and trauma within the counseling context has on clinicians (gubi & jacobs, 2009). clinicians reported that their own r/s identity was impacted by their secondary exposure to r/s abuse and trauma. specifically, the participants endorsed feelings of anger toward the church and a desire to justify their own r/s beliefs. additionally, they noted their mood and emotions were affected by their exposure to the abuse and trauma (e.g., irritability, needing space to “ground” themselves after sessions). participants also reported receiving little or no training in working with clients who endorse r/s abuse and trauma and mixed experiences when seeking supervision for these clients, sometimes finding supervisors helpful and willing to engage and other times having negative supervisory experiences. discussion several important findings emerged in the literature review. first, there is some consensus across studies in defining r/s abuse and trauma. although researchers highlighted variations in how r/s abuse and trauma has been conceptualized and defined, three primary factors appear to be consistent across studies: (a) misuse of power, (b) psychological harm, and (c) spiritual harm. understanding these themes, one can define r/s abuse and trauma as a misuse of power in an r/s setting resulting in psychological and spiritual harm. second, few researchers have utilized psychometrically supported approaches to quantitatively measure r/s abuse and trauma. although primarily addressed in a theoretical or qualitative manner, researchers have made progress in measuring r/s abuse and trauma more objectively, such as with keller’s (2016) saq.  third, r/s abuse and trauma is highly prevalent and is often affected by one’s intersection of identities, such as being a member of the lgbtq  community and holding an r/s identity. thus, when thinking about r/s abuse and trauma, it is important to assess and respect cultural factors present in the lives of clients. although r/s are recognized by the american psychological association as important diversity factors for clinicians and researchers to attend to (vieten & lukoff, 2022), understanding that the intersection of r/s identities and other sociocultural identities could potentially leave a client more at risk for r/s abuse and trauma is important for better attending to clients’ needs and holistically providing care for individuals. fourth, individuals who enter into abusive r/s settings may either initially be vulnerable and/or perceive the r/s setting as positive. upon realizing the negative aspects of the r/s setting, they may begin to feel more disengaged or desire to depart from the group. to compound their stress, leaving the group can be difficult due to the use of scare tactics or perceived consequences. better understanding the process of entering and the consequences of exiting abusive r/s settings, and how to maximize client safety and wellbeing, is important for understanding how to protect individuals from r/s abuse and trauma, perhaps by providing education and healthier forms of coping and support. additionally, r/s abuse/trauma and domestic violence may often co-occur, with either the spouse using r/s means to manipulate and abuse their partner or religious leaders using their r/s power to encourage individuals to remain in r/s abusive situations. recognizing the comorbidity that can occur between these types of abuse, it is important to thoroughly assess for r/s abuse and trauma when working with individuals who have experienced domestic violence. fifth, the religious community often inflicts retraumatization following r/s abuse and trauma by siding with the perpetrator of the abuse and isolating the victim apart from the religious community. although it may be tempting to focus primarily on the primary perpetrator of the r/s abuse and trauma, the religious community that witnesses the abuse is also often at fault for causing secondary r/s abuse and trauma through victim blaming, isolating the victim, or siding with the primary abuser over the victim. r/s abuse involves an entire system; therefore, it is  
  this document is copyrighted by the american psychological association or one of its allied publishers. this article is intended solely for the personal use of the individual user and is not to be disseminated broadly.  religious and spiritual abuse  important to take a systemic approach to conceptualizing, treating, and preventing r/s abuse and trauma in the future. sixth, r/s abuse and trauma can result in a variety of negative outcomes, including emotional, psychological, physical, and spiritual harm (e.g., increased risk for opioid use and increased symptoms of depression, anxiety, and trauma-related symptoms). some participants also reported identity-related changes following r/s abuse/trauma, including spiritual transformation, a stronger faith following the abuse, and healing. these outcomes are consistent with a review of the literature that examined the relationship between childhood abuse and religion/ spirituality—the majority of those studies indicated a decline in religiousness/spirituality or a combination of decline and growth (walker et al., 2009). the resilient outcomes could potentially be understood as posttraumatic growth. posttraumatic growth occurs when individuals report increased functioning following a traumatic event (tedeschi & calhoun, 2004). however, such work may be examining a subset of individuals who were able to demonstrate resilience amid difficulty; more work is needed to explore identity-related changes following r/s abuse. finally, interventions to educate individuals on r/s abuse and trauma are promising methods for helping increase awareness and potentially prevent r/s abuse and trauma from being perpetrated. these interventions could potentially be utilized to target larger populations of individuals or within therapy groups and individual sessions. limitations the results of the literature review should be interpreted in the context of the limitations of the included studies. the research designs implemented in the reviewed studies have some important limitations, such as a lack of comprehensive/ varying methodologies and diverse participant samples. most of the quantitative studies utilized cross-sectional designs, so causal conclusions should not be made. additionally, increased diversity regarding age, race/ethnicity, gender identity, sexual orientation, and r/s identities are needed. the majority of participants included in the samples were white female adult christians, which decreases the generalizability of the findings to non-christians and racial/ethnicity minorities. also, the majority of participants  227  were from the united states and western europe, which decreases the generalizability of the findings to individuals from other parts of the world. the methods of measuring r/s abuse and trauma also have some limitations. the measures included in the reviewed studies utilized likert scales, which may be prone to response bias (leak & parsons, 2001; paulhus, 1991). additionally, many of the studies utilized questions created by the respective researchers to assess r/s abuse/ trauma without existing evidence about the reliability and validity of those methods. even the studies that attempted to use a more formal means of assessing r/s abuse and trauma need more research to assess the psychometric properties of those measures and explore how varying methods of measurement may impact prevalence rates. for example, in the rsanc scale (kvarfordt & sheridan, 2007), social workers were asked to identify which types or r/s abuse they had seen in their clinical work, and the most frequently endorsed type of spiritual abuse witnessed was “aspects of modern culture (e.g., materialism, technology, messages from media) that are detrimental to children’s and youth’s spiritual and religious development” (p. 156). while this item may potentially tap into a domain of r/s abuse, it could be argued that it represents a relatively low bar to be considered r/s abuse. areas for future research due to the limited number of studies that quantitatively or qualitatively assessed r/s abuse and trauma, there are many possible directions for future research. first, researchers should work to improve measures of r/s abuse and trauma. the current measures assessing r/s abuse and trauma need further validation and replication. additionally, it would be beneficial to develop alternative methods other than self-report measures for assessing r/s abuse and trauma, such as a structured interview. second, researchers should explore potential factors that may be associated with r/s abuse and trauma (e.g., attachment to god, religious coping). there are many questions that need to be addressed. for example, are there specific protective or risk factors that result in an individual being more/less likely to experience r/s abuse and trauma? if there are associated protective factors, how might we foster those to better protect people from r/s abuse and trauma?  
  this document is copyrighted by the american psychological association or one of its allied publishers. this article is intended solely for the personal use of the individual user and is not to be disseminated broadly.  228  ellis et al.  what outcomes emerge when experiences of r/s abuse and trauma serve as a risk factor? furthermore, more work is needed to explore individual, relational, and contextual factors that may facilitate the process of r/s abuse and trauma. for example, are certain types of r/s leaders more prone to perpetrate r/s abuse and trauma? are certain types of relationships more susceptible to r/s abuse and trauma? are there societal and contextual factors that make r/s abuse and trauma more likely to occur? as more studies accumulate, it will be important to explore the variability in the effects of r/s abuse and trauma, as well as potential moderator variables. furthermore, as studies with similar measures accumulate, meta-analyses could help to address questions about variability and moderators with more precision. third, researchers should explore the intersection of r/s trauma and other various forms of abuse. although five of the reviewed studies explored r/s abuse in relationship to domestic violence, and sexual abuse perpetuated by religious leaders has received attention, it is important to continue expanding the scope of investigations to consider the intersections between r/s abuse and trauma with other forms of trauma and abuse and how a network of experienced abuse might impact individuals. fourth, additional research on the differences between those who experience r/s abuse and trauma and choose to retain their r/s identity and those who choose to denounce their r/s identity is needed. previous work has examined reasons why people deidentify from religion, including religious trauma (mclaughlin et al., 2020). however, despite leaving religion, such individuals may continue to think and act in ways that are decidedly religious—exhibiting a religious residue (van tongeren et al., 2021). similar work could be examined here. for example, do those who choose to retain versus denounce their r/s identity have similar psychological outcomes? are there differences in resilience or perceived posttraumatic growth between those who choose to retain or denounce their r/s identity? finally, more research on all levels of r/s abuse and trauma prevention and treatment is needed. how can r/s abuse or trauma be prevented altogether? how can psychologists attend to those at a higher risk of experiencing r/s abuse and trauma? what treatment options are available for those who are currently or have in the past  experienced r/s abuse and trauma? there are many directions for future exploration of r/s abuse and trauma that will hopefully provide guidance on engaging in this necessary field of research. clinical implications better understanding r/s abuse and trauma can assist clinicians in working to educate their community on r/s abuse and trauma to increase awareness and prevent perpetration of r/s abuse. providing resources to the community via online information or informative workshops could be ways that psychologists could practice social justice in preventing r/s abuse, specifically attending to those whose intersecting identities may make them more at risk for experiencing r/s abuse. utilizing available resources such as the religious trauma institute (https://www.re ligioustraumainstitute.com) and collaborating with religious leaders in the community to discuss the signs and symptoms of r/s abuse are important steps that clinicians can take to attend to their community’s spiritual health. additionally, understanding the nature and impact of r/s abuse and trauma will assist clinicians in better assessing when clients are experiencing or are at risk for r/s abuse. supporting clients and helping them recognize the signs of healthy versus unhealthy religious communities is one way that clinicians can serve their clients. in navigating these issues, it is important to remember that what is “healthy” or desirable for one client in regard to their religious community may not be what is “healthy” or desirable for another. however, assisting clients in recognizing when power is being abused or creating space for them to identify negative psychological or spiritual effects they may be experiencing is an important function of therapy. if clients do label their experience(s) as r/s abuse or trauma, it is important for clinicians to validate their experience, supporting the client as they process the pain and hurt, and potentially reassess their spirituality or find meaning from their past experience. ultimately, clinicians should work to empower clients to find r/s healing, whether that be adopting a new r/s identity or reconciling their faith with their past negative experiences in a healthy way. when working with clients experiencing other forms of abuse or trauma, it is important to also  
  this document is copyrighted by the american psychological association or one of its allied publishers. this article is intended solely for the personal use of the individual user and is not to be disseminated broadly.  religious and spiritual abuse  assess for the potential presence of r/s abuse. for example, in working with a survivor of domestic violence, it may be beneficial to also explore their r/s identities, the r/s identities of their perpetrator, and how those r/s beliefs impacted them within the context of domestic violence, their r/s communities, and in the present. additionally, if r/s abuse and trauma is present, clinicians should take a systemic approach, recognizing that although the abuse may have been primarily perpetrated by one individual, there is likely additional r/s abuse and trauma caused by the religious congregation in the wake of the primary r/s abuse. in the process of clinically attending to r/s abuse and trauma, it is important for clinicians to be aware of their own r/s experiences and potential reactions that may occur in therapy. for example, some clinicians who hold an r/s identity may be pulled to defend their faith or tempted to change their clients’ religious/spiritual identification. others may feel conflict in their own r/s identities and wrestle with consolidating their client’s abuse with their own beliefs. some clinicians may have experienced r/s abuse themselves and feel especially sensitive to this area, while others may not hold an r/s identity and feel their client should abandon their r/s identity to avoid future r/s abuse and trauma. these are many ways a clinician’s r/s identity and experiences could interact with their client’s r/s identity and experiences. it is important for clinicians to engage in self-reflection and seek supervision in processing their reactions to these clients in therapy. conclusion the purpose of this article was to provide a systematic review of the existing empirical research on r/s abuse and trauma. the reviewed studies suggest that r/s abuse and trauma typically involve misuse or abuse of power which results in psychological and spiritual harm. survivors of r/s abuse described the psychological and spiritual impacts of their trauma, noting that it feels like an attack on the self. this form of abuse has a high prevalence rate and can co-occur with other forms of trauma and abuse, such as domestic violence. future research should work to improve assessment of r/s abuse and trauma, identify potential factors associated with r/s abuse and trauma, explore the intersection of r/s abuse and  229  trauma with other forms of abuse and trauma, identify differences between survivors of r/s abuse and trauma who retain their r/s identity versus those who reject their r/s identity and develop prevention and treatment efforts for r/s abuse and trauma. references references with an asterisk indicate the study used in the review of the literature *adebayo, o., & evbuoma, k. (2021). religious abuse messaging and effects on married couples in lagos state, nigeria. covenant journal of communication, 8(1), 102–128. *adekoya, h. o., adebayo, o. m., & ajilore, k. (2019). effect of social media spiritual and emotional abuse messages on comprehension and behavioural practices of married couples in lagos state, nigeria. global journal of health science, 11(6), 146–146. https://doi.org/10.5539/gjhs.v11n6p146 *bagwell-gray, m. e., thaller, j., messing, j. t., & durfee, a. (2021). women’s reproductive coercion and pregnancy avoidance: associations with homicide risk, sexual violence, and religious abuse. violence against women, 27(12–13), 2294–2312. https://doi.org/10.1177/10778012211005566 *bent-goodley, t. b., & fowler, d. n. (2006). spiritual and religious abuse: expanding what is known about domestic violence. affilia, 21(3), 282–295. https://doi.org/10.1177/0886109906288901 *berry, b. o. (2010). spiritual abuse in the christian community (no. 3424416) [doctoral dissertation, asbury theological seminary]. proquest dissertations & theses publishing. https://libproxy.library .unt.edu/login?url https://www.proquest.com/disse rtations-theses/spiritual-abuse-christian-community/ docview/757247472/se-2?accountid 7113 *bilsky, k. d. p. (2013). when the sacred hurts: using grounded theory analysis to understand how former members experienced abuse of religious authority in christian groups (no. 3576284) [doctoral dissertation, west virginia university]. proquest dissertations & theses publishing. https://libproxy.library .unt.edu/login?url https://www.proquest.com/disserta tions-theses/when-sacred-hurts-using-grounded-theoryanalysis/docview/1465384253/se-2?accountid 7113 bonelli, r. m., & koenig, h. g. (2013). mental disorders, religion and spirituality 1990 to 2010: a systematic evidence-based review. journal of religion and health, 52(2), 657–673. https:// doi.org/10.1007/s10943-013-9691-4 childers, m. (2012). holy havoc: chaplains as first responders in healing spiritual abuse. chaplaincy today, 28(2), 37–42. http://www.professionalcha plains.org/  
  this document is copyrighted by the american psychological association or one of its allied publishers. this article is intended solely for the personal use of the individual user and is not to be disseminated broadly.  230  ellis et al.  *crocker, s. c. (2021). persevering faith: a qualitative exploration of religious trauma and spiritual resilience in sexual minority christians (no. 28721870) [doctoral dissertation, regent university]. proquest dissertations & theses publishing. https://libproxy .library.unt.edu/login?url https://www.proquest.com/ dissertations-theses/persevering-faith-qualitativeexploration/docview/2582797914/se-2?accountid  7113 *davis, m., & johnson, m. (2021). exploring black clergy perspectives on religious/spiritual related domestic violence: first steps in facing those who wield the sword abusively. journal of aggression, maltreatment & trauma, 30(7), 950–971. https:// doi.org/10.1080/10926771.2020.1738615 exline, j. j., pargament, k. i., grubbs, j. b., & yali, a. m. (2014). the religious and spiritual struggles scale: development and initial validation. psychology of religion and spirituality, 6(3), 208–222. https://doi.org/10.1037/a0036465 finkelhor, d. (1987). the trauma of child sexual abuse: two models. journal of interpersonal violence, 2(4), 348–366. https://doi.org/10.1177/ 088626058700200402 gibson, l. e., & leitenberg, h. (2001). the impact of child sexual abuse and stigma on methods of coping with sexual assault among undergraduate women. child abuse & neglect, 25(10), 1343–1361. https:// doi.org/10.1016/s0145-2134(01)00279-4 *glasscock, d. s. (2019). spiritual abuse among cult exmembers: a descriptive phenomenological psychological inquiry (no. 13900573) [doctoral dissertation, grand canyon university]. proquest dissertations & theses publishing. https://libproxy.library.unt.edu/ login?url https://www.proquest.com/dissertationstheses/spiritual-abuse-among-cult-ex-membersdescriptive/docview/2284210906/se-2 *gomez, a. i. (2004). the lived experience of a response of denial from christian community after trauma (no. mq93643) [master’s thesis, langley, bc, trinity western university]. proquest dissertations & theses publishing. https://libproxy.library.unt.edu/login?url https://www.proquest.com/dissertations-theses/livedexperience-response-denial-christian/docview/ 305051707/se-2?accountid 7113 grasso, d. j., ford, j. d., & greene, c. a. (2019). preliminary psychometrics of the structured trauma-related experiences and symptoms screener for adults (stress-a) in an urban prenatal healthcare clinic. psychological trauma: theory, research, practice, and policy, 11(8), 927– 935. https://doi.org/10.1037/tra0000476 *gubi, p. m., & jacobs, r. (2009). exploring the impact on counsellors of working with spiritually abused clients. mental health, religion & culture, 12(2), 191–204. https://doi.org/10.1080/13674670802441509 johnson, d., & vanvonderen, j. (1991). the subtle power of spiritual abuse. kaapstad.  *johnston, c. l. (2021). the predictive relationship of religious trauma and spiritual abuse on meaningmaking, trust, and depression (no. 28545319) [doctoral dissertation, north central university]. proquest dissertations & theses global. https://libproxy.library .unt.edu/login?url https://www.proquest.com/disserta tions-theses/predictive-relationship-religious-trauma/ docview/2582791499/se-2?accountid 7113 *kamminga, d. l. (2018). association of spiritual abuse and opioid addiction (no. 10840869) [master’s thesis, purdue university global]. proquest dissertations & theses publishing. https://libproxy .library.unt.edu/login?url https://www.proquest.com/ dissertations-theses/association-spiritual-abuse-opioidaddiction/docview/2085901518/se-2?accountid 7113 *keller, k. h. (2016). development of a spiritual abuse questionnaire (no. 10182382) [doctoral dissertation, texas women’s university]. proquest dissertations & theses publishing. *krueger, m. (2018). clergy nonsexual misconduct in protestant churches: a mixed methods study (no. 27741033) [doctoral dissertation, california southern university]. proquest dissertations & theses publishing. https://libproxy.library.unt.edu/login? url https://www.proquest.com/dissertations-theses/ clergy-nonsexual-misconduct-protestant-churches/ docview/2401981826/se-2 *kvarfordt, c. l. (2010). spiritual abuse and neglect of youth: reconceptualizing what is known through an investigation of practitioners’ experiences. journal of religion & spirituality in social work, 29(2), 143– 164. https://doi.org/10.1080/15426431003708287 *kvarfordt, c. l., & herba, k. (2018). religion and spirituality in social work practice with children and adolescents: a survey of canadian practitioners. child & adolescent social work journal, 35(2), 153–167. https://doi.org/10.1007/s10560-017-0513-5 *kvarfordt, c. l., & sheridan, m. j. (2007). the role of religion and spirituality in working with children and adolescents: results of a national survey. journal of religion & spirituality in social work, 26(3), 1–23. https://doi.org/10.1300/j377v26n03_01 *landers, a. l., danes, s. m., campbell, a. r., & hawk, s. w. (2021). abuse after abuse: the recurrent maltreatment of american indian children in foster care and adoption. child abuse & neglect, 111, article 104805. https://doi.org/10.1016/j.chia bu.2020.104805 lawson, c. (2016) spiritual abuse questionnaire (saq). lighthouse trails. https://www.lighthouse trailsresearch.com/blog/?p 29604 leak, g. k., & parsons, c. j. (2001). the susceptibility of three attachment style measures to socially desirable responding. social behavior and personality, 29(1), 21–29. https://doi.org/10.2224/sbp.2001.29 .1.21 mclaughlin, a., van tongeren, d. r., teahan, k., davis, d. e., rice, k., & dewall, c. n. (2020). who  
  this document is copyrighted by the american psychological association or one of its allied publishers. this article is intended solely for the personal use of the individual user and is not to be disseminated broadly.  religious and spiritual abuse  are the religious “dones?”: a cross-cultural latent profile analysis of formerly religious individuals. psychology of religion and spirituality. advance online publication. https://doi.org/10.1037/rel0000376 *oakley, l. r. (2009). the experience of spiritual abuse within the christian faith in the uk (no. u500459) [doctoral thesis, manchester metropolitan university]. ethos e-theses online service. https://ethos.bl.uk/orderdetails.do?uin uk.bl.ethos .492902 *oakley, l. r., kinmond, k., & humphreys, j. (2018). spiritual abuse in christian faith settings: definition, policy and practice guidance. journal of adult protection, 20(3/4), 144–154. https://doi.org/ 10.1108/jap-03-2018-0005 *oakley, l. r., & kinmond, k. s. (2014). developing safeguarding policy and practice for spiritual abuse. the journal of adult protection, 16(2), 87–95. https://doi.org/10.1108/jap-07-2013-0033 oman, d. (2014). defining religion and spirituality. in r. f. paloutzian & c. l. park (eds.), handbook of the psychology of religion and spirituality (2nd ed., pp. 23–47). guilford press. page m. j., mckenzie j. e., bossuyt p. m., boutron i., hoffmann t. c., mulrow c. d., shamseer, l., tetzlaff, j. m., akl, e. a., brennan, s. e., chou, r., glanville, j., grimshaw, j. m., hro bjartsson, a., lalu, m. m., li, t., loder, e. w., mayo-wilson, e., mcdonald, s., : : : moher, d. (2021) the prisma 2020 statement: an updated guideline for reporting systematic reviews. plos medicine, 18(3), article e1003583. https://doi.org/10.1371/journal.pmed .1003583 paulhus, d. l. (1991). measurement and control of response bias. in j. p. robinson, p. r. shaver, & l. s. wrightsman (eds.), measures of personality and social psychological attitudes (pp. 17–59). academic press. https://doi.org/10.1016/b978-012-590241-0.50006-x pew research center. (2012). global religious landscape. https://www.pewforum.org/2012/12/18/globalreligious-landscape-exec/ pew research center. (2017). more americans now say they’re spiritual but not religious. https://www. pewresearch.org/fact-tank/2017/09/06/more-ame ricans-now-say-theyre-spiritual-but-not-religious/ *simmons, b. w. (2017). coming out mormon: an examination of religious orientation, spiritual trauma, and ptsd among mormon and ex-mormon lgbtqa adults (no.10724/38227) [doctoral dissertation, university of georgia]. open access theses & dissertations. https://getd.libs.uga.edu/ pdfs/simmons_brian_w_201712_phd.pdf simon, a., hauari, h., hollingworth, k., & vorhaus, j. (2012). a rapid literature review of evidence on child abuse linked to faith or belief. childhood wellbeing research centre. https://citeseerx.ist  231  .psu.edu/viewdoc/download?doi 10.1.1.1067.5285 &rep rep1&type pdf stone, a. (2013). thou shalt not: treating religious trauma and spiritual harm with combined therapy. group, 37(4), 323–337. https://doi.org/10.13186/ group.37.4.0323 *swindle, p. j. (2017). a twisting of the sacred: the lived experience of religious abuse (no. 10264116) [doctoral dissertation, university of north carolina at greensboro]. proquest dissertations & theses publishing. https://www.proquest.com/docview/ 1927630238?pq-origsite gscholar&fromopenview  true tedeschi, r. g., & calhoun, l. g. (2004). posttraumatic growth: conceptual foundations and empirical evidence. psychological inquiry, 15(1), 1–18. https://doi.org/10.1207/s15327965pli1501_01 tomlinson, j., glenn, e. s., paine, d. r., & sandage, s. (2016). what is the “relational” in relational spirituality? a review of definitions and research directions. journal of spirituality in mental health, 18(1), 55–75. https://doi.org/10.1080/19349637 .2015.1066736 van tongeren, d. r., dewall, c. n., chen, z., sibley, c. g., & bulbulia, j. (2021). religious residue: cross-cultural evidence that religious psychology and behavior persist following deidentification. journal of personality and social psychology, 120(2), 484–503. https://doi.org/10.1037/pspp0000288 vieten, c., & lukoff, d. (2022). spiritual and religious competencies in psychology. american psychologist, 77(1), 26–38. https://doi.org/10.1037/ amp0000821 walker, d. f., reid, h. r., o’neill, t., & brown, l. (2009). changes in personal religion/spirituality during and after childhood abuse: a review of the literature. psychological trauma: theory, research, practice, and policy, 1(2), 130–145. https://doi.org/10.1037/a0016211 *ward, d. j. (2011). the lived experience of spiritual abuse. mental health, religion & culture, 14(9), 899– 915. https://doi.org/10.1080/13674676.2010.536206 wood, b. t., worthington, e. l., jr., exline, j. j., yali, a. m., aten, j. d., & mcminn, m. r. (2010). development, refinement, and psychometric properties of the attitudes toward god scale (atgs-9). psychology of religion and spirituality, 2(3), 148– 167. https://doi.org/10.1037/a0018753 zinnbauer, b. j., & pargament, k. i. (2005). religiousness and spirituality. in r. f. paloutzian & c. l. park (eds.), handbook of the psychology of religion and spirituality (pp. 21–42). guilford press. received april 18, 2022 revision received july 2, 2022 accepted july 18, 2022  
       


authors_index: greening, neville
secondary_title_index: scientific research journal
title_index: phenomenological research methodology
abstract_index:
       the phenomenological research methodology relates to several approaches that in turn, they are applied to single cases or to the
  deliberate samples that are carefully chosen. like individual studies, it is easier to identify issues that show discrepancies, failures, favorable inferences, and attention to distinct situations while conducting management research (groenewald, 2004 pg. 87). clark moustak as theoretical underpinnings of phenomenology guide the reader through the process of how to manage a phenomenological study step-by-step. and so, this provides more in-depth insights on the successful phenomenological studies from distinct contexts, including the field of healthcare, therapy, psychology, victimology, as well as investigations involving gender. while conducting a phenomenological research methodology, it often pertains the four necessary steps of bracketing, intuiting, analyzing and describing. this paper looks at phenomenological research methodology applied in a nursing context.     

full_text_index:
       scientific research journal (scirj), volume vii, issue v, may 2019 issn 2201-2796  88  phenomenological research methodology neville greening doctor of philosophy academic mixed research methods osaka university-8-1-1 aomatani-higashi, minoh, osaka 562-8558 japan email: osaka.university2017@gmail.com doi: 10.31364/scirj/v7.i5.2019.p0519656 http://dx.doi.org/10.31364/scirj/v7.i5.2019.p0519656  abstract: the phenomenological research methodology relates to several approaches that in turn, they are applied to single cases or to the deliberate samples that are carefully chosen. like individual studies, it is easier to identify issues that show discrepancies, failures, favorable inferences, and attention to distinct situations while conducting management research (groenewald, 2004 pg. 87). clark moustak as theoretical underpinnings of phenomenology guide the reader through the process of how to manage a phenomenological study step-by-step. and so, this provides more in-depth insights on the successful phenomenological studies from distinct contexts, including the field of healthcare, therapy, psychology, victimology, as well as investigations involving gender. while conducting a phenomenological research methodology, it often pertains the four necessary steps of bracketing, intuiting, analyzing and describing. this paper looks at phenomenological research methodology applied in a nursing context. keywords: phenomenological research methodology, bracketing, intuiting, analyzing, describing  1.0. introduction clark moustakas focuses on the theoretical underpinnings of phenomenology, in references to other scholar's elucidations, including husserl and others. moustakas guides the reader through the process of how to conduct a phenomenological study step-by-step. and so, this provides more in-depth insights on the successful phenomenological studies from distinct contexts, including the field of healthcare, therapy, psychology, victimology, as well as investigations involving gender. as well, his assertions are the inclusion of letters and other tools of research that are used in designing and conducting studies. more precisely is the fact that according to his elaborations, phenomenological analysis connects with different qualitative approaches that include ethnography, symbolic interactionism, and hermeneutics (glaser, 2017 pg. 69). from this simple phenomenological articulation, his research seeks to provide a description rather than explanation through starting from a free perspective where hypotheses and preconception phenomenological research methods are effective in bringing forward the individual's perceptions and experiences at very manipulative and challenging structural assumptions (moustakas 1994 pg. 12). for that case, through an interpretive dimension to this phenomenological study, this article aims to examine the role of phenomenological research methodology in management research, the steps involved in phenomenological research method, and my understanding of phenomenological research methodology by applying it to a chosen management topic – in a nursing context.  www.scirj.org  2019, scientific research journal http://dx.doi.org/10.31364/scirj/v7.i5.2019.p0519656  
  scientific research journal (scirj), volume vii, issue v, may 2019 issn 2201-2796  89  2.0. phenological research methodology the phenomenological research methodology is associated with some approaches that, in turn, are applied to single cases or to the deliberate samples that are selected. with such individual studies, it is easier to identify issues that show discrepancies, failures, favorable inferences, and attention to distinct situations while conducting management research (groenewald 2004, pg. 87). on the contrary, in research that involves multiple participants, it is easier to note the strength of inferences that are heightened by the rapidly occurring actors with more than one participant. consequently, it becomes increasingly easier to distinguish between qualitative and statistical validity when phenomenological research methodology is used (smith, 2015 pg. 121). also, this research methodology is significant in indicating the presence of factors and their implications in distinct contexts of cases, but; it only applies in situations where the experimental approach has been used in suggesting the extent to which the population from which the participants or examples were drawn. what’s essential with phenomenological research methodology, it is easier to provide detailed comments on the situations of individuals that otherwise do not lend themselves to direct generalization, just the same way the survey research is conducted (schutz, 1970 pg. 81). 3.0. general theories however, for the cases where validity is significant, there is need to develop general theories that will back this research methodology, in turn, provide the readers with the ability to work through their findings to the methods and investigate how the researcher has managed to develop some critical interpretations (sanders, 1982 pg. 45; moustakas, 1994 pg. 5). as if that is not enough, while using phenomenological research methodology in management research, the researcher may not appear in person, even though this is rare in public-domain reports. finally, the phenomenological research method is good at surfacing deep concerns and providing the platform where the voice is heard. unfortunately, this is less favorable and not always comfortable with some participants like funders and other clients, in specific, the situations where the researcher exposes challenges and assumptions that are taken for granted (hycner, 1985 pg. 187). irrespectively, many organizations perceive this facet of exposing the assumptions that are taken for granted as a key to bringing in terms the prompting action or even as a challenge to complacency (moustakas 1994 pg. 12). 4.0. four essential steps while conducting a phenomenological research methodology, it often pertains the four necessary steps of: 1) bracketing – this is the process where preconceived beliefs and opinions concerning the phenomenon research are identified and held in abeyance. in this process, as sanders (1982 pg. 33) attempts to ascertain, the researcher brackets out the surrounding and any presuppositions contained in a bid to confront the data in a very pure form. this is regarded as the www.scirj.org  2019, scientific research journal http://dx.doi.org/10.31364/scirj/v7.i5.2019.p0519xx  
  scientific research journal (scirj), volume vii, issue v, may 2019 issn 2201-2796  90  central component of phenomenological reduction where the isolation of genuine phenomenon is done regarding what is already established of the event. 2) intuiting – after bracketing out is done, intuition follows, where the researcher now remains focused on the attributed meaning of the phenomenon by the preceded research. through this process, a shared understanding of a phenomenon on whatever being studied is achieved. to efficiently accomplish this process, the researcher should provide the variance of the data until a common understanding is met. therefore, this process calls for the researcher to be immersed in the study and the phenomenon being studied. 3) analyzing – after accomplishing the intuition process, the analysis is the next step. in this process, coding is done where categorizing and making sense of the significant meanings of the phenomenon is created. polkinghorne (1989 pg. 69); and moustakas (1994 pg. 118) stresses that persistent working with the detailed data results to the emergence of essences and universal themes. when the researcher is in this process, there is the need to immerse for as long as possible for attaining pure and thorough description of the phenomenon. 4) describing – the critical step of any phenomenological research methodology is the description. in the descriptive stage, this is where comprehension and definition of the phenomenon are done by the researcher. this is purposed to provide the final step that catapults communication and offers distinctions and critical descriptions in both written and verbal form.  5.0. phenomenological research applied in a nursing context one of the management issues where phenomenological research methodology can be applied is in a nursing background. nevertheless, while many caregivers may be on the verge to relate to the phenomenological approach since, they see it as value sharing of nurses, it might be necessary but not sufficient on its own (oiler, 1982 pg. 167). by using the examples by clark moustakas, nurses use phenomenological research methodology for many purposes (moustakas 1994 pg. 79). of paramount, this method gives support for the re-examination of the experiences that are taken for granted while offering caring services. this goes as far as examining the qualities of the knowledge that allows the nurses to identify its essence. and so, the goal of this methodology in the nursing context emerges to be a framework where a person's lived experiences are accurately described regarding the phenomenon being studied. gorden (1975 pg. 115) states that for any nurse to relate to the phenomenological research methodology, it aids in valuing the experiences of individuals by making them feel like they have already gained the required skills, like interviewing. what they ought to comprehend is that even with skills of interviewing, this may not be a suitable method only. reports by jasper (1994, pg. 67) asserts that there is an increased number of nurses who have been drawn to phenomenology. perhaps, the fact that in nursing, it's possible to consider experiences of a whole person, thus delivers a comprehension to patients by being perceptive and synthesizing www.scirj.org  2019, scientific research journal http://dx.doi.org/10.31364/scirj/v7.i5.2019.p0519xx  
  scientific research journal (scirj), volume vii, issue v, may 2019 issn 2201-2796  91  with them, provide an outlet to the precarious acumen. it aids an individual in exercising control over their healthcare. what's more, using this methodology provides the nurses with respect for people, through listening and believing them. in this case, nurses can now relate the methods being used to deliver care with the information given to obtain necessary data. quality listening skills in nurses is a notion that enables the correct creation of a good rapport in a short period. all these and many others are dependable skills in nursing, where it's enough to allow them to carry out the proper interview in the type of research that interests them. 6.0. conclusion the very most significant phenomenological approaches are the descriptive and interpretative phenomenological approach (lopez & willis, 2004, pg. 98). on the one hand, using a descriptive phenomenological approach by nurses make them believe that it is impossible to read the mind of their clients in an entirely and emphatic manner. balls (2008, pg. 131) emphasizes that using this approach is better than using your own experiences as a nurse to interpret those of others. also, a nurse using this method in conducting research, one would be expecting to see some bracketing out their preconceptions and ensure that there is a neutral approach to their topic of interest. somewhat, this may mean even there is no need for conducting a literature search before any research is being carried out as a way of avoiding interviews contamination (annells, 2007 pg. 57). on the other hand, nurses who use the interpretative phenomenological approach are needed to indicate how their choice of research topic, research questions, and interpretations have been shaped by their own experiences. therefore, many are expected to write the appendix to the open work. it would be inherently wrong for nurses to assume that using phenomenological research methodology is an easy option or an indication of having the necessary skills for nursing. there is a need to understand the distinct approaches in phenomenology for nurses to direct and provide information on the research process at every stage of their profession (husserl, 2002 pg. 35). conflicts of interest: the author declares no conflicts of interest regarding the publication of this paper references [1] annells, m., 2007. guest editorial: what's common with qualitative nursing research these days? journal of clinical nursing, 16(2), pp.223-224. [2] balls, p., 2008. phenomenology in nursing research: methodology, interviewing, and transcribing. nursing times, 105(32-33), pp.30-33. [3] glaser, b., 2017. discovery of grounded theory: strategies for qualitative research. routledge. www.scirj.org  2019, scientific research journal http://dx.doi.org/10.31364/scirj/v7.i5.2019.p0519xx  
  scientific research journal (scirj), volume vii, issue v, may 2019 issn 2201-2796  92  [4] gorden, r.l., 1975. interviewing: strategy, techniques, and tactics. “the” dorsey press. [5] groenewald, t., 2004. a phenomenological research design illustrated — international journal of qualitative methods, 3(1), pp.42-55. [6] husserl, e., 2002. the shorter logical investigations. routledge. hycner, r.h., 1985. some guidelines for the phenomenological analysis of the interview data.  human studies, 8(3), pp.279-303.  [7] jasper, m.a., 1994. issues in phenomenology for researchers of nursing. journal of advanced nursing, 19(2), pp.309-314. [8] lopez, k.a., and willis, d.g., 2004. descriptive versus interpretive phenomenology: their contributions to nursing knowledge. qualitative health research, 14(5), pp.726-735. [9] moustakas, c., 1994. phenomenological research methods. sage. [10]. oiler, c., 1982. the phenomenological approach in nursing research. nursing research, 31(3),  pp.178-181.  [11] polkinghorne, d.e., 1989. phenomenological research methods. existential-phenomenological perspectives in psychology: exploring the breadth of human experience, pp.41-60. [12]. sanders, p., 1982. phenomenology: a new way of viewing organizational research. academy of management review, 7(3), pp.353-360. [13]. sanders, p., 1982. phenomenology: a new way of viewing organizational research. academy of management review, 7(3), pp.353-360. [14]. schutz, a., 1970. ed hr wagner on phenomenology and social relations chicago. [15] smith, j.a. ed., 2015. qualitative psychology: a practical guide to research methods. sage.  www.scirj.org  2019, scientific research journal http://dx.doi.org/10.31364/scirj/v7.i5.2019.p0519xx  
       


secondary_title_index: bmc medical research methodology
title_index:
       a specific method for qualitative medical research: the ipse (inductive process to analyze the structure of lived experience) approach     

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       sibeoni et al. bmc medical research methodology https://doi.org/10.1186/s12874-020-01099-4  (2020) 20:216  technical advance  open access  a specific method for qualitative medical research: the ipse (inductive process to analyze the structure of lived experience) approach jordan sibeoni1,2* , laurence verneuil2, emilie manolios2,3 and anne revah-levy1,2  abstract background: this paper reports the construction and use of a specific method for qualitative medical research: the inductive process to analyze the structure of lived experience (ipse), an inductive and phenomenological approach designed to gain the closest access possible to the patients’ experience and to produce concrete recommendations for improving care. this paper describes this innovative method. methods: ipse has five steps: 1) set up a research group, 2) ensure the originality of the research, 3) organize recruitment and sampling intended to optimize exemplarity, 4) collect data that enable entry into the subjects’ experience, and 5) analyze the data. this final stage is composed of one individual descriptive phase, followed by two group phases: i) structure the experience, and ii) translate the findings into concrete proposals that make a difference in care. results: this innovative method has provided original findings that have opened up new avenues of research and have important practical implications, including (1) the development of patient-reported outcomes, (2) clinical recommendations concerning assessment and treatment, (3) innovative ways to improve communication between patients and doctors, and (4) new insights for medical pedagogy. conclusions: ipse is a qualitative method specifically developed for clinical medical research to reach concrete proposals, easily combined with quantitative research within a mixed-method study design and then directly integrated within evidence-based medicine. keywords: qualitative research, patient-reported outcomes, research methodology, care  background the need for a new qualitative method conceptualized by physicians  as the role of patients in their own medical management radically evolves, more collaborative practices that * correspondence: jordansib@hotmail.com 1 service universitaire de psychiatrie de l’adolescent, argenteuil hospital centre, 69 rue du lieutenant colonel prud’hon, 95107 argenteuil cedex, france 2 ecstrra team, umr-1153, inserm, universite de paris, f-75010 paris, france full list of author information is available at the end of the article  consider the patient’s perspective in this process are progressively replacing the older approach of paternalistic medicine [1]. patients’ preferences, choices, and needs have been placed at the core of treatment. this idea relies on a paradigm shift that places the patient’s lived experience at the center of the care process. that is, patients are now considered to be the expert on their own lived experience; and their voices must be heard to enable the achievement of a more person-centered medicine. this paradigm shift is illustrated by the   the author(s). 2020 open access this article is licensed under a creative commons attribution 4.0 international license, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the creative commons licence, and indicate if changes were made. the images or other third party material in this article are included in the article's creative commons licence, unless indicated otherwise in a credit line to the material. if material is not included in the article's creative commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. to view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. the creative commons public domain dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.  
  sibeoni et al. bmc medical research methodology  (2020) 20:216  development of concepts such as patient experts [2], patient partners [3], and peer-support workers in psychiatry care [4], but also by the evolution of the principles of evidence-based medicine (ebm). the concept of ebm emerged in the 1980s with the aim of rationalizing medical practices and hierarchizing the medical literature. this concept first relied only on (i) external clinical data (that is, results from randomized control trials and meta-analysis), with (ii) medical expertise subsequently included, and most recently, (iii) patients’ preferences added [5]. ebm considers, nowadays, that the bestinformed medical decision is the one at the intersection of a venn diagram composed by these three circles. this paradigm shift is also illustrated by the development of new concepts intended to capture patients’ preferences better: patient-reported outcomes (pros) and patientreported outcome measures (proms). according to the fda-nih biomarker-working-group glossary definition, a pro is “a measurement based on a report that comes directly from the patient, about the status of a patient’s health condition without amendments or interpretations of the patient’s response by a clinician or anyone else” [6]. today, clinical trials use pros/proms increasingly often [7]. they are essential outcome measures, demanded by health authorities and regulatory agencies, and useful for physicians, patients, and health policy-makers. in this new era of person-centered medicine, many authors have concluded that an initial phase of qualitative research is needed early in the construction of all pro tools to explore patients’ experiences [8– 10]. the pro good research practices task force of the international society for pharmacoeconomics and outcomes research (ipsor) [10, 11] has also published suggestions for conducting qualitative studies intended to support the content validity of pro instruments. qualitative health research (qhr) is a relatively recent field, covering a broad area — from the description of illness experience to the sociocultural organization of health care — and using a myriad of qualitative methods coming from other theoretical fields, mostly social sciences: sociology (i.e., symbolic interactionism with grounded theory [12], ethnography [13]), psychology (i.e. phenomenological psychology [14–17]), case study, narrative, and linguistics [18, 19]. other qualitative methods have been developed specifically for qhr in applied disciplines, mainly by and for nursing sciences [20, 21], and in primary care [22], focusing on specific issues (e.g. experience of specific illness, of caring, of help seeking). qualitative research is now booming in biomedical clinical studies [23] in many medical specialties, aimed at obtaining an in-depth understanding of phenomena, directly from the perspective of the people experiencing them. these studies have either applied a qualitative method from another field, or relied exclusively on a  page 2 of 21  thematic analysis approach intended only to structure how the data are analyzed and the results presented [24]. according to morse, one goal of qhr is to “bridge the gap between scientific evidence and clinical practice” [20]. this is already the case at a “review” level with the work of the “cochrane qualitative & implementation methods group” for the dissemination and incorporation of qualitative results in systematic reviews, that is, qualitative evidence synthesis [25]. but, so far, there has been no medical qualitative research method specifically tailored to produce rigorous data from the lived experiences of both patients and physicians to directly inform ebm. for instance, there are no specific qualitative methods to explore the perceived efficacy of a treatment to determine efficacy criteria relevant for patients themselves. medical research should expect qualitative studies to produce knowledge with the potential to improve patients’ care and lives, and not simply conceptual knowledge, that is, knowledge for its own sake, as qualitative methods from the social sciences produce [20]. within nursing research, thorne has developed “interpretive description”, an inductive qualitative method with roots in phenomenology, ethnography, and grounded theory but which endeavors not to theorize the results but rather to offer practical outcomes for nurses’ daily practices [21]. although applicable to other areas of health, including clinical medical practice [26, 27], interpretive description does not focus on the lived experience of the stakeholders but rather on contextualizing illnesses in multiple domains (e.g. experiential, spiritual, political, cultural, etc.). our group, which has worked more than a decade on the analysis, dissemination, and use of qualitative methods in medicine, has developed expertise in their use for exploring complex questions around the experience of diseases and their treatment [28–30]. we consider that physicians have specific concerns and that their medical training and professional experience enable them to contribute to the field of qualitative medical research differently than nurses and other healthcare professionals do. thus, as both medical doctors and experienced qualitative researchers, we have become convinced of the need for a new qualitative method designed by physicians for addressing specific issues in clinical medical research. we advocate that this new method should meet several criteria: 1. to thoroughly capture the lived experience of patients and other stakeholders: how they live their disease and its treatment and how they recount it [31], not as an end but a means, to connect experiential knowledge with physicians’ medical knowledge and to develop concrete proposals for  
  (2020) 20:216  page 3 of 21  improving the health care pathway, treatment, and clinical research. to be completely structured to allow a group of physicians, after receiving appropriate training, to conduct rigorous, systematic qualitative medical studies, that is, with all stages of the design clearly described and operationalized. to use vocabulary and concepts that make qualitative medical research accessible and meaningful for physicians and for administrative and policy-making bodies to directly involve patients within the research process to integrate qualitative medical research within ebm.  encounter between researchers and research participants [33, 34]. many qualitative methods, including ethnographic, narrative, and phenomenological, fit into this paradigm, —or have been adapted to it, such as charmaz’s adaptation of grounded theory from a constructivist perspective [37]. ipse fits epistemologically into a constructivist paradigm as we postulate that the production of knowledge relies on three elements: (i) subjectivity as a space for constructing human reality, (ii) intersubjectivity as a strategy for accessing valid knowledge of human reality, and (iii) understanding that human reality takes place in daily life. these elements underlie the strengths of this method, which is characterized by flexibility in the progressive construction of the object under study, constantly adjusted to the characteristics and complexity of human phenomena, and always takes the subjectivity of the researchers and the participants into account while combining several techniques of data collection and analysis. phenomenology literally means the study of what appears. at the very beginning of the twentieth century, phenomenology became the name of a philosophical current founded by husserl [38]. he aimed to study how objects appear to the subject’s consciousness and to describe the essence of a phenomenon not by describing the object as it exists but by describing the experience of the subject. phenomenology can be descriptive or interpretive, that is, associated with hermeneutics (science of interpretation) [39]. within qualitative research, phenomenological approaches seek to capture the lived experience of a subject about a phenomenon, to understand how this phenomenon appears in the individual’s conscious experience. in the field of phenomenology, experience is conceived as uniquely perspectival, embodied, and situated. phenomenological approaches are particularly relevant for conducting research on experiences, thoughts, imagination, intentions, desires or volition. there are many phenomenological qualitative approaches, coming mainly from the field of psychology, either descriptive (giorgi’s descriptive phenomenological approach [14], its adaptation by colaizzi [40], and moustakas’s heuristic method [16]) or interpretative/hermeneutic (interpretative phenomenological analysis (ipa) and van mannen’s approach) [15, 17]. many of them use a theoretical vocabulary and philosophical concepts that are not easily accessible for physicians. our early work used well-known qualitative phenomenological approaches: one descriptive, that is, colaizzi’s method [41] and one hermeneutic: ipa [42–48]. recently, philosophers working in the field of phenomenology have criticized some of these methods. zahavi wrote about the approaches of ipa and van mannen that “qualitative health researchers interested in phenomenology should look elsewhere for theoretical  sibeoni et al. bmc medical research methodology  2.  3.  4. 5.  since none of the existing qualitative methods meet all these criteria, we decided to progressively develop our own: inductive process to analyze the structure of lived experience (ipse). ipse: theoretical backgrounds  some qualitative methods have been suggested in medical research, such as qualitative theory-development studies or qualitative elicitation research within a cognitive model [32]. these are based on directive, taskoriented interviews that we think excessively restrict the direction of the conversations for both participants and interviewers. we want instead to keep the research open to what the participants’ narratives of the experience can add, to allow them to share what they have lived. we strongly believe that truly taking their experience in dealing with an illness or its treatment into account requires letting them recount it freely, as they want to and see fit. the exploration of the lived experience is for us the core of what qualitative methodology can contribute to medical research. to do so, the method must fit into the constructivist paradigm [33, 34] and be informed by a phenomenological approach [14], but without overly theorizing the underlying epistemological and philosophical knowledge, which would impede its practicability. lived experience can be defined as personal knowledge of the world gained through direct participation and involvement in the event or phenomenon. lived experience refers to human activities that are immediate, situated and daily, which are lived without thinking about or paying attention to them (pre-reflexive experience) [35]. constructivism comes from the work of the philosopher immanuel kant [36]. it considers that knowledge emerges from a human process of construction. as a research paradigm, constructivism conceives knowledge as a shared construction built on the  
  sibeoni et al. bmc medical research methodology  (2020) 20:216  inspiration and methodological guidance” [49]. as for moustakas’s method, appelbaum noted that, although it uses key phenomenological terms, this method is not phenomenological but rather grounded in a humanistic therapeutic perspective [50]. moreover, hermeneutic approaches assume that human beings are always already engaged in interpretative meaning-making activities. they do not seek to capture the patients’ lived experience, but only the meaning they give to it. these aspects do not appear appropriate for application in medical research. in line with thorne [21], we consider that the interpretative underpinning in qualitative medical research must be more pragmatic and focus on eliciting concrete proposals for improving treatment. a descriptive approach, that is, “develop [ing] a textural description, what the participants experienced, and a structural description, how they experienced it in terms of conditions, situations or context” [51] appeared to us more appropriate to integrate into ebm and pro. however, the descriptive phenomenological approaches [14, 40] are mainly methods for analyzing qualitative data (i.e., interview transcripts) and not global research methods (methods structuring a systematic research process from a to z). in particular, while they underline the need to collect data of first-person accounts of types of experience, they do not provide detailed instructions for the data collection process or study design. furthermore, descriptive approaches consider access to the lived experience as the goal of the approach without any other more practical and concrete objectives or perspectives. as mentioned above, we consider that within qualitative medical research, lived experience should be considered a means rather than an end. all stages of ipse are informed by a phenomenological descriptive approach, not only the analytical procedure, as each stage contributes in its own way to capture and describe the lived experience of the participants. at the same time, the objectives of ipse differ from those of other phenomenological approaches used in qualitative health research: it seeks to improve the quality of care, by producing concrete measures (about treatment and care pathways) and to propose new avenues of research. the two cornerstones of ipse  the choice of the name ipse (inductive process to analyze the structure of lived experience) underlines the method’s two cornerstones: the inductive process and the analysis of the structure of lived experience. ipse relies on an inductive process: the procedure is exploratory, and no research hypotheses are formulated before starting; rather, they emerge from the material, through methods designed to penetrate as far as possible into the participants’ lived experience. because the data are collected and analyzed simultaneously, the analysis  page 4 of 21  can affect the collection of the data, directly from the material, that is, the narrative of the participants’ lived experience [31]. the most exemplary inductive approach in qualitative research is grounded theory [12], in which the researchers must suspend their relations with previous theories and limit their review of the literature, so that they can be fully attentive to the unexpected and the novel and can allow local theories to be emerge directly by the context and the material [52]. the ipse inductive approach does not, however, imply disregarding either practical or theoretical medical knowledge when formulating research questions and objectives. the starting point of an ipse study is always an unanswered question about the experience of individuals involved in medical care, unanswered questions by experienced physicians specializing in the topic. these specialized physicians are part of the research group and contribute to all the stages, including the definition of the areas to be explore in the data collection procedure. however, in line with the grounded theory approach [12], the physicians are not to share their knowledge with the qualitative researchers conducting interviews and analyzing data. a qualitative researcher is his or her own instrument [53] and his or her preexisting knowledge and preconceptions (i.e. assumptions, values, interests, theories, beliefs, emotions, etc.) influence how data are collected, explored, analyzed, interpreted, and presented [54]. usually, researchers using a qualitative phenomenological approach claim they perform epoche, that is, that they “bracket” or set aside their preconceived knowledge and preconceptions of the phenomenon being researched [54]. phenomenological philosophers, however, argue that this husserlian term has been misused and misinterpreted by qualitative researchers [55]. using terms such as epoche and reduction would, we think, confuse physicians and impede the accessibility of the ipse method to physicians. we consider instead, along with other researchers such as moustakas [16], that what matters is not to bracket the preconceptions but to identify and acknowledge, and make them explicit, through the act and work of reflexivity [56], which we will describe fully later. only in this way can researchers avoid blind spots and cognitive biases, that is, the systematic errors in thinking that occur when people are processing and interpreting information-, especially confirmation bias, selection bias and the curse of knowledge [57, 58] that can hinder both access to the participants’ experiential knowledge and the discovery of new useful knowledge. the analysis of a structure of lived experience is the main goal of our method. the descriptive phase of the analysis is inspired by colaizzi’s method [40], but our approach is systematic and the structure of the experience is not an end but a means, since it is translated into  
  sibeoni et al. bmc medical research methodology  (2020) 20:216  concrete proposals for improvement in the health care pathway, for treatment, and for clinical research.  method the ispe method has five stages that structure the entire research process (fig. 1).  stage 1: setting up a research group  the research group always includes two physicians specializing in the topic, generally three researchers with expertise in qualitative methods, and, when possible one or two patients who experience the phenomenon under study. in total an ipse research group ideally contains five to seven members. this number is necessary to ensure that the study is rigorous and trustworthy.  page 5 of 21  – the two physicians specializing in the topic are necessary because they both perform the systematic review (stage 2) and ground all the research process into practical and theoretical medical knowledge without impeding the inductive process. – the three qualitative researchers collect the data (stage 4) and analyze it (stage 5, descriptive individual phase). we consider that three are necessary to avoid confining the data collected and analyzed in the sole perspective of one researcher, or confronting only two opposing points of view. as for the two patients: in both participatory [59] and heuristic approaches [16], participants are not viewed as study subjects but as co-researchers who are an integral part of the research process. ipse strongly supports a more participatory approach in which service users should be directly involved in the qualitative medical  fig. 1 ipse, a new method for qualitative research applied to clinical medical research, in 5 stages  
  sibeoni et al. bmc medical research methodology  (2020) 20:216  research process [60], but with a different innovative strategy — to integrate directly, when possible and appropriate, into the research group one or two patients who have experienced the phenomenon or had the disease under study. this strategy follows the same principles as those underlying the use of peer-support worker in psychiatric departments to allow a more person-centered and recovery-focused approach [4]. participating patients requires a short training on qualitative research in general and the ipse approach in particular, which we provide in 3 days before the research starts. integrating patients within the research group is not mandatory as it can sometimes be quite difficult to find such patients willing to be trained and participate. however, the research group must meet at least twice with “subjects of the experience” that is, patients other than the participants, in the same situation (via patient associations, for example) (i) at the very beginning of the research to develop a research question that really matters for the patients; and (ii) at the end to obtain feedback and validation of the results from the patients themselves. this group oversees the entire research project, making all decisions collegially. we aim for heterogeneity in the group’s members, in terms of culture, knowledge, sex, age, occupation, and background. this diversity helps enrich the research at every stage, so that the results are more robust and relevant and not limited to a single perspective.  stage 2: ensuring the originality of the study  we follow the common principles of good practice in research, one of which is that a study must always begin by examining the existing qualitative and quantitative literature on the subject. inductive approaches generally assume that to prevent interference by existing data, researchers beginning a qualitative study must not review the literature. on the other hand, there is little reason to replicate a qualitative study, since the importance of this type of research is measured by the novelty of the information it provides. it is thus important to avoid reinventing the wheel with each study, which would result in literature overloaded by similar but different or differently labeled concepts — what morse describes as “theoretical congestion” [20]. moreover, it is as important to ground the research in a rationale informed by medical literature, for example, by specifying or redefining the study objectives, as it is to remain attentive to the unexpected and novel [52] to produce original findings. this epistemological issue is known as meno’s paradox, enunciated by socrates in plato’s meno: “we cannot look either for what we know, nor for what we do not know; what we know because, as we know it, we do not need  page 6 of 21  to look for it, what we do not know because we do not even know what to look for [61].” to resolve this conundrum, we have developed an original group procedure: the two physicians who are experts in the topic conduct a systematic review of the qualitative and quantitative literature to confirm the study’s relevance and originality. to remain inductive and open to novelty, as mentioned above, the other group members have access to this review only after the data analysis has been completed. the tragedy of modern knowledge is, as morin stated, that “the exponential increase in knowledge and references ... stands in the way of reflecting on knowledge” [62]. it is therefore important that physicians share the minimum of necessary knowledge to inform the study without impeding it by the curse of knowledge [57]. stage 3: recruitment and sampling, aiming for exemplarity  after defining the research question, the group selects the study site or sites best able to optimize the feasibility of recruitment, depending on the study topic. it also defines the inclusion and exclusion criteria. in our method, sampling aims to attain exemplarity, that is, to select participants who, according to the research group (especially the physicians and the patients), have experienced quintessential, typical, or archetypal examples of the situation being studied. it thus uses purposive sampling, that is, selects the subjects likely to provide the most information about the phenomenon studied [63]. unlike other recruitment strategies in qualitative research (i.e., homogeneous or convenience sampling), we are looking for a variety of exemplary situations by including participants who might enrich and add something new to what was previously found. the patients included might thus differ by sex, age, social and family status, degree of involvement, disease history, comorbidities, duration of treatment, and outcomes. this enables a broader understanding of the phenomenon under study. because the analysis takes place simultaneously with the data collection, the latter continues for as long as the analysis of the material continues to provide new information useful for exploring the topic. sample size in qualitative research is not defined in advance. it is determined by data saturation, usually defined as when the analysis of new material no longer yields new findings [64]. saturation is, as morse stated, “the key to excellent qualitative work” [65]. it is indeed an essential criterion of validity in qualitative research, especially for qualitative studies intended to lead to pro development [66], as it ensures in-depth study of the phenomenon and suggests that further interviews are unlikely to produce new findings. this point has been heavily criticized, however, for it appears impossible to affirm saturation with certainty; that  
  sibeoni et al. bmc medical research methodology  (2020) 20:216  is, even if data saturation is a helpful idea for qualitative researchers, there are no pragmatic and consensual guidelines for determining when the point of data saturation has been reached [67]. for this reason, in line with grounded theory approaches, we prefer the concept of “theoretical sufficiency” [68]: data collection and analysis are complete when the researchers consider that the axes of experience obtained provide a sufficient explanatory framework for the data collected. our minimum sample size is always at least 20 subjects, a choice made to optimize the visibility of our work: it enables publication in specialized journals accustomed to the large sizes in quantitative samples and randomized clinical trials, and unfamiliar with qualitative research, where sample size is not a criterion of methodological rigor. stage 4: data collection, access to experience  the quality of the data collection determines the quality of the results. the goal is to reach the narrative of the experience [69]. the tool used to obtain this narrative always depends on the context, in either individual interviews or focus groups. researchers in charge of data collection procedure should always consider the risk that face-to-face questioning might limit the subjects’ ability to narrate — to talk about — a subject so deeply personal, especially vulnerable persons [70] and adapt the data collection process to ensure they reach this narrative. patients can find it difficult, even intrusive, to talk about their lived experience of a disease [71]. most of the time, the ipse data collection procedure relies on visual narrative support for the participants, aimed at enhancing the narrative by reducing inhibitions. this support may be a photograph, or a clinical vignette, or a short video clip directly related to the experience under study. it also facilitates the relationship and communication between the researcher and the subjects [70]. photo-elicitation is the visual narrative support method we use most often [72]. this tool helps participants to think about a picture — ideally one they took themselves or, sometimes chosen with caution by the research group for the purpose of introducing the object of the study without influencing the participants. the positive effects of photo-elicitation on the research process have been widely described in qualitative literature: it improves the quality of the data collected [73], it promotes active cognitive involvement and better participation in the research [74] and when the participants take the picture themselves, it empowers them, by putting them in a more active position and thereby giving them the opportunity to influence the research process more strongly [75]. in interviews, the qualitative researchers systematically start by asking the participants to comment and react to  page 7 of 21  the experience-related visual support. the latter usually begin and spontaneously continue speaking about it and especially their own experience. the researchers then move on to open-ended questions [76], structured by the areas to explore, developed in turn from: (i) reading two pilot interviews, which will not form any part of the data analyzed for the study, (ii) the qualitative researchers’ own thoughts, each with different insights according to his or her own explicated preconceptions on the subject, and (iii) the knowledge and representations of the physicians experts in the topic. the group collectively chooses the areas, but these may be modified throughout the research process by each interview conducted. the interviewers use an interactive conversational style [77]. in an ipse study, participants are considered the experts on their own experience. qualitative researchers must conduct interviews that offer them the opportunity to recount it. in practice, they use prompts based on the “life-world” [78], a phenomenological concept with five dimensions (i.e., lived body, lived time, lived space, otherness and selfhood) through which the everyday actions and thoughts of the participants can be explored. all interviews are recorded and then transcribed verbatim, including the nonverbal aspects (e.g., pauses, hesitation, and laughs). the data are anonymized. the transcripts obtained are the object of the analysis. stage 5: data analysis, from the structure of the experience to its translation into concrete proposals  our analytic process is rigorous, detailed, systematic, and sharable. it relies on an inductive, phenomenological method and is intended to lead to concrete suggestions for improving aspects of treatment and of the health care pathway. it has two stages: one of independent work by individual researchers, and one of pooling the data collectively, by the group (fig. 2). individual procedure - descriptive phase  at least three of the qualitative researchers independently and simultaneously conduct a systematic descriptive analysis aimed at conveying each participant’s experience. this procedure is not original; it has been already proposed in other phenomenological approaches, including ipa [15] and that colaizzi’s method [40]. in fact, our descriptive analytic phase is inspired by colaizzi’s analytical procedures and leads to the drafting of a structure of the experience, related to what colaizzi named the “fundamental structure of the phenomenon” [79]. for each interview, this involves – listening and reading: we suggest that qualitative researchers analyzing the data listen to the recorded  
  sibeoni et al. bmc medical research methodology  (2020) 20:216  page 8 of 21  fig. 2 stage 5 of ipse. from the demonstration of the structure of the experience to its translation into concrete proposals. a. the procedure of each researcher, initially individually, corresponds to the descriptive analysis phase, including: i) listening to and reading the interview, ii) cutting up the text in descriptive units and then regrouping them into categories, this operation is performed for each of the 20 interviews, which are analyzed transversally. b. this structuring phase involves a group procedure (at least 3 researchers) with regular pooling of the data and analysis, during which the theoretical sufficiency is assessed. during this phase, the axes of experience are produced and the group determinates the central axes of experience, which result in the proposal of a structure of the lived experience. finally the practical phase, which leads from triangulation by the literature to concrete proposals (guidelines, pro)  interview twice — once without taking notes, and a second time while taking notes throughout. they can refer to these notes during the analysis and share them (or not) during the group process. next, they read the interview transcript three times, taking notes at each reading. this process bathes the researchers in each participant’s expressive style and enables an overview of the narrative. these numbers of times to listen to and read the interview are of course suggestions; these remain the decision of each researcher. for instance, some researchers prefer to transcribe their own data and do not need to listen and read as much as a researcher discovering the data for the first time. however, in our experience, for data not transcribed by the researcher, listening twice and reading three times appear to be a perfect compromise to really  saturate oneself with the material without wasting too much time. – exploring the experience word by word: the researchers explore the interview meticulously and cut up the entire text (in units of one or several words) into segments called descriptive units (table 1). these descriptive units are not preestablished and remain as close as possible to the participants’ words. – regrouping the descriptive units into categories: the units are categorized, that is, they are regrouped according to their proximity of meaning and experience, wherever they may be in the interview. this reorganization reveals the framework of the participants’ experience (fig. 4). these stages are carried out with the help of “qsr” nvivo12 software to create and assemble the descriptive  
  sibeoni et al. bmc medical research methodology  (2020) 20:216  page 9 of 21  table 1 word for word exploration, example of decoupage transcript (excerpt)  words to be coded  descriptive units  i have the impression  have the impression  interviewer: what exactly is it that is complicated? woman: i have the impression that people look at my hands, they are strange, these hands...so i tend to hide them.  people are looking at my hands  looking at my hands  they are strange, these hands  strange hands  so i tend  tend  to hide them  hide my hands  interviewer: i don’t understand, i’m sorry, you hide your hands because who is looking at them? woman: the people at work look at my hands  the people at work  colleagues  look at my hand  looking at my hands  wait  wait  i’m thinking  thinking  it’s more the women  more the women  finally i’m more often with the women too  environment of women  it’s more the women, yes  more the women  yes, yes i’m just now realizing it  understand  interviewer: the people at work in general or some people in particular? woman: wait, i’m thinking, it’s more the women, finally i’m more often with women too, yes, it’s more the women  interviewer: it’s different for you, that is, the gaze of another woman or of a man — you’re going to experience them differently? woman: yes, yes i’m realizing that now, but it’s totally crazy, it’s that the women looking at me is going to bother me more, is going to be more ...be more...  now  now  but it’s completely crazy  ridiculous  it’s that a woman looking at me  women looking  bother me more  be bothered  is more ... be more ...  more the women  interviewer: more? woman: i’m going to be more sensitive... but i don’t know why. you have the answer, because i don’t.  i’m going to be more sensitive  hesitation  but i don’t know why  be more sensitive to it  you have the response  not know why  because i don’t  you have the response not know why  interviewer: no i don’t know either, you’re a woman yourself.... woman: i have always had the impression that women observe more than men... or else, yeah, i have the impression that the women stare at me much more than men do.  units and provide graphic support for their reorganization. this descriptive analysis is performed separately for each interview. progressively, the researchers independently analyze all of the interviews thus far explored, cross-sectionally, by regrouping similar categories and excluding none of them.  i’ve always had the impression  have the impression  that women observe more than men...  women observe more  or else  or else  yeah i have the impression that  have the impression  the women stare at me much more than the men stare at me  more the women be stared at  group process-the structuring phase and then the practical phase  during this group process phase, the three researchers who segmented and coded the text now meet and work with the other group members, that is, the physicians experts in the topic, the other qualitative researchers,  
  sibeoni et al. bmc medical research methodology  (2020) 20:216  and the patients, all of whom have familiarized themselves with the data (by listening and reading all the interviews as many times as necessary), without performing the descriptive analysis. the group’s heterogeneity has a heuristic function essential for the construction of the results: the group enables the coconstruction by all group members of important points of the experience linking a set of implicit perspectives, made up of each researcher’s culture, theory, knowledge, sex, function, and background. the three researchers meet with the rest of the group after the analysis of five interviews, then 10, then 15, then 20, etc. ... to share the categories that have been uncovered and assess their theoretical sufficiency. in practice, for organizational reasons mostly, group meetings can occur after the analysis of more or less than five interviews; however, we recommend this rhythm of meetings because of our experience: we found that sharing the content of the descriptive analysis of more than five interviews can result in a superficial sharing that impairs the quality and originality of the results, while more frequent meeting appeared to be time-consuming without providing richer data analysis.  page 10 of 21  the structuring phase in practice, during these twohour meetings, the group must: regroup the categories into axes of experience: the reorganization of the categories must uncover the framework of the participants’ experience, which we call its axes. these axes must be constructed such that each can be linked to its subjacent categories. naming the axes must make it easy to read the results and highlight the original and relevant points. in practice, the names, the number, and the content of the axes may well change several times before their structure is finalized (fig. 3). determine the structure of lived experience characterized by the central axes: this is an action that is delicate, iterative. this phase involves an important dimension of choice. exhaustive results, unranked, may dilute the original points and the new information, thus impeding any translation of the results into direct implications. the final structure of lived experience does not reflect the many intermediate stages required to reach it, stages during which some axes of experience will be regrouped and some even  fig. 3 intermediate stages of the structuring phase (from axes of experience to the structure of lived experience). the objective of the structuring phase is to produce a proposed structure of the lived experience. the three researchers meet with the rest of the research group. this collective group procedure can be defined as a co-construction by the researchers of important points of the experience. a. it involves sharing all the categories and constructing the organization of the axes of experience obtained during the descriptive phase, sometimes changing the name of the axes, sometimes changing categories from one axis of experience to the other. b. this is an intermediate stage of organizing or naming the axes. the structuring phase is a repeated act with an important dimension of choice. some axes of experience will not discarded to determine the central axes of experience and terminate by c., the proposed structure of the lived experience  
  sibeoni et al. bmc medical research methodology  (2020) 20:216  abandoned. it is very important during this phase that the physicians who analyzed the literature consider and discuss the originality and relevance of each axis, or on the contrary, its previous mentions or triviality according to the literature. at the end of these two stages, the group, all together, writes up a proposed structure of the experience within the context in which it was explored, composed of its central axes of experience; this will be the study’s results section. practical phase the objective of this phase is the signature of the ipse method, concordant with thorne’s interpretive description [21]: the translation of the findings into proposals about the health care pathway, its clinical implications, and the perspectives for further research. accordingly, the results will propose, for example, supports for interviews or practical recommendations that physicians can use directly with these patients. a process of triangulation with the data in the literature completes the analytic process. this is not a process original to ipse, of course, but rather a good practice that should be followed in all qualitative health research [20, 22]. the physicians experts in the topic and responsible for the literature review now share with the group their in-depth analysis of the literature from several databases (pubmed, psycinfo, cinalh, and web-ofscience (ssci)) to identify the original aspects of the results and their differences and similarities with the literature. the completed study is then reported in a scientific article that meets the coreq criteria [80]. coreq is a useful checklist of items that should always be included in reports of qualitative research. although some items are directly related to criteria for analytic rigor, such as reflexivity or triangulation, the coreq checklist provides an outline for reporting important aspects of qualitative research and not guidelines for performing it. rigor and methodological quality of ipse  we identified and operationalized seven methodological points to ensure the quality and rigor of ipse studies. some are already recognized criteria of rigor for qualitative research (triangulation, attention to negative cases, transferability, reflexivity), others are innovative and specific:  page 11 of 21  including colaizzi, recommend that participants validate these results. there are practical difficulties in obtaining feedback from the entire group of participants. our method offers a methodological innovation by progressively replacing feedback by study participants by presentations of the study and conversations with other subjects of the experience. this action ensures the credibility of the results and guarantees their transferability. the results obtained by the ipse method have a singular status, as accessible and expected, but also uncovered and surprising. the expected effects are both agreement and surprise, through the uncovering of evidence “hidden” until then. the subject of the experience should be able to say: “it’s exactly that, but i had never formulated it like that”. triangulation  this concept refers to the use of multiple methods or data sources as a rigorous procedure to ensure a global understanding of the phenomenon under study [81]. there are four types of triangulation: “method triangulation, investigator triangulation, theory triangulation, and data source triangulation” [82]. in an ipse study, at least three researchers are involved with data collection and individual analytical procedures; several data collection techniques can be used in the same study (for instance, individual interview and focus group); and triangulation with the literature is systematically carried out. attention to negative cases  particular attention must be paid to these cases in which new elements can differ radically from the emerging structure of the experience. most of the time, these negative- sometimes contradictory- cases will be integrated into the results. if a case differs completely from the proposed structure of the experience, we consider that theoretical sufficiency has not been reached and conduct new interviews and analyses. the question of the choices of the central axes of experience  our objective is not knowledge for its own sake, but knowledge for improvement in patients’ care and in their lives. the choices, always guided by this objective, are determined by the relevance and not the recurrence of the axes of experience. researchers’ subjectivity and reflexivity  patient involvement and feedback of the “subjects of experience”  we have already mentioned that some patients should be part of the research group, or at least be invited to help develop the research question and to give feedback about the results. for the latter point, many authors,  the issue of reflexivity must be addressed. it can be defined as the researchers’ reflection of their role in the study and its effects on their findings at every step of the research process [56]. a recurrent hazard in qualitative research is that the results become the reflection or confirmation of the researcher’s preconceptions and beliefs  
  sibeoni et al. bmc medical research methodology  (2020) 20:216  [83]. the process of reflexivity enables researchers to avoid the pitfalls of applying their own preconceptions and assumptions to the material. they must take care to clarify their position, as much in their encounter with the material to be analyzed as in the research group meetings. to do this, the researchers involved in the study must answer these two questions regarding the study: – (i) what are my preconceptions and my beliefs about the phenomenon under study and the research question? to address this question, they must each list all of their preconceptions and beliefs first to themselves and then share them with the group – (ii) what are my expectations regarding this study? the researchers must question — themselves and each other — their personal motives to be a part of the research and what they are expecting to find or to achieve. this reflexive position is worked on constantly in the group, during open discussions between the researchers. more than in the field notes, it is in the conversations, exchanges, and discussions between the researchers that reflexivity accomplishes its work. transferability  qualitative research studies are performed in specific contexts. what matters for their results however is that they are transposable [84]; in our ipse approach, this means that the structure of the experience is transferable, that it resonates with what other patients live beyond the context of the study. the assessment of the transferability of results ultimately lies with readers, who must decide if the setting of the study is sufficiently similar for its results to be transferable to their own context [85]. we ensure the transferability of the structure of the experience by obtaining feedback from patient associations or other representative groups. also, as shown by the creation of a pro tool validated by a quantitative psychometric study (currently being written up) in scleroderma, validation in a large sample of other subjects demonstrates the transferability of our results. a tool developed and structured by our method focusing on the lived experience of patients appears transferable and closer to reality than tools based on the theories and inferences of the professionals who create them [86]. the language of the analysis  it seems important to specify that our position is to anchor our research work in the participants’ language as well as their words. the research is conducted entirely in french, the language of the participants, and the  page 12 of 21  researchers develop and write the results in this same language. finally, at the last stage, the article is sent to a bilingual (english-french) professional scientific translator, and the authors and translator consult frequently to ensure that the words and meaning stay as close as possible to those of the participants.  results the use of the ipse approach has provided original findings enabling practical implications, such as (1) development of pros focusing on areas not yet covered by existing scales, (2) clinical recommendations concerning assessment and treatment, (3) innovative ways to improve communication between patients and doctors, and (4) new insights for medical pedagogy. pro development the lived experience of hand involvement in patients with systemic sclerosis (ssc)  table 2 presents an exemplary ipse study exploring hand involvement among patients with ssc. the structure of lived experience described in our results revealed that the distress of patients dealing with functional impairment of their hands is linked especially to the loss of what had been important parts of their lives before the disease (leisure activities and hobbies, work, a musical instrument, a family activity). in other words, the intensity of the functional impact was related to “what i can no longer do” rather than to “what i cannot do.” the existing scales either focus on the very targeted assessment of individual components of hand involvement in ssc (the raynaud’s conditions score [87], the hand mobility in scleroderma scale [88], and the delta finger to palm [89]) or are generic functional scales validated for this disease, evaluating the functional impact of this involvement and its daily repercussions, at home, at work, and on qol (the cochin hand function scale [90], the arthritis hand function test [91], and some specific items of qol scales for scleroderma, such as the scleroderma health assessment questionnaire [92]). these scales evaluate the ability to perform some actions of daily life, such as cleaning or getting dressed, but do not include this dimension of a function they once had, which had been important, and was now lost. here, access to the lived experience and its rigorous analysis make it possible to show that it is this loss of function that is painful. similarly, our results show that patients develop strategies to compensate for this functional involvement, which no longer presents a problem in their daily life, although functional scales continue to detect it as a functional problem. the question of the visibility of their hand impairment, to themselves and to others, was also crucial in the lived experience of the participants. the esthetic  
  sibeoni et al. bmc medical research methodology  (2020) 20:216  page 13 of 21  table 2 example of an ipse study: the lived experience of hand involvement in patients with systemic sclerosis (ssc) context  ssc is a rare autoimmune chronic disease characterized by vascular injury, immune dysfunction, and an abnormal fibrotic process that can affect multiple organ systems including the skin, lungs, gastrointestinal tract, and cardiovascular system. skin is always involved, sometimes with raynaud syndrome and other frequent forms of hand involvement, associated with various often cumulative processes: joint, cutaneous, microvascular, bone, and nerve abnormalities. the repercussions of hand involvement play a central role in functional limitations and affect quality of life substantially. existing quantitative research on hand involvement in ssc has mainly evaluated its functional, disabling, and esthetic aspects. these studies are based on preconceptions of how to define and measure hand involvement, preconceptions that do not come from patients’ lived experience. no published research has provided patients with the opportunity to describe their experiences and perspectives about the emotional challenges and areas of distress they face.  objective  to explore how patients with ssc experience the effect of their disease on their hands  stage 1  research group included - two dermatologists specialized in ssc: lv, a professor, and dh, a resident in this specialty; - three researchers expert in qualitative methods (js, a male psychiatrist, arl, a female professor of medicine and em, a female psychologist). the group’s members were highly diverse especially in terms of knowledge, age, and background. the group started the research by meeting a group of patients (n 5) recruited from lv outpatient practice, in the caen university hospital. all of them emphasized the central role of hand involvement in their daily lives.  stage 2  the two clinicians reviewed the qualitative and quantitative literature systematically to confirm the relevance and originality of the study. they verified that no qualitative study had dealt with the specific experience of hand involvement in ssc, although a substantial qualitative literature has looked at the global experience of ssc patients as a whole. to maintain an inductive process, the other group members did not have access to this review until the practical phase of stage 5.  stage 3  the research group defined the inclusion and exclusion criteria, intended to attain this exemplarity. inclusion criteria: - age: 18 or older - scleroderma diagnosis according to the acr/eular criteria (european league against rheumatism, 2013) - involvement of the hand (raynaud phenomenon) - agrees to participate in the research exclusion criteria: - age 18 - psychiatric disorders or impairments of cognitive function that would prevent a useful interview the group selected an appropriate study site: a multidisciplinary outpatient department, in the caen university hospital, where dermatologists, rheumatologists, vascular specialists, rehabilitation specialists, orthopedists, and internists assess and treat patients with ssc, especially those with hand involvement. the university of paris-descartes council for health research ethics assessment approved the study protocol. all patients provided informed written consent before inclusion. because patients had several consultations a month, a large amount of clinical and paracliniclal data were available: clinical elements, psychometric assessments, and additional examinations. social and demographic data, rodnan scores (of skin thickening), the cochin hand function scale (measuring functional involvement of the hand), and scores on the specific scleroderma health assessment questionnaire (shaq) qol scale were collected for all included patients. these data were not to be analyzed but collected to present the clinical characteristics of the sample in detail. we used our purposive sampling strategy and included patients differing by age, social and family status, hand involvement, disease history, and comorbidities, continuously looking for potential heterogeneity. data saturation was reached with 12 patients, but to ensure the theoretical sufficiency of our results, we included 21, reaching our preferred minimum sample size of 20 participants.  stage 4  a researcher first met each participant to obtain his or her written consent and to collect social and demographic data and any relevant clinical scores. this facilitated the subsequent research interview, a few days later. it was clear that data for this study had to be collected in individual interviews as we wanted to reach an individual lived experience. we were nonetheless aware that patients might find it difficult, even intrusive, to talk about parts of their sick bodies. we therefore chose to provide them with visual narrative support: a photograph of a hand with raynaud’s phenomenon, a characteristic disabling manifestation in 95% of ssc cases (fig. 4). photo-elicitation has not previously been used in any qualitative study of patients with ssc. the interview systematically began by asking participants for their reaction to the photograph. we conducted open-ended interviews, structured by areas to explore, chosen collectively by the group. these areas were selected after a review of two pilot interviews based solely on photo-elicitation: 1. disease history, onset of the disease (potential question: how long have you had this disorder?) 2. hand involvement (potential question: can you tell me how your hands are damaged by this disease?) 3. daily life (potential question: what bothers you the most on a daily basis?) 4. emotion (potential question: how does it make you feel when you think about the current state of your hands?) 5. care (potential question: what was helpful?) each interview lasted from 45 to 60 min. they were conducted by two experienced researchers, from february 2015 through april 2016.  participants  this study included 21 participants: 18 women and 3 men. their mean age was 60 years at the time of the interviews. 18 had limited cutaneous ssc and 3 diffuse cutaneous ssc. its effect on their hands were diverse: all had raynaud syndrome (n 21), but some also presented joint involvement (n  
  sibeoni et al. bmc medical research methodology  (2020) 20:216  page 14 of 21  table 2 example of an ipse study: the lived experience of hand involvement in patients with systemic sclerosis (ssc) (continued) 10), calcifications (n 11), sclerosis (n 15), telangiectases (n 6), hyperkeratosis (n 6), digital ulcers (n 12), digital necrosis (n 1), and sub/periungual hemorrhages (n 6). the mean rodman score was 8.1/51, the mean score on the cochin hand function scale was 15.6/85, and the mean shaq score 1.2/3. stage 5 structure of experience  the analysis of the interviews enabled us to identify three central axes of experience: (1) my hands, myself; (2) my hands and others; and (3) treatments and strategies used by the participants. 1. my hands, myself (i) what i see of my disease through my hands: the patients considered the involvement of their hands was visible. they reported changes in the color, shape, and texture of their fingers, most often evoking emotions of rejection or disgust. many described a major esthetic impact, saying their hands are ugly to look at, again with a strong emotional component. finally, and especially, the participants considered this visible hand involvement as evidence of their disease and its prognosis, experiencing this damage as a permanent reminder of their illness and a witness of its development and its severity (ii) what i no longer feel: most participants complained about the loss of sensitivity in their hands. they reported numbness, a feeling of skin tightness, or constantly cold hands. they underlined the daily effect of this loss of sensitivity. numerous patients also complained about hand pain that handicapped them in their daily lives. (iii) what i can no longer do: the participants underlined what they could no longer do because of the impairment of their hands. all mentioned an impact on their work. depending on their job, some felt helpless, unable to perform their work duties. others found it impossible to keep their jobs. some explained that they continued working, despite the pain. finally, others directly linked the hand involvement to their difficulties in finding employment. participants also reported major problems doing housework. finally, many reported having had to give up hobbies or pleasures that mattered greatly to them, such as gardening, sewing, or playing music. the functional impact was always associated with emotions of anger, frustration, or sadness. 2. my hands and others (i) others looking at their hands: most patients considered that this hand involvement exposed their disease to the eyes of others. some stressed the impossibility of hiding their hands from the sight of others; others mentioned esthetic discomfort that was greatest in social interactions and starting the instant they observed someone looking at their hands. they inferred the negative thoughts of others who looked at their hands. they imagined that these people had to find their hands strange or “dirty” and would worry about the potential risk of contagion. (ii) interpersonal relationships: all participants reported an important impact on relationships, especially in interactions with those close to them. many complained that they had to ask others for help every day because of their hand impairments. they reported experiencing unbearable dependence, more unbearable for some than the disease itself. they also reported a feeling of that they could no longer do these things themselves. some said they accepted help only out of a feeling of resignation, while others preferred to refuse the assistance offered, even if they suffered. less often, some patients said they were aware of their disability and had no trouble asking for help with some activities. these aspects of assistance and dependence were especially present in the participants’ descriptions of their relationships with those close to them. some underlined essential support from their family, while others grumbled that their actions and behavior were constantly watched. some participants found their family’s support inadequate and reported conflicts with them; they felt lonely and misunderstood facing a life encircled by restrictions. finally, some reported especially what they could no longer do with those they were close to, special moments they could no longer share. only two mentioned in this regard an effect of their hand impairment on their sex life. 3. treatments and strategies (i)perceived efficacy of the treatments prescribed: many patients reported the direct efficacy of some drugs that made their symptoms disappear; nonetheless, they regretted the transience of their effect or that they could not use them more often. similarly, surgical treatments were described as effective, helping to relieve the pain. they were sensitive to techniques that permitted functional improvements and judged their efficacy indirectly, by the lack of disease progression. sometimes they found that neither medication nor physical therapy was effective. others, however, considered that the treatments’ adverse effects outweighed their positive effects. (ii)patients’ strategies: the participants reported the strategies that they used to battle hand damage on a daily basis and to preserve some pleasures. they had developed various means, most often material, to overcome these impairments: using a dishtowel to open a bottle, a nutcracker or a screwdriver to open jars, pliers to grasp small objects, etc.). all explained that they wore gloves, in summer as in winter, to prevent raynaud’s phenomenon. some complained about the discomfort these gloves engendered. they also described their strategies for maintaining some pleasures, by finding ways to preserve or adapt their hobbies and leisure activities.  stage 5 practical phase  the structure of lived experience has revealed that the intensity of the functional impact was related to “what i can no longer do” rather than to “what i cannot do.” the question of the visibility of their hand impairment, to themselves and to others, was crucial, with two original aspects revealed by our study: i) the permanent exposure of their disease to the eyes of others — both in social interactions and in more personal relationships — underlines its effect on relationships; ii) it serves as a permanent reminder of the disease to the patients, inducing constant concerns about their survival, their existence. this revealed the importance of other dimensions than functional impairment in the lived experience: esthetic, relational, emotional and existential. practical implications for healthcare professionals: - pro development: construction of the hande scale, - recommendations for clinicians: clinicians should routinely evaluate hand functions that patients used in ways important to them and have now lost, the impact of the visibility of the disease due to this hand involvement, and should also explore the esthetic, emotional, relational, and existential issues that result. our results also suggest the need for trust in the patient/physician relationship, to alleviate the patient’s distress in dimensions inaccessible to medication.  criteria of rigor  feedback to subjects of experience: in the study presented in this paper, we used all of these criteria to ensure the rigor of the analysis and thus the trustworthiness of the results. the feedback of “subjects of the experience” was conducted by  
  sibeoni et al. bmc medical research methodology  (2020) 20:216  page 15 of 21  table 2 example of an ipse study: the lived experience of hand involvement in patients with systemic sclerosis (ssc) (continued) presenting the research to a group of patients (n 20) from the department of internal medicine at cochin hospital, a reference center for ssc. these patients all recognized their own experience in the structure we proposed. the question of the choices of the central axis of experience: only two participants mentioned the effect of hand involvement on sexual relations. we included this subject in our results to improve the patients’ lives, because this subject is difficult for patients to raise with doctors. triangulation, reflexivity, attention to negative cases limitations  1. it took place in france, and caution is required in transposing our results to other places because medical care depends strongly on the organization of the medical system as well as on the country’s economy. 2. this was a single-center study and all patients recruited in this study were followed in specialized departments (dermatology, rheumatology, internal medicine, and others). it would be interesting to see the results of other studies reproducing this design in other medical settings, such as, for example, that of general medicine. however, we think that this study meets the aim of qualitative research: it may be transferable to other contexts.  repercussions on qol in ssc have been already explored by dermatology qol scales, the dermatology life quality index questionnaire [93] or the satisfaction with appearance scale (swap) [94]; and the esthetic impact of hand involvement can be assessed by the 6-item brief swap, validated for ssc [95]. the ipse approach enabled the emergence of two original results about the visibility of hand involvement: i) the permanent exposure of their disease to the eyes of others — both in social interactions and in more personal relationships — underlines its effect on relationships; ii) it serves as a permanent reminder of the disease to the patients, inducing constant concerns about their survival, their existence. beyond the functional impact of hand involvement in ssc and the esthetic repercussions, relational and existential aspects directly associated with patients’ emotional distress also appeared to be an important part of patients’ experience. the different qualitative studies exploring the sources of emotional distress among people living with ssc [96–103] have never explored the lived experience of hand involvement in this disease. these  fig. 4 regrouping of codes into categories with nvivo 12  emotional, relational, and existential aspects have never been described specifically for hand involvement in either ssc or other autoimmune diseases affecting the hands, and no scale used to assess hand involvement contains items assessing these aspects. the ipse approach has thus made it possible to enrich the data available on the lived experience of ssc patients with hand involvement. the current scales, obtained from questionnaires constructed without exposure to patients’ lived experience, inform clinicians especially about the functional dimension of their patients’ disease but do not allow them to provide comprehensive management for these patients that covers what matters from the patients’ perspective. it is especially important to take their perspective into account in that this is a chronic disease that cannot be cured and has no specific treatment. our results thus allowed us to construct an appropriate, relevant –and missing- pro tool, the hande scale, intended to be a useful tool enabling detection of the different dimensions of hand involvement in ssc: functional (and loss of function), emotional,  
  sibeoni et al. bmc medical research methodology  (2020) 20:216  relational, existential, and esthetic. based on our results and using the vocabulary of the patients we interviewed, we generated 18 items associated with their lived experience. a final version of 16 items was subsequently obtained during a validation study with 105 patients that showed the relevance of the scale for assessing the global experience of hand involvement in patients with ssc. this new pro scale will be considered as an outcome measure in future trials. this illustrates the direct integration of ipse studies in ebm. pro development in the field of child and adolescent psychiatry  pediatric pro assessment is a very recent field of research, and empirical evidence about quantitative instruments within this age-specific population is still scarce [104]. we are currently constructing two adolescent psychiatry pro scales based on the results of two qualitative studies: (i) one about the treatment of adolescents with anxiety-based school refusal [105], and (ii) another assessing the therapeutic alliance in the treatment of adolescents with anorexia nervosa [106]. (i). this qualitative study, exploring how 20 adolescents with anxiety-based school refusal and 21 of their parents experienced psychiatric treatment, revealed some divergences between the two groups on their perception of efficacy and enabled us to construct a relevant pro for both adolescents and their parents. this tool integrates original aspects found in our study: assessment of both external (return to school) and internal (self-transformation) goals of care, the duration of care (an effective treatment as rapidly as possible vs. the need for a treatment period sufficiently long to allow adolescents to change and develop) and unexpected care-linked relationships. (ii). this study explored the experience of therapeutic alliance among 15 adolescents with anorexia nervosa (an), 18 or their parents and their 8 psychiatrists. crossing these three perspectives makes it possible to identify aspects that are missing in scales currently used to measure therapeutic alliance in the treatment of an in adolescents, such as the awai or the haq-cp [107, 108]: parents’ negative representations of “psychiatry” focusing on somatic aspects of treatment and the omnipresence of the issue of relationships. items on relationship in the scales currently used concern only the relationship with care providers and focus on its perceived quality. in our results, relationships are involved in all three components of the definition of therapeutic alliance: the quality of the association, the objective of treatment, and the means to  page 16 of 21  achieve this objective. similarly, the current scales do not mention the role of the adolescent–parent relationship, which appeared to play a key role in the construction of the therapeutic alliance in our results. we are therefore developing a pro scale on this topic that includes specific items: (1) the quality of the relationship with staff as a means of getting better, (2) the impact on the alliance of parental involvement in treatment, (3) the impact of treatment on the parents’ point of view about the adolescent and the relationship between adolescents and their parents, and finally (4) agreement about the objectives for improving family relationships generally and adolescent–parent relationships in particular. clinical recommendations  clinical recommendations drawn from the results of ipse studies are intended directly for the physicians themselves. assessment and diagnosis  clinical implications from ipse studies can be innovative concrete guidelines, supported by the structure of lived experience of patients and other stakeholders, to improve the quality of the clinical assessment and of the diagnosis process. for instance, based on the results of the study of hand involvement in ssc, using the same rationale presented above, we provided clinicians with clinical implications regarding the assessment of hand involvement among patients with ssc: (i) clinicians must assess this involvement globally and not by segmenting the evaluation with several scales that target especially functional involvement; (ii) they should routinely evaluate hand functions that patients used in ways important to them and have now lost and the impact of the visibility of the disease due to this hand involvement, and (iii) should also explore the esthetic, emotional, relational, and existential issues that result. in another study, we explored the experience of the diagnostic pathway among 20 patients with acromegaly, a rare disease with a substantial diagnostic delay. our results revealed the direct associations between diagnostic delay and the doctor–patient encounter [28]. the literature has already emphasized the key role of any doctor, regardless of specialty, in identify the signs, symptoms, and comorbidities of acromegaly by becoming involved and seeing the unseen’ [109]. to identify the disease as early as possible, however, our results suggest that physicians must allow themselves to question the patient proactively and to consider clinical processes beyond their own specialty, in other words, seeing the unseen is not enough if physicians do not say the unsaid.  
  sibeoni et al. bmc medical research methodology  (2020) 20:216  page 17 of 21  therapeutic implications  recommendations addressing the care pathway  the ipse approach is particularly well suited to exploring complex therapeutic processes and the perceived efficacy of treatment. the approach enables the description of therapeutic levers and efficacy criteria directly relevant to patients and other stakeholders and could contribute to achieving a more person-centered medicine.  for the study of anxiety-based school refusal mentioned above [105], we were able to provide recommendations about the outcomes and the duration of care: treatment must last long enough, in a place dedicated to care, to allow adolescents to become involved in their care and to reflect on the personal changes they need, but also to offer them the possibility of multiple human encounters, some of which — expected or unexpected — will turn out to be determinant in their development. treatment should strive to combine and coordinate two outcomes of equal importance: a rapid return to school for the parents, and a sufficiently long time in care to enable a self-transformation for the adolescents.  improving patients’ lives  we conducted two studies to explore the lived experience of cancer treatment; one crossed the perspectives of patients (n 30), their families (n 30), and their oncologist (n 10) [30], while the other one focused on what affects the quality of daily life of patients with cancer (n 30) during active treatment [110]. our results led to some clinical recommendations to achieve patient-centered cancer treatment, that is, that physicians integrate the dimension of care into the curative treatments performed so that patients to live as well and not simply as long as possible [30]. to achieve this task, we found an original therapeutic lever that acts like a relational tool for physicians: the support object, defined as an object, a relationship or an activity particularly invested by the patients in their daily lives, which makes them feel good and makes the cancer and its treatment bearable. when patients are able to choose and be involved with a support object, the physician must support them and converse with them on this topic to help them maintain this investment throughout the health care pathway and to establish a trusting relationship and therefore, according to our results, improve their quality of daily life, without using up very much of the physician’s time [110].  improving families’ lives  therapeutic implications drawn from ipse studies can also concern families and relatives. for example, we conducted a study to explore how 20 older siblings describe and perceive the care received by their brother or sister in child psychiatric centers specialized in the management of children with autism spectrum disorder [111]. the literature has already recognized the need for both global family-centered treatment approaches [112] and specific programs intended for the siblings of children with serious diseases [113] to help them cope with their brother/sister’s condition, but our study revealed that when older siblings play and claim a role of helping and caring for the child with asd, they benefit from their empowerment and involvement in this treatment, and physicians benefit from their perspective on this treatment.  patient-physician communication using the structure of lived experience  first of all, the systematic undervaluation of symptoms by physicians reveals some distortion in physicianpatient communication [114–116]. the integration of patients’ points of view into their management through the intermediary of structures of experience obtained with ipse would promote this communication. in an ideal context of shared medical decision-making, the involvement of patients in their management requires that they receive complete and appropriate information on which they can base their choices. complete information requires that they have been heard and that their narrative of their disease has been considered. in our study of hand involvement in ssc, we systematically provided feedback to the clinicians, so that they could apply these new results uncovered by our exploration. improving communication, reducing confusion  the ipse approach, especially when crossing perspectives, can also provide innovative ways to improve communication between patients and doctors. we conducted a study among 20 patients and 10 physicians aimed at exploring the experience of neuroendocrine tumors (nets), rare gastrointestinal tumors characterized by their rarity, the difficulty of their diagnosis, their often better prognosis, and their complex and long management [29]. the primary — and original — result of this study is the important experience of confusion found among patients. we have provided a statement that all physicians can use to support patients diagnosed with nets to reduce their confusion, especially the semantic confusion as it explicitly uses the term cancer. this communicative tool meets patients’ needs (i.e. silent symptomatology, name, evolution, treatment and monitoring) including the need to improve patient-physician communication. it has been used in specialized medical consultations but also in training  
  sibeoni et al. bmc medical research methodology  sessions of medical gastroenterology.  trainees  in  (2020) 20:216  oncology  and  medical pedagogy  here again, the structure of experience can always directly serve as training support to provide to medical students with relevant information about how patients experience both their disease and their care. ipse approach can also reveal specific needs or gaps in the physician’s training and provide new insights. revealing training needs  in our study crossing perspectives between patients with cancer, their families, and their oncologists, we found that physicians had difficulties dealing with patients’ negative emotions during consultations and that this could be a barrier to their access to the factors that improve the patients’ capacity to live as well as possible. we suggested that physicians dealing on a regular basis with patients with cancer should receive a specific medical education that directly addresses the issues of coping with, recognizing, eliciting and using patients’ feelings as a therapeutic tool. new insights for medical pedagogy  in our study regarding acromegaly diagnosis, patients reported having faced deficiencies in the medical world’s awareness of acromegaly. indeed, acromegaly is a rare disease that doctors see very rarely and are therefore unlikely to think about. our results led to suggesting the intervention of patient experts [2] in medical schools, so students can hear about their experience of diagnostic errors that lead to diagnostic delay and about its early and current clinical signs. future doctors, who have received such training, will be more aware of the need for a high level of suspicion and active questioning to reach a diagnosis and should thus be more likely to think of the signs observed or reported as potential indicators of acromegaly.  discussion all the studies presented here, and their practical implications, focus on the day-to-day clinical practice of physicians: relationships and communication in care, duration of care, therapeutic alliance, care issues, and outcomes. these aspects, related to the patient’s subjectivity and the patient-physician relationship, are very often forgotten or even excluded from medical research [20]. we consider, along with other scholars in qualitative health research [20, 21], that many advances in medicine and patient care are impossible until qualitative methods are fully integrated into the research arsenal. qualitative research should — but does not yet —have a major role to play in clinical medical research;  page 18 of 21  use of these methods remains a minority, even marginalized, option. many medical researchers still apply a hierarchy — based on a paradigm confusion — between research methods according to the sole presence of quantitative research criteria, such as sample size, objectivity, and reproducibility; they inaccurately conclude that qualitative research is inferior and reduce it to a secondary role, always conceived of in the context of mixed-method research [117]. in other words, qualitative medical research is a victim of the burden of proof [118] and of the tyranny of the average [119]. for qualitative research to be able to fully contribute to medical research, it requires better recognition and appreciation from the entire medical community. this is what the ipse approach is trying to achieve by staking out a medical position within a rigorous and systematic qualitative method. 1. the ipse approach is to be integrated within ebm through mixed-method study designs resulted from a pragmatic and mutually enriching partnership between qualitative and quantitative methods [120]. 2. setting up research groups involving both physicians and patients is an innovative and original idea. this multiples the perspectives and enriches the data and results. moreover, patient involvement helps to direct research towards person-centered medicine and finally, it allows the research process to maintain an inductive approach providing new results while remaining anchored in relevant medical issues. 3. almost everyone agrees that it is important to understand what patients and other caregivers are going through. but to what extent? the first objective of an ipse study should always be to achieve concrete improvements in patients’ lives (or those of other stakeholders) by leading to practical changes such as pro development and being used to construct health recommendations or policies, while respecting the fundamental principles of qualitative research. however, the ispe approach has some pitfalls. first, it is a very demanding and ambitious research method. an ipse study is as constraining in terms of workload and time as any other clinical medical research. it also requires abandoning the idea that a qualitative research requires fewer human, financial, and technical means. second, in exploring an experience in depth in an interview, the researcher can expose the subject’s distress, especially when the question concerns the experience of a disease. this is an important ethical point: the researcher must systematically report this distress to the patient’s physician.  
  sibeoni et al. bmc medical research methodology  (2020) 20:216  conclusion ipse is an innovative method and an important contribution to current methodological developments aimed at improving the quality and rigor of qualitative research in the medical field, for it anchors the research to the lived experience of those involved in medical care (patients, family, professionals) and it proposes concrete suggestions based on the results, including the development of pros. no structured qualitative methods have previously recommended the direct involvement of patient experience into pro construction, before assessing psychometrics characteristics of the scale. ipse is a qualitative method specific for clinical research in medicine, designed to enable the implementation of pragmatic improvements. our approach, which allocates to the experience of all the stakeholders in medical care its necessary role in the research process, is part of the movement for collaborative person-focused medicine and can be integrated easily in mixed-methods study designs [1]. abbreviations coreq: consolidated criteria for reporting qualitative research; ebm: evidence-based medicine;; hande: hand autoimmune disease lived experience; ipa: interpretative phenomenological analysis; ipse: inductive process to analyze the structure of lived experience; ppi: patient and public involvement; pro: patient reported outcome; qol: quality of life; shaq: scleroderma health assessment questionnaire; ssc: systemic sclerosis acknowledgements we would like to thank all the patients for their participation in this study. we also want to thank la societe francaise de dermatologie; and jo ann cahn for the translation in english. authors’ contributions js, lv,em and arl conceived and designed the study; collected the data; analyzed the data; js, lv, em and arl wrote the paper. all authors had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. all authors read and approved the final manuscript. funding no funding. availability of data and materials the datasets analyzed during the current study are available from the corresponding author on reasonable request. ethics approval and consent to participate the paris-descartes university review board (ceres) approved the research protocol (irb number: 20140600001072) of the study presented in table 2. all participants provided written informed consent. consent for publication all the participants gave their written consent. competing interests the authors declare that they have no competing interests. author details 1 service universitaire de psychiatrie de l’adolescent, argenteuil hospital centre, 69 rue du lieutenant colonel prud’hon, 95107 argenteuil cedex, france. 2ecstrra team, umr-1153, inserm, universite de paris, f-75010 paris, france. 3service de psychologie et psychiatrie de liaison et d’urgences,  page 19 of 21  hopital europeen georges pompidou ap-hp, hopitaux universitaires paris ouest, paris, france. received: 10 february 2020 accepted: 11 august 2020  references 1. truog rd. patients and doctors — the evolution of a relationship. n engl j med. 2012;366:581–5. 2. elberse je, caron-flinterman jf, broerse jew. patient-expert partnerships in research: how to stimulate inclusion of patient perspectives. health expect. 2011;14:225–39. 3. santana mj, manalili k, jolley rj, zelinsky s, quan h, lu m. how to practice person-centred care: a conceptual framework. health expect. 2018;21:429–40. 4. sticher l, bonsack c. peer support workers : a novel profession in psychiatry. rev med suisse. 2017;13:1614–6. 5. sackett dl, rosenberg wm, gray ja, haynes rb, richardson ws. ebm: what it is and what it is not. bmj. 1996;312:71–2. 6. fda-nih biomarker working group. best (biomarkers, endpoints, and other tools) resource. bethesda: food and drug administration (us); 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