Clients’ experiences with a Trauma-sensitive mindfulness and compassion group intervention: a first-person perspective on change and change mechanisms

Abstract

Background: Trauma-related symptoms are common and there is a need for treatment interventions targeting underlying core vulnerabilities regardless of the client’s diagnosis. Mindfulness and Compassion interventions have shown promising results in trauma treatment. However, little is known of how clients experience such interventions. Objective: This study describes clients’ experiences of change after participating in a transdiagnostic group intervention, Trauma-sensitive Mindfulness and Compassion Group (TMC). Method: All 17 participants from two TMC groups were interviewed within one month of completing treatment. Transcripts were analysed using reflexive thematic analysis with a focus on how the participants experienced change and change mechanisms. Results: Three main themes of experienced change were developed: Becoming empowered; A new relationship to oneself and one’s body; and Gaining more freedom in relationships and life. Four main themes were developed to capture clients’ experiences of change mechanisms: New perspectives give understanding and hope; Accessing tools facilitates agency; Significant moments of awareness open up to new possibilities, and Circumstances in life that facilitate change. Conclusion: We discuss and reflect upon participants’ experiences of the effects of participating in a TMC group and the mental and emotional costs of doing the work and present a broader perspective on change processes overall.

Keywords:

• Trauma
• treatment
• CPTSD
• mindfulness
• compassion
• self-compassion
• clients’ perspective
• change mechanisms

Clinical or methodological significance of this article: Trauma-related symptoms are common in clinical populations and many clients struggle with difficulties staying present and strong feelings of shame and guilt, symptoms that have been shown to be a hindrance to recovery. Our study indicates that an intervention based on a Trauma-sensitive Mindfulness and Compassion group can be a valuable resource in trauma recovery. The findings also point to the importance of preparing clients for the effort needed to do change work, while at the same time communicating hope. Giving clients new perspectives on the change process itself appears to be a crucial factor, helping them to identify and savour moments of change.

Introduction

Exposure to traumatic stressors is common: about 70% of the world’s population is exposed to at least one potentially traumatic event in their lifetime (Kessler et al., 2017). Researchers have reported associations between trauma exposure and the risk of mental health problems. Posttraumatic Stress Disorder (PTSD) is the most widely recognized trauma-related condition, characterized by intrusive memories, hypervigilance, and avoidance. Clinicians and researchers focusing on survivors of repeated relational trauma in childhood (i.e. complex trauma) have reported a broader range of symptoms following this kind of exposure (Karatzias & Cloitre, 2019). In line with this, complex PTSD (CPTSD) was included as a separate diagnostic category in ICD-11 (World Health Organization, 2019). CPTSD includes the core symptoms of emotional dysregulation, negative self-concept, and relational difficulties in addition to the core symptoms of PTSD. Numerous studies conclude that trauma exposure and PTSD/CPTSD are associated with an increased risk of a broad range of general mental health problems, including depression, anxiety, substance misuse, and eating disorders, as well as adverse health outcomes, functional impairments, and reduced quality of life (Brady et al., 2000; Brenner et al., 2019; Spitzer et al., 2009).

To help clients overcome their trauma-specific symptoms, evidence-based individual trauma treatments based on exposure are now recommended as first-line treatment in trauma treatment guidelines (APA, 2017; NICE, 2018). However, current exposure-based treatments have limitations. Although effective for many clients with PTSD, exposure therapy typically has high drop-out rates (Varker et al., 2021) and many clients report substantial levels of residual symptoms (Bradley et al., 2005). More recent evidence indicates that exposure therapy is less beneficial for CPTSD clients with childhood trauma and that these clients can benefit from more multifaceted, recovery-oriented and personalized care (Karatzias & Cloitre, 2019; Smith et al., 2016). Moreover, although convincing evidence shows that the therapeutic relationship and adaptations to clients’ preferences and inherent abilities strongly contribute to treatment outcome, these factors are not mentioned in the treatment guidelines for PTSD (Norcross & Wampold, 2019). In addition, many clients only partially meet the criteria for PTSD/CPTSD and consequently risk being excluded from specialized trauma treatment options despite having clinically significant symptoms (Weiss et al., 1992). Researchers and clinicians therefore highlight the need to develop a broader therapeutic approach, with more client-centred, flexible, multi-modular and innovative interventions, targeting also the cluster of CPTSD symptoms (emotional dysregulation, negative self-concept, and disturbances in relationships) and comorbid conditions (Karatzias & Cloitre, 2019; Mcfetridge et al., 2017).

Group-based trauma treatments have shown promising results (Schwartze et al., 2019) and it is argued that group-based interventions target factors that are specifically important in CPTSD recovery processes, such as normalizing trauma responses, decreasing shame, and offering a possibility to develop trusting relationships (Herman, 2015; Stige et al., 2013). It has been suggested that transdiagnostic group-based interventions designed to treat underlying core vulnerabilities, rather than just one disorder, would give more clients access to trauma-specific treatment while simultaneously targeting comorbid conditions, reducing suffering and reaching more people despite limited health care resources (Gutner et al., 2016).

Mindfulness-based treatment interventions have been increasingly recognized as effective for a variety of mental health issues (Keng et al., 2011). Promising results indicate that mindfulness-based therapies are effective in reducing avoidance of difficult feelings and memories, reducing shame-based cognitions, improving attention control and emotional regulation skills, and cultivating an accepting attitude towards oneself (Banks et al., 2015; Boyd et al., 2018; Williston et al., 2021). Over the past decade, interventions to strengthen self-compassion, directly addressing the relationship with oneself in the face of suffering, have also shown promise (Bluth & Neff, 2018). A systematic review of PTSD and self-compassion by Winders et al. (2020) found that increased self-compassion was associated with reduced PTSD symptoms. Lack of self-compassion and high levels of shame and guilt have been shown to maintain PTSD/CPTSD symptoms, and it has been suggested that integrating self-compassion practices in trauma treatment might increase the efficacy of treatment and target symptoms of negative self-concept, shame, affect dysregulation, and isolation (Karatzias et al., 2019; Øktedalen et al., 2015).

Despite their therapeutic promise, concerns have been raised regarding possible harms of mindfulness-based therapies (Farias et al., 2020) and clients with PTSD are at risk of experiencing increased distress and intrusive memories (Zhu et al., 2019). This underlines the importance of taking trauma symptoms into account when introducing mindfulness-based interventions and to investigate clients’ subjective experiences (Kelly & Garland, 2016; Müller-Engelmann et al., 2019). A recovery-oriented practice relates largely to finding ways to live a meaningful life from the person’s own perspective, which makes recovery processes best examined from a phenomenological perspective (Binder et al., 2016). There is, therefore, a need for more research on transdiagnostic trauma-informed mindfulness-based treatments of trauma-related disorders, taking clients’ experiences into account. To our knowledge, no previous studies have investigated clients’ experiences of a combined mindfulness and compassion intervention for trauma clients. This study contributes by exploring participants’ perspective of change and change mechanisms after participating in a Trauma-sensitive Mindfulness and Compassion group intervention (TMC).

Methods

Study Setting

The current study used the same manual-supported TMC group intervention in two different settings. Group 1 was a closed group treated at a specialized outpatient facility for adult clients with CPTSD and complex dissociative disorders. Group 1 was led by two clinical psychologists (including the second author). Group 2 was connected to specialized mental health services, but the intervention itself was carried out at a community centre. The community centre has collaborated with the District Psychiatric Centre (DPS) for many years, hosting an TMC group open to anyone attending the community centre in addition to clients connected to the DPS. This open concept was continued through the study intervention, but only clients connected to the DPS were included in the study. The first author, a psychotherapist/physiotherapist, led group 2. A previous article from this project reported decline in symptoms following participation in TMC and presented an analysis of participants’ experiences of adverse effects of TMC. The intervention was experienced as challenging, but no serious adverse effects were uncovered (Salvesen et al., in press).

The Trauma-sensitive Mindfulness and Compassion (TMC) Treatment Approach

The TMC approach consists of 16 weekly group sessions, each lasting 2 h. The first 10 sessions focus mainly on building mindfulness capacities, and the last 6 sessions on developing compassion toward self and others. Between sessions, participants are encouraged to do exercises with the support of audio files. The approach was developed with a transdiagnostic perspective, including clients with a variety of trauma-related symptoms (Gutner et al., 2016). An overview of exercises and how they may target different PTSD/CPTSD symptoms can be found in the Supplementary material. A previous publication includes a more thorough description and discussion of the TMC approach (Strand & Stige, 2021).

TMC is developed with a set of goals related to trauma treatment: coping with trauma-related symptoms, building capacity for voluntary attention, self-care, positive affect and connection with others (Mcfetridge et al., 2017). Trauma-related psychoeducation is combined with grounding, mindfulness and compassion practices (Germer & Neff, 2019; Gilbert & Procter, 2006; Wallace & Shapiro, 2006) with the aim to make these practices as safe as possible for people dealing with trauma-related symptoms. The all-pervasive attitude is that each client needs to explore and discern what works best for them and make individual adjustments adapted to their capacity. All exercises are presented as laboratories to help participants feel free to execute needed adaptions.

Recruitment and Participants

All potential participants had to fulfil the criteria for at least one psychiatric disorder and receiving specialized mental health services. In addition, participants had to: (1) report traumatic experiences and trauma-related symptoms; (2) be between 18 and 65 years of age; and (3) give informed consent to participate in the study. Exclusion criteria were: (1) acute suicidality or psychosis; (2) substance abuse interfering with treatment; (3) crisis interfering with treatment; and (4) violent behaviour.

All nine clients from group 1 and all 11 clients from group 2 agreed to participate and were included in the study. Two dropped out before the interventions started and one had to be removed because of ineligibility caused by a crisis that interfered with treatment. This left a total of 17 participants (2 men), aged 22–60 years.

All but two participants in the study reported several relational traumas in childhood, such as sexual violations, physical abuse, emotional abuse, bullying and/or witnessing others being physically or sexually molested. One participant was exposed to repeated violence and abuse as a young adult, and one had experienced loss of a parent as a child and a traumatic loss as an adult. In addition, participants reported other terrifying situations in childhood and as adults, such as being threatened with a weapon, life-threatening disease or life-threatening accident. All but two of the participants had received treatment in specialized mental health care before attending the TMC group. The degree to which they had received trauma-specific treatment varied. Some had participated in a stabilization group, some had received some degree of exposure therapy, some had just spoken about their trauma history, and some had had minimal focus on trauma. Four of the participants had been admitted to psychiatric wards. Twelve of the participants received concurrent individual treatment, some on a regular basis, some upon request when needed.

Data Collection

All participants were interviewed within four weeks of completing the TMC group intervention. The first and second author interviewed participants from the group they had not led to ensure minimal emotional impact on participants’ responses. Interviews were conducted under close supervision from the third author. The interview schedule was developed prior to the start of the study, and based on clinical experience, feedback from previous TMC group participants, and literature. Questions were open-ended, aiming to gather detailed and rich data regarding participants’ experiences (Finlay, 2011). The interviewers used follow-up questions to check if they had captured the meaning of participants statements properly and to give space for participants to clarify or deepen their statements. In addition, interviewers wrote notes after each interview to collect non-verbal experiences and other impressions from the interview situation.

Data Analysis

A reflexive thematic analysis with a hermeneutical-phenomenological approach (Braun et al., 2022) was used to analyse and interpret the data, aiming to tap into the embodied and lived experiences of the participants while also taking into account the researchers’ influence on the interpretation process. Data analysis started with all three authors reading all interview transcripts in two rounds to familiarize themselves with the data. All authors then met, and the analytical focus was decided: What do participants describe as having changed after participation in the TMC group, and what change mechanisms do they describe? Then the first author, in close collaboration with the third author, systematically coded all interviews, generating initial codes by identifying and labelling relevant features of the data related to the two analytical questions. Codes were analysed by searching for relationships between codes across the data and a thematic structure with main themes and sub-themes was created. All three authors took part in reviewing the themes in relation to both coded data for each theme and the entire data set, resulting in adjustments of the thematic structure. The themes were finally discussed and set by all authors. In the process of writing the article, data analysis continued, and some themes were reviewed, transformed, and renamed again. When presenting the results, the following terminology has been used to describe the number of participants (out of totally 17) connected to each category: 3–5 of the participants are termed some, 6–8 several, 9–13 many, 14–16 most of the participants. The coding was practically managed by using NVivo 12 software.

Reflexivity

All the authors have a humanistic approach to trauma and psychotherapy. The first (psychotherapist) and second (psychologist) author both works clinically with complex trauma clients and have over time developed and used the TMC approach in their practice. Both are trained in Mindful self-compassion and expressive arts therapy, and they have extensive experience in practising mindfulness and compassion themselves. The second author also has training in Cultivating Emotional Balance. The third author, a clinical psychologist and professor, has extensive clinical experience with trauma treatment and qualitative research. Throughout the research process, all authors aimed to keep a reflexive standpoint. It was considered important that the third author had no investment in the TMC programme and could take the leading role in critically evaluating the analysing process, helping the first and second author to detect their pre-understanding and ensure that it did not unduly affect the research process. The first and second author had expected that participants would follow the pedagogically structured programme to a greater extent when practising at home. Instead, participants described very individualized and different ways of using the tools.

Results

Due to the complexity of the material and the fact that participants’ experience of change and mechanisms contributing to change were closely intertwined, the results are presented together in one article. In the following, three main themes related to change and four main themes related to mechanisms of change will be presented. All the participant’s names are fictitious, and quotes are presented without specific details that can risk the anonymity of the participants. The developed main and sub-themes are presented in Table I.

Table I. Main and sub-themes developed through data analysis

Research focus:	Participants’ experiences of change			Participants’ experiences of change mechanisms
Main themes:	1.1 Becoming empowered	1.2 A new relationship to oneself and one’s body	1.3 Gaining more freedom in relationships and life	2.1 New perspectives give understanding and hope	2.2 Accessing tools facilitates agency	2.3 Significant moments of awareness open up to new possibilities	2.4 Circumstan­ces in life that facilitate change
Sub-themes:	1.1.1 Coping with Dysregulation	1.2.1 Staying connected	1.3.1 Becoming more expressive and truer towards oneself and one’s needs	2.1.1 Understanding trauma reactions		2.3.1 Noticing and recognizing inner sensations
	1.1.2 Trusting one’s strengths and value	1.2.2 Befriending oneself in the face of suffering	1.3.2 Discovering and grasping new opportunities	2.1.2 Understanding processes behind self-criticism soften its impact		2.3.2 Moments of interaction challenge old patterns
				2.1.3 Gaining a more realistic view of and ownership to the change process

Participants’ Experiences of Change

All participants reported important changes following participation in the TMC group, conceptualized as an ongoing process, rather than a set outcome. Moreover, these changes related to three main domains, presented here as three main themes: Becoming empowered; A new relationship to oneself and one’s body; Gaining more freedom in relationships and life.

Becoming empowered

This main theme captures a sense of mastery, having the strengths and power to act, and trusting one’s abilities. The theme had two interrelated, but distinct sub-themes: Coping with dysregulation and Trusting one’s strengths and value.

Coping with dysregulation

All participants expressed, to varying degrees, increased competence to cope with triggering situations. They could make more sense of, and obtain an observational distance to, their symptoms, allowing them to re-evaluate the situation.

What is actually dangerous here and now? Try to analyse a bit more, instead of just shutting down … the more I know about or talk about the problem, the more I understand, the easier it is to meet it [the symptom] when I get it into my face. (Lisa)

When understanding that overwhelming feelings belonged to the past, it was possible to act more constructively in the situation:

I managed to cope with these situations, and gradually it took less time and didn’t completely put me off any longer. After a while I could use less time and energy to calm down, and it made everyday life much better. (Marie)

For some participants, being able to handle triggering situations was experienced as coping with frustration and anger. Some participants experienced better sleeping patterns and fewer nightmares, and one participant entirely stopped taking sedatives. However, coping with dysregulation was an ongoing everyday challenge for all participants; sometimes it was possible to meet these symptoms in a new way and sometimes it was not: “It is when the storm is raging that it’s most difficult to remember the tools you have learned.” (Lena)

Trusting one’s strengths and value

Many participants described a new feeling of trusting themselves and their strengths. Some described it as a quality of trust inside, others as a feeling of strength or mastery:

It has given me so much strength that I no longer feel weak and sick. I’m not there anymore. I don’t see myself as a victim. I have quit that, and it’s a huge relief. Before I felt so weak, so sick, not worth much … so it’s absolutely huge that I simply have gained power over my life. (Petra)

Mia described a new trust related to deserving to have a place: “I shall also have a place … it’s something about the self-destruction that has been before. I, Mia, has not existed”. Feeling more empowered gave several participants a new sense of responsibility for their own development process, and some participants described a new sense of pride – pride that they could see their resources and acknowledge what they have accomplished in life:

I feel a sense of pride for this [doing crafts], I do. I don’t dwell on that for long. But I can more easily say that I’m good at it. I could never have said that a few years ago. It would be bragging. (Anna)

A new relationship to oneself and one’s body

This main theme captures participants new capability to relate to themselves, to be more in contact with themselves, more embodied, and the ability to stay with sensations and offer themselves more self-care. This theme had two sub-themes: Staying connected and Befriending oneself in the face of suffering.

Staying connected

All but one participant described an increased contact with themselves, with their body, sensations, and feelings: “I’ve learnt to listen to my body and trust myself.” (Petra) For Emily, this resulted in a transformative experience leading to a shift from alienation to befriending the body: “I’ve always felt like a refugee in my body, and then I got a feeling that my body actually wanted to be on my team.” For most of the participants, increased contact with themselves was like a double-edged sword. On one hand it opened new possibilities, on the other hand they had to deal with difficult feelings, thoughts, and bodily sensations instead of avoiding them. Several of the participants described an increased intensity of symptoms; some described increased vulnerability due to less dissociation from the pain that originated from childhood. One participant suddenly felt more anger instead of being depressed and numb. Nevertheless, the change towards staying connected with oneself was predominantly a positive experience for all participants:

I’ve received much more in return [by participating] than I thought I would get. You notice how you think and how you feel, what’s good for you and what’s not, so you don’t lose yourself in others, finding out that you can set boundaries. (Beth)

Some participants encountered parts of themselves that had been dissociated: “I have discovered these exiles and that I have to take care of them.” (Emily) Some participants highlighted a new ability to notice and appreciate positive sensations as well, helping them to choose to do more self-care activities: “Another thing I have become … [good at is] to create positive breaks and recharge with things that I know I like and that give me peace and quiet and happiness and such.” (Katie)

Befriending oneself in the face of suffering

All participants described changes in how they related to themselves while they were in contact with painful feelings and reactions. Through the therapy process they realized that their reactions were trauma-related and normal, resulting in less shame and more acceptance of themselves:

I think it [TMC group] has changed the relationship to myself when I have a hard time. I don’t internalize those difficulties so much, and don’t think it is me that is defective or wrong and all that … And I also feel I am less ashamed of who I am. (Emilie)

Most of the participants described that they still had an inner critical voice, but they could more easily notice it and consciously shift from self-destructive tendencies to more acceptance and self-care, strengthening the supportive inner voice: “Before it was only criticism, but now I can see that I have a value … I listen to myself. In a way, I am my own friend that I can talk to.” (Ada) Some participants described how befriending themselves affected other relationships: “I’m much more kind to my partner too.” (Petra) Some participants found it highly challenging to relate to their own suffering with more kindness, but described change as having moments of warmth towards themselves. Two participants had no distinct self-critical voice, but discovered other, more subtle ways in which they had been counteracting themselves; this insight helped them find their own strategies for self-care.

Gaining more freedom in relationships and life

This main theme emerged from participants’ stories describing new experiences of freedom to be themselves with their strengths and vulnerabilities. Through analysis, two sub-themes were developed: Becoming more expressive and truer towards oneself and one’s needs and Discovering and grasping new opportunities.

Becoming more expressive and truer towards oneself and one’s needs

Many participants described a greater ability to be themselves in relationships with other people. They could more freely express their feelings, needs and vulnerabilities, and experienced that it elicited new responses from people around them: “But the thing that’s so beautiful is precisely that … instead of hiding your vulnerabilities … how differently people behave towards you when you acknowledge and show your vulnerability.” (Katie) Many of the participants highlighted an increased ability to set boundaries, leading to a greater personal space and enabling them to choose activities based on their desires and not on guilt, duty or others’ expectations:

There are situations where I before wouldn’t have been able to say a clear no, but where now I can manage to say, both with words and body language: “No, I don’t want that, so just forget it.” Whereas before I would surely have gone beyond my own boundaries. (Beth)

Several of the participants described an increased ability to set boundaries when encountering other people’s problems and needs, being less stuck in old patterns of trying to help everyone: “It’s not my responsibility to always solve things or help others who are having difficulties.” (Susanne) Marie described a process of tolerating becoming more visible as a woman:

I’ve got a life back … that I can live again, not be so terrified, that I can fix my hair and that I can buy new dresses. I’ve never bought dresses before. Never is the wrong word, but very seldom. I can better tolerate seeing myself as a woman. That I have a woman’s body and that I don’t have to walk around in sportswear. Maybe I’ll wear a nice skirt, and even though someone might notice some feminine curves, it’s alright with me. (Marie)

Participants also described changes in terms of a new ability to ask for help, talk about sexuality and share knowledge gained from the TMC group with relatives and friends.

Discovering and grasping new opportunities

Many participants described that they now actively sought out new possibilities in life, choosing activities based more on their own desires than on expectations from others. Ada had dropped out of her studies at the university and the TMC process helped her realize that she for many years had dreamt of a practical rather than an academic profession, making it possible to change direction:

It’s something that I have dreamt of since I was a little girl, but then I started on other things, thinking that I should get a bachelor’s degree or something. I thought that was better and smarter. Now I have fallen back on doing what I want … it feels very okay and right. (Ada)

Emilie went to church more: “I’m much more active there [in church] where I live … I’m conscious of, and search for love”. Taking new opportunities was for many participants related to a feeling of being capable of approaching challenges instead of avoiding them. Katie had avoided a vital medical intervention for more than 10 years, risking her life, due to traumatic experiences in the past. During the TMC intervention she faced the challenge and managed to find a way to go through with the intervention: “Instead of just avoiding thinking about it I have approached it and really faced up to it in a completely different way than I have managed before”. Many participants described changes relating to everyday activities, and how they now grasped opportunities to do more positive things:

It has changed a lot. So many possibilities have opened, for example that I can go out on the terrace or wherever I am. Being on the platform waiting for the train … I can observe, listen to the birds, to the leaves, the sound of the wind and rain. And when I wake up in the middle of the night, as I often do, and I have difficulty falling asleep again, then, when it rains I can think, “Oh, so nice to hear the raindrops.” (Petra)

Some participants expressed that they could see new possibilities related to work in the future, like being able to work again, extend their working hours or chose another profession.

Participants’ Experiences of Change Mechanisms

Analysing which mechanisms participants described as helpful in their recovery process, four main themes crystallized: New perspectives give understanding and hope; Accessing tools facilitates agency; Significant moments of awareness open up to new possibilities; and Circumstances in life that facilitate change.

New perspectives give understanding and hope

Gaining new perspectives and thus understanding more about themselves and their recovery process turned out to be a key mechanism of change described by all participants. This main theme had three sub-themes: Understanding trauma reactions; Understanding processes behind self-criticism soften its impact; and Gaining a more realistic view of and ownership to the change process.

Understanding trauma reactions

All participants highlighted the importance of learning about common reactions to stress and trauma. Their symptoms took on meaning instead of being terrifying, incomprehensible, and shameful, sparking a hope that change was possible. With insight, it was also easier to place the reason for the reaction in the past: “I can see what it was about and think that I was 6 years old then and now I’m not.” (Vibeke) Katie describes how gaining insight into one’s symptoms was not only an intellectual process, but also an emotional one:

The theoretical part [in the group] gives intellectual insight, and not only intellectual. But that comes first, and then come some emotional insights because of the things one has understood, yeah, then emotions linked to the insight also get activated.

Most of the participants highlighted that being in a group sharing experiences helped them feel less abnormal and ashamed and they could more easily accept their reactions as natural and common to all human beings. As described by Helen:

So, being together with others who have had traumatic experiences, without talking about trauma histories. When I hear about the reactions … One thing is when the course leader talks about what’s normal. When it gets confirmed by the group, it gives such resonance.

Understanding processes behind self-criticism soften its impact

Many participants described getting a new perspective on their critical inner voice as important. The perspective that self-criticism could serve as an important part of one’s defence system was particularly significant in helping participants understand their old patterns and facilitate change:

So, my inner critic is just trying to protect me. That concept was very important to me. When I understood that, it took a lot of the sting away from my inner critic. So, it’s a really important thing for me. It was a eureka moment to me. (Jane)

Insight into the function of the inner critical voice did not mean that it disappeared: “I quickly get that self-criticism, but I am more aware that it doesn’t have to be true.” (Emily) With understanding, several participants described that it was possible to activate collaboration with critical inner voices, opening up ways to treat oneself with more self-care:

It isn’t criticism; they are helping me. And that makes it much easier to be friendly towards them … when they’re guardians, right? They take care of me but then sometimes they go overboard, so I have to put them in their place a bit. (Ella)

Understanding the value of taking care of oneself decreased the shame and guilt related to prioritizing self-care and setting boundaries: “Maybe it will be easier to help others if I help myself first. This is the biggest lesson I learned from this process; it is not wrong to pay attention to oneself.” (Anna)

Gaining a more realistic view of and ownership to the change process

Most participants highlighted the necessity of getting new perspectives on the change process itself. Hope for change is essential but can also trigger unrealistic expectations of a quick fix, leading to disappointment and more hopelessness. Many participants, when they understood how deep and profound the change process was, and realized the need for repetition and baby steps forward, experienced renewed hope and could appreciate minor changes:

I have to work on it, without being forced, but that is what gives results. There are no easy solutions, not for anyone. I work on it all the time, not just now and then, being aware of it in everyday life. It’s important for me that I see that I need it. (Randi)

Several participants described a clear shift in perspective when they understood they must do the work for their own sake, not to be a good client or to fulfil expectations from others: “It’s me that’s in the centre. I’m the one something is going to happen with. I’m the one who has to work on it. That was a little hard to grasp immediately.” (Ella)

Accessing tools facilitates agency

All participants underlined the importance of getting tools that helped them to take charge in situations and to do something to cope with reactions:

Now I’ve learned several techniques to calm myself down and it takes less time now. I still have it [flashbacks and panic attacks], but now I know: okay, it is what it is and I try to handle it with different techniques. (Marie)

Most of the participants expressed the significance of accessing tools that enabled them to enhance self-care in one way or another. As described by Helen:

I feel I have some tools now. All this about self-acceptance and self-compassion that’s so clear at this course [TMC group]. Trying to meet myself and therefore also meet others with acceptance and sticking to it, working myself away from mental self-flagellation.

Many participants highlighted the importance of having freedom to discover which tools worked for them. By exploring different exercises, noting their effects on themselves, and actively choosing what works, participants gradually built more confidence to tackle greater challenges. As described by Katie:

When you know you can go back and forth, go in and out of things [discomfort], and that you can stop. When you know it won’t take you hostage, then you dare to go further. As long as you feel safe all the way, you can continue, keep going deeper and deeper,

Many participants also highlighted the importance of accessing simple tools that could be incorporated into routines in everyday life, making it possible to integrate new ways of being. These tools could be helpful both in challenging situations and to create good experiences and be present in one's everyday life.

Significant moments of awareness open up to new possibilities

Participants described significant moments of inner or outer awareness which opened up to new possible ways of sensing, responding, or acting in a situation. Many participants also referred to significant experiences from previous or concurrent individual therapy, revealing a continuous interaction between different therapy processes. Experiences built on and complemented each other. The analysis showed two interrelated but distinct sub-themes: Noticing and recognizing inner sensations and Moments of interactions challenges old patterns.

Noticing and recognizing inner sensations

Noticing unpleasant sensations, staying with them, and accepting what is, was described as significant moments by most of the participants. Leading to different changes as being able to relax, let go of things or choose new ways of responding. Feelings and symptoms could be met as messages instead of something negative: “Because it’s necessary [to recognize the activation in the body] I can easier identify where it comes from and healing takes place … It gets processed and released” (Katie). For most of the participants moments of noticing and recognizing inner sensations also was a key to be able to actively choose to meet oneself with more kindness and self-care:

I stop and take in what I feel, what is it that makes this now? I listen to myself, that I am a friend that I can talk to in a way … Now I take time to analyse my problem instead of making negative comments to myself. (Marie)

Moments of inner contact also gave access to noticing positive feelings, needs, values and deeper meaning in life. Many of the participants had a lifelong story of listen to the feelings and needs of others, and less practice in feeling their owns: “Because to me it’s a lot about taking up space and be allowed to take up space. To feel and be in contact. Who am I? What do I want?” (Mia). Several participants described significant moments when they were able to notice the body signalling the need for a boundary: “Now I feel, feel when I get a shorter temper, the initial signals, and that the body shouts “no”” (Helen) Several participants also highlighted the significance of distinguishing between oneself and others, making it possible to actively letting go of signals from the surroundings when needed, and how the group context contributed to this: “I am very good at scanning the situation, I’m good at everything that’s around me … Then I thought: that’s not why you’re here [TMC group] … Now it’s about yourself” (Sylvia). Being in contact with oneself and accepting what is, was described as an ongoing challenge by many of the participants. For some participants these processes elicited grief regarding the way they had related to themselves earlier:

There is some extra grief too, because one gets aware of that one didn’t listen, didn’t have the ability, to one’s body and what’s happening. Because there were clear signals. That I partly have inflicted this on myself. Yes, it becomes a grief, but this course [TMC group] helps me process it much better. And to live with it! (Petra)

Moments of interaction challenge old patterns

Most of the participants described significant moments of interaction with others in the group and how this initiated change. Sharing experiences and reflections opened up for moments of connection and new deeply felt sensations of not being alone:

And not to be alone … Even though one of course knows that many people have experienced similar things and that they are left with the same feelings as we have. It’s quite something to actually meet, and just feel it, right? (Emily)

Moments when participants felt respected and accepted by other participants and group leaders were described as significant, enabling them to dare to be seen and heard: “One doesn’t have to be afraid that people will look down on you, look at you askance. Everyone understands that this hurts, that it is difficult. One is not afraid to say what one feels.” (Jane)

Many participants highlighted the necessity of feeling safe to be able to open up to positive interactions in the group. Having both the freedom to stay silent and a clear structure to follow made it possible to feel safe and present and several participants underlined that not talking about their trauma histories was essential. Participants also described significant moments of interaction outside the therapy room. Mia, who had grown tough to be able to look after herself in a difficult childhood, described a soul-stirring encounter with an old acquaintance.

It was really nice, and I found myself thinking … I liked him a lot. I haven’t been able to feel things like that before, because I haven’t been able to be present in a conversation before. But then I actually felt that he … I felt touched by him.

Mia’s realization that it was possible to feel this connection again gave her hope.

Circumstances in life that facilitate change

Many participants referred to contexts and situations outside the therapy room that influenced the change process. Several participants described important relational events, for example in a trusting relationship with a family member, a friend or an animal, or even that they experienced a strong connection to the author of a book. Two participants described how a major life crisis initiated seeking therapy, opening up for change. Emily described giving birth to a child as a starting point, enabling her to feel love: “It has been a long process, and it might have started with me giving birth to a child. It was quite miraculous that I, with my background, was able to experience such love to my child.” Helen articulated how change is a long-term process and how circumstances in life outside therapy can facilitate change:

My children have moved out. That gave me more space in my everyday life. I’ve structured my life in a completely new way. So there have been a lot of important changes, but of course it began at one end and lasted several years. That made it possible for me to really tackle the underlying causes. (Helen)

Discussion

Exploring how trauma clients experienced change and mechanisms of change following participation in the TMC group provided a rich picture of change processes overall, in addition to more specific understanding of the effects of participating in a TMC group. Our findings are in harmony with the intention of the TMC programme, showing that it may target the core symptoms of PTSD/CPTSD and tap into core processes of change. These findings are supported by quantitative data from this project, as reported in another article, showing a significant decrease in PTSD, CPTSD and dissociative symptoms following participation in the TMC programme (Salvesen et al., in press).

Psychoeducation is considered an important part of phase 1 trauma treatment for complex trauma (Mcfetridge et al., 2017) and gaining new perspectives through psychoeducation was experienced as a key mechanism of change by all participants in this study. One interpretation could be that psychoeducation helped participants by making sense of their symptoms, letting them feel normal, lessening their shame, and fostering their hope. This understanding would be in line with previous research proposing hope to be a transdiagnostic mechanism promoting positive changes in symptoms and a sense of empowerment (Chamodraka et al., 2017). Our findings show how the group format enhanced the effect of the psychoeducation for most of the participants, offering more perspectives, sufficient distance to be able to relate to the topic at hand, and emotional moments when participants recognized themselves in others, as reflected in the sub-theme Moments of interaction challenge old patterns. This is in line with previous literature on group-based treatments for trauma survivors (Herman, 2015; Stige et al., 2013), and the known change factor of universality in group psychotherapy (Yalom, 1995). With shame and withdrawal being common symptoms after relational trauma (López-Castro et al., 2019), our findings shed light on how understanding trauma reactions (psychoeducation) and feelings of not being alone (group format) facilitated recovery-related processes, including reduced shame and experienced connection to others.

In addition to psychoeducation, skill training is considered vital for building integrative capacity and regulation skills in phase 1 trauma treatment (Mcfetridge et al., 2017). This is also supported by our findings, as accessing tools was experienced as a key mechanism of change by all participants, reflected by the main theme Accessing tools facilitates agency. Participants’ experiences shed light on how mindfulness and compassion exercises may target PTSD/CPTSD symptoms and promote recovery by strengthening core capacities, such as being present, recognizing inner sensations, controlling focus of attention, regulating emotions and relating to oneself with an attitude of acceptance and kindness. With increased presence and embodiment, participants also experienced exposure to difficult feelings, sensations, and memories they had previously avoided, and they exposed themselves in new ways in the group. This highlights how the TMC approach, focusing on practising mindfulness and compassion in addition to safety, also has clear exposure components and that the group format involves exposure that can be particularly challenging for CPTSD clients. This points to the difference between short term coping strategies such as grounding, and more challenging mindfulness-based exercises that involve emotional processing (Williston et al., 2021).

Other studies have shown the importance of adapting mindfulness-based interventions to trauma clients in order to make them more effective and tolerable and reduce drop-out (Kelly & Garland, 2016; Müller-Engelmann et al., 2019). Our findings support this and suggest that the TMC intervention helped participants normalize their reactions, choose a regulating focus when needed and counteract feelings of failure. We suggest that the intervention achieved this by: (1) including psychoeducation about common challenges during mindfulness exercises; (2) introducing mindfulness with focus on pleasant sensory experiences; (3) practicing grounding to handle emotional dysregulation; and, (4) practicing to shift focus between something safe and something more challenging. Many participants also described that understanding self-criticism as a way to protect oneself, was important to be able to soften its impact. This is in line with Gilbert and Procter (2006) arguing for the importance of reframing self-criticism as a safety behaviour in order to help clients be able to meet their reactions with empathy and kindness. In the TMC approach the concept of multiple-part selves and the role of the inner critic are used to help participants understand and gain some distance to their self-critical voice (Fisher, 2020). Our findings can therefore be seen as examples of the processes involved in gradually building integrative capacity and expanding the window of tolerance in trauma-specific treatment (Ogden et al., 2006). Our findings also underline the importance of allowing participants freedom to choose and tailor exercises to themselves. This supports clinical experience indicating that trauma survivors need to feel they are free to move away from a situation in order to feel safe enough to stay (Ogden et al., 2006). Repeated relational trauma is characterized by being helpless and captured in a situation and autonomous activation of submission as a survival strategy. Submission and powerlessness lead to alienation from onés body and a fragmented sense of self, the opposite of experiencing ownership over one’s own body and self-agency, the perception that we can influence our physical and relational environment (Moore, 2016). Our findings support the notion that trauma disorders can be viewed as being associated with a perturbed sense of agency and that strengthening self-agency is critical for recovery (Ataria, 2015).

An unexpected aspect of our findings was how very differently participants used the tools when practising at home. Even though the programme is pedagogically structured with exercises that are assumed to become gradually more demanding, participants did not use them in this structured manner. They moved back and forth between different exercises, and many mainly used a few from the first part of the programme and less from the last part related to self-compassion. At the same time most of the participants described that they worked on enhancing self-care and self-compassion and they all experienced some change in the form of less self-criticism and a kinder attitude towards themselves in the face of suffering. One interpretation of this could be that participants profited from psychoeducation and exploring exercises with focus on self-care/self-compassion in the group, but then felt free to explore this theme from their point of view in their own recovery process. One can argue that this might be a result of an increased sense of agency, where participants felt less obligated to follow the leaders/structure and could follow their own needs instead.

The importance of tools as a gateway to increased agency is also interesting to relate to the experienced mechanism of change captured in the sub-theme Significant moments of awareness open up to new possibilities. This theme illustrates how moments of awareness with an attitude of acceptance could give participants a perceived sense of something new and new possibilities. One can argue that such significant moments facilitate change and recovery processes by generating a positive upward spiral where change fosters change, quite the opposite of feeling stuck and powerless in a negative spiral of trauma reactions. Our findings mirror the close interplay between the change mechanisms gaining new perspectives, accessing tools, and sensing/feeling something new. This is in line with a meta-ethnographic study analysing how patients with chronic illness experience mindfulness-based approaches, suggesting that mindfulness-based therapy facilitates a movement back and forth between meta-cognitive knowledge and meta-cognitive awareness (felt sense) and that it is through these movements participants are involved in a process of “translating knowing into being” (Malpass, 2012). One can also argue that this process may be of particular relevance in treatment of relational trauma, where deeply rooted trauma-related beliefs about oneself need to be addressed and changed (Herman, 2015). Even though these clients might know that they have a distorted view of themselves, old, embodied reactions continue until the clients repeatedly experience something new on a bodily and emotional level, until a process of “translating knowing into being” is facilitated.

Overall, participants described change as an ongoing process and not a set outcome. A deeper understanding of the change process itself, that there is no “quick fix” and that the effort one puts into the process is for oneself and not to please others, was important to most of the participants in that it allowed them to recognize, appreciate and savour small changes in the desired direction. Participants mainly described changes as moments of meaning in their lives and not in terms of coping with trauma reactions and healing from trauma. Examples include being able to feel love, communicating personal boundaries to a family member for the first time, or feeling empowered by managing triggering in a work situation. Symptom relief could be a part of their story but was not separated from their personal meanings and lives. Our findings are in line with those of other qualitative studies exploring the first person perspective on change, where change is experienced as an individual and multifaceted process (Binder et al., 2010; Mount, 2020) and support the call for applying recovery principles in the treatment of trauma (Smith et al., 2016).

The three main themes of change we developed – Becoming empowered; A new relationship to oneself and one’s body; Gaining more freedom in relationships and life – all reflect experiences where participants could acknowledge and act more in accordance with themselves, their needs, dreams, and values, instead of being driven by shame, old defence patterns or others’ expectations. They felt more alive and connected to others; they could be more visible and expressive and less inhibited and withdrawn. From this perspective, change can be viewed as a transformative process of opening up, more about becoming who you already are, than becoming something new. These findings are consistent with Malpass (2012), describing clients’ experiences of mindfulness-based approaches initiating a transformative process that gradually shifted their relationship to themselves. However, the process required hard work, for some it activated grief, and many participants also experienced the process as a risky, albeit tolerable journey, as described in a previous article based on this intervention (Salvesen et al., in press ). One can argue that the challenging dance between safety and uncertainty is precisely what makes the TMC approach effective. Our findings point to the importance of having a safety focus, taking clients preferences into account, preparing them for the hard work they will need to do, while at the same time communicating hope and letting it be their own choice to participate.

Our findings indicate that the TMC approach can include clients at different stages and with a multitude of different trauma-related symptoms and has potential as a recovery-oriented transdiagnostic treatment module, fitting into the modular approach to treatment suggested by Karatzias and Cloitre (2019). This study also substantiates the criticism against trauma treatment guidelines’ uniform focus on individual evidence-based exposure therapies (Norcross & Wampold, 2019) and indicates that other approaches can be of great value in trauma recovery.

Limitations

To shed light on the integrated quality of the two research questions, we decided to report the findings in one article. While this allowed us to shed light at the experiential interplay between change and mechanisms of change, this decision meant that a finer grained category structure and more substantial descriptions of themes and subthemes could not be presented. Several concerns can be raised due to the fact that the researchers who developed the TMC programme also led the groups and conducted interviews. Participants may have felt obligation to agree to participate in the study, to complete the group therapy and to give positive responses, although they were not interviewed by their therapist. The researchers might have been motivated towards positive results to confirm the value of the treatment programme. On the other side one might argue that the researchers’ multiple roles constitute a potential strength of the study. With deep-seated knowledge about the theme and context of the study, the researchers had a heightened sensitivity for the nuances communicated by the participants, which can be an advantage in the process of making sense of participants’ experiences (Finlay, 2011). Future studies should be carried out by independent researchers to further explore the transferability of the findings to different clinics and therapists in the health-care system.

Ethical Approval and Consent to Participate

The study was approved by the Norwegian Regional Committees for Medical and Health Research Ethics (2018/1371NORD). All participants took part in the study with fully informed consent.

Acknowledgements

Our deepest thanks go to the participants for sharing their stories and reflections with us and thereby laying the ground for the whole study. MW, KTS and SHS developed the study design and planned the data collection. MW and KTS conducted the interviews with supervision from SHS. MW analysed the data and designed the manuscript in close collaboration with SHS and KTS. All authors have approved the final manuscript.

Disclosure Statement

The first and second author have published the TMC manual and receive royalties for sales.