Relationality
As a thematic finding for this review, the concept of relationality demonstrated how experiences living with, coming to know, and engaging in treatment for PTSD are neither isolated nor stable events in the lived worlds of PTSD. These experiences are, at least in part, dependent upon how (or from where) one stands in relation to others and self. While what qualifies as PTSD and its potential treatments were couched within the clinical languages of the DSM or evidence-based psychotherapies, how those diagnoses or treatments were enacted was often described as contingent on the forms of internal and external relations at play. Our engagement with the concept of relationality reflected on this contingency and worked to draw out how descriptions of things like therapeutic relationships, relationships with others outside of therapy, and relationships with one’s self interacted with the effects or values placed on the variety of included therapies.
In the previous review of iCBT for major depressive disorder and anxiety, we found that patients were often concerned with elements like the pace of treatment, communication or monitoring features, and the demands of fully engaging with treatment.38 However, the variability in focus of these concerns and their suggested solutions made it difficult to identify generally appreciated aspects of iCBT programs intended to treat major depressive disorder or anxiety. As such, our primary conclusion pivoted around the idea that assuming a one-size-fits-all model of iCBT would disregard this variability and “neglect the importance of tailoring emphasized within patient experiences.” (p. 39).38
Our broadened reading of relationality for the current review supports this overall conclusion and may help to provide further insight into where or how this tailoring might happen when considering the potential uses of iCBT for PTSD. While it is recognized in the sections on “content” and “process” that treatment success relies on the internal makeup, logic, and course of a chosen intervention, our analysis of the forms and importance of relationships described throughout the included literature suggests that these components are already well situated within larger fields of relations. Simply put, our analysis suggests how concerns with treatment content or processes can more easily rise to the fore and become addressable through an attentive appraisal of how one stands in their relations.
The value of being attentive to relations is reflected in the way strong therapeutic relationships can provide the grounds for providers and their patients to navigate disparate preconceptions of interventions (like iCBTs) or encourage sticking with chosen interventions by instilling a sense of being heard, respected, and of a “shared humanity.” Even if not pursued, having the opportunity to actively collaborate in one’s own treatment decisions, and thus the opportunity to tailor treatment, could further establish a sense of comfort with treatment and foster the sense that “I can do this.” With higher dropout rates from iCBT programs meant to treat PTSD, as compared with wait-lists, it is possible these programs could benefit by re-evaluating the touchpoints between patient and provider, as well as the overall space provided to develop strong relationships.
This is important when working through which patients might be appropriate for iCBT (or how to adapt particular iCBTs to an individual patient), but also when thinking through the asks being placed on the shoulders of the individual undergoing treatment. The included literature tended to work through notions of “readiness” or “motivation” by situating the responsibility “to be ready” on the patient. Interventions, particularly those focused on exposure, were understood as stable objects that anyone could engage in given the right level of preparedness and motivation. As such, readiness and treatment were seemingly understood as activities of “doing” or “knowing.” Doing (or having done) work to develop the right affect management skills (which is typical of early iCBT modules) and positive coping strategies (again, typical of early iCBT modules) were considered necessary components of the exposure-ready patient. For iCBT programs that include exposure elements, one way of supporting patients and building awareness of how difficult this might be for them could be to ensure a clear understanding of the relationship between how the development of these skills or strategies is connected to the thoughts or behaviours they are meant to address, and why this matters for the exposure elements of treatment.
The notion of readiness also included conversations around a third component of the exposure-ready patient: motivation. What it meant to be motivated, or how motivation was felt to play a role in successful treatment, could be different depending on whether people were considering their treatment goals in the moment, or contemplating what a new life might look like after successful treatment. This temporal shifting of notions of motivation has the potential to reframe motivation from questions of “How do I stand in relation to myself? (Am I ready to do this?)” to “How do I stand in relation to myself in the world? What does (hopefully) successful treatment change about the world I live in?” When readiness is considered as primarily coming from a space of patient characteristics making them ready to engage with a therapy (or not), we lose sight of the way in which patients, treatments, and their providers are situated within larger worlds. As such, assessing an individual’s readiness to engage in a treatment like iCBT may benefit from broader conversations than whether an individual has the appropriate skill set or willingness to change.
Therapeutic Relationships
Patients and providers consistently described the development and maintenance of a strong therapeutic relationship as an important component of treatment for PTSD.99–101,105,106,108,109 Descriptions of the work these relationships could do and what they might look like in practice took on multiple forms, but most hinged around the assumption that stronger relationships meant stronger results. In its simplest form, a well-established relationship could help to bridge potentially differing valuations of treatment purpose or utility of treatment held by providers and their patients.99,100,105 And while bridging often took the form of providers garnering buy-in for a suggested course of treatment from their patients,99,100,105 it could also indicate interest in pursuing collaborative approaches to treatment.106,109 Being a collaborative partner in treatment helped to develop a sense of respect and provided patients with the opportunity to engage with therapy “at my pace.” (p. 227).109 This could help them feel more capable of incorporating the techniques being shared during therapy into their lives and more aware of what they might be achieving (or not) through treatment.109
Fostering this relationship early on (whether based on collaboration or not) could establish the groundwork from which to comfortably have difficult conversations regarding veering off track from the treatment goals,101,109 or whether chosen treatments still felt right and should continue to be pursued.101,105,108 The asks associated with successful completion of treatments for PTSD, particularly those engaging with re-exposure to traumatic memories or situations (i.e., PE and CPT), can be quite challenging and require a lot of active participation on the part of patients.100,107 Feeling as though a provider understood this and could recognize when they (as in the patient) were struggling, could “make it a little bit easier to show up.” (p. 53).101
While this could be as straightforward (and imprecise) as developing a “good working relationship,” (p. 9),100 it could also be caught up within notions of shared humanity,106,108 feeling heard,109 and being acknowledged as more than just another patient downloading expert knowledge.106,108,109 In this way, some practitioners saw a strong relationship as a way of sharing in their patients’ journeys rather than directing them from a removed space of objective expertise.106
“You notice that the clients are different… How they respond to you when you’re not trying to be technically perfect…or when you’re not trying to be the expert…you know. I think that’s…a mistake we all make, this idea that we have to be the expert all the time…and that’s not what they’re looking for… You can get that out of a book.” (p. 198).106
Concerned with the felt restrictions placed on them in an in-patient setting oriented toward eight 12-week intervention time frames, this provider suggests that caring for their clients happens somewhere outside of the space of expert knowledge. Knowledge can (and should) certainly be passed along but situating themselves in a space outside of expertise with their clients could open the door for a “shift then in therapy.” (p.197).106 Not doing this could make the treatment feel packaged and like something you can get “out of a book.”
Developing these types of relationships, however, can take time and is often easier said than done. This could be particularly true of residential programs where rigid timelines100,106 and structural pressures to pursue a one-size fits all, “diagnose-treat-discharge” model to care provides little room to build anything more than an “artificial therapeutic relationship.” (p. 196).106 This could not only be damaging to the patient’s desire or ability to pursue and continue treatment, but it could also leave providers feeling disconnected, desensitized, deskilled, and ultimately “complicit in their patient’s distress.” (p. 196).106 This could be further exacerbated by a lack of continuity in care. Speaking of the lengthy referral process in the US Veterans Affairs system, one veteran explained, “Then she tells me, okay I’m going to assign you a new therapist. I’m thinking, shit I gotta go through this again. That’s when I quit, yeah, that day.” (p. 539).99 Hopping from provider to provider could be difficult for patients as with each new provider there was a renewed need to describe their traumatic experience(s).
If we are to take seriously the value placed on therapeutic relationships described here, ensuring iCBTs are able to be engaged in ways that permit the development of these relationships is important. Given the described importance of these relationships it seems less likely that unguided iCBTs for PTSD would be considered as useful or chosen over guided iCBTs by both providers and patients. While expected or desired ideas of what a relationship might look like, and how one goes about developing it, can certainly vary by person (e.g., there may be individuals who prefer unguided or minimal guidance), implementing and engaging in iCBT programs that take this variability into account would also need to be considered. The freedom for patients and their providers to collaboratively adapt chosen iCBT programs to suit relationship needs or desired outcomes would help alleviate the difficulties of this variability.
That being said, relying on the iCBT program alone to foster this relationship and successfully treat PTSD is not sufficient. The uptake and, hopefully, subsequent positive effect of an intervention like iCBT is, at least partially, already situated within a relationship established on trust, respect, empathy, shared humanity, and active listening.99,105,106,108,109 With this in mind, it is important to acknowledge that using iCBTs to treat PTSD is likely not appropriate for everyone. Even if concerns over adaptability and collaboration are satisfied, it is possible that the modular design and limited timeframes of iCBTs could limit the opportunity for providers to downshift from expert to listener. Of course, it is possible that the movement between expert and listener could be more related to the provider’s own ability to navigate the needs of their patient within the treatment paramenters rather than the design of any intervention. Simply put, some providers may struggle with meeting patients needs of desiring this depth and form of relationship regardless of intervention (e.g., be that iCBT or face-to-face CBT), and responsibility for fostering this sort of relationship should not be situated squarely on the intervention alone.
In many ways this resonates with how some traditional healers understood their role in caring for their clients. One healer noted,
“The way healers work — or medicine people work — is they don’t actually do anything themselves. They build their connection through their teachings, through their way of life, through how they live. And their connection becomes very strong. So what they do is, they do ceremony. And in that ceremony they actually are consulting with some of these spirits that people are experiencing. They consult with the people’s spirits. And when they do that consulting…those spirits know how to help this person heal.” (p. 71).110
In this example, while healers are indeed holders of expert knowledge, this knowledge is grounded in their ways of life — this knowledge implicates the healer as more than expert knower. To successfully care for their clients, a healer needs to consult with something other than themselves. Then, and only then, does the healer know how to help this person heal. In this way, caring is grounded in that relational aspect of a therapeutic relationship.
Relationships With Family, Friends, and Other Peers
A growing awareness of the shifting relations between family, friends, and peers was articulated as playing an active role in coming to realize something was off, eventual pursuit of treatment, and desired forms of treatment.101,108,109 Living with PTSD can be disruptive to the daily norms of family life and for some people it took their loved one’s expressing concern to initiate treatment. “I mean a couple of times I’d go upstairs and lock the door and I would stay upstairs for two days… It was my partner who picked up on it. It was causing a lot of rifts between me and her. But I was like yeah, let’s go and give it a go and see what happens.” (p. 226).109 Understood as a problem situated within a larger field of relations than themselves, some individuals even expressed a desire for their friends and family to be collaborative participants in therapy.109 While a desire for collaboration was often tied to notions of developing independence or control over their lives, it was also considered important to the development of lives outside of active therapy.109
The presence of strong ties to family or peers also contributed to the will to stick with treatment.101,108 While some indicated being driven by the commitment they had made to their peers regarding treatment completion,101 for others, knowing that they were not alone throughout treatment108 and could count on loved ones was integral to treatment success. “My other half was supportive of it. She was here every day. If she hadn’t’ve been here every day I think I’d’ve walked out.” (p. 53).101
Given the largely individualized space of iCBT programs that are built around a patients’ drive to develop their own relationships or skills to build these relationships, it could be important to consider ways of incorporating participation from family and friends. While not every person living with PTSD will need their family, friends, or peers to be involved, finding a way to recognize the importance of these relationships could help to maintain treatment goals for some patients.
Relationship With One’s Self
As a diagnostic category marked by clinically recognizable poor relations with one’s self (e.g., criteria C, D and E in DSM-V),4 the commonality of conversations concerned with how that self might be implicated in treatment is perhaps unsurprising. While these conversations were typically situated within a language of readiness, it is important to note how the use (and meaning) of terms like “readiness” or “motivation” shifted among participants. Most providers and many of their patients interpreted and used these terms as a way of articulating both patient suitability (or not) for certain forms of PTSD treatments,100,104,107 and desires to change or “do” something about how one was living.102,109 For others living with PTSD, being ready could be a reflection on treatment suitability (or not) for their lives,99,105 and an engagement with just what treatment might mean for their lives.102,108,109 One asked, “What do I need right now to make myself ready for treatment?” and the other, “How will being ready for, and engaging in, treatment ask me to live differently in the world?” While subtle, the shifting inflection point between these two uses draws attention to the temporal frames involved in seeking, receiving, and completing treatment for PTSD.
Though it is important to note that concerns with readiness “to do” tended to be situated within clinical frames of treatment, they were not the exclusive domain of providers as they were often shared by patients, as well. That being said, we do take our framing of this understanding of readiness from providers working within the US Department of Veterans Affairs. As such, readiness for evidence-based psychotherapies, like PE and CPT, was described as reflective of a patient’s “affect management skills,” “psychiatric and external stability,” and an individual “readiness to change.”100,104,107 In this way, treatment success is tied to a form of readiness that happens when a patient’s ability to self-manage is paired with their “hunger”100 to change. As trauma-focused treatments predicated on the therapeutic importance of re-exposure to traumatic memories, feelings, or situations, without this base, practitioners worried that treatment could ultimately be unsuccessful.100,104,107 Following an eight-week PE or CPT protocol is “fast and furious and so it can feel, I think in some ways, and we’ve seen this with some of our veterans, kind of like ‘whoa, I don’t know if I can do this.’” (p. 6).100 Without knowing that “I can do this,” the fast-ness and furious-ness might overwhelm the veteran and render a treatment unsuccessful. While a number of stopgaps had been established in these programs to develop readiness in their clientele (i.e., psycho-educational and skill building groups),100,104 dropout rates were often still linked to patient readiness — “About a third are dropping out and typically they’re not dropping because they don’t need it.” (p. 93–94).104
In this reading, it is possible to make statements like “I think there’s probably no bad client for CPT and PE. It’s just getting clients to be willing to do those treatments that’s the challenge.” (p. 139).107 The interventions themselves are seen as stable objects full of therapeutic potential, ready and waiting for the motivated individual. While this was indeed echoed by many individuals living with PTSD across intervention types,99,101,102,105,108,109 it was, at times, complicated by slightly disparate understandings of what qualified as motivation or “a willing[ness] to do those treatments.”
For some, a desire “to do” was caught up within feelings of deservingness. This is not surprising given that an “exaggerated blame on self or others” is a possible indication under criterion D for PTSD.4 Questioning whether one deserves to heal makes it possible to say, “I still felt that I didn’t deserve to be happy or to have nice thoughts or to be kind to myself. I thought that by [being compassionate], there were things that would make me smile and I felt, well, I know it sounds silly, as if I wasn’t allowed to smile.” (p. 499).108 Describing motivation as a “willingness to do” or “hunger” to change fails to recognize a potential disconnect between what might be wanted and what is able to be done.
For others, that motivation is simply a matter of wanting “to do” something devalues the extent of the ask being passed along to individuals engaging in treatment. Knowing that something feels off and wanting to address that something can butt up against concerns of what it means to face that something — “Am I going to like the person that I’ve become? Because I’ve been like this, with these memories and these thoughts for so long.” (p. 499).108 For this individual, the question was less about do I want to “do it,” (as they had “done it” in the form of compassion-focused therapy) and more, “Who am I without these memories and thoughts?” As such, assessing readiness or motivation might be less about wanting “to do” and rather something more like a reflection on the aftereffects of that doing and how it can upend one’s lived world.
Again, this is not to say that providers and their clients were universally at odds when describing notions of readiness or motivation. Many patients aligned with providers by describing a sort of upfront desire to do, “Yes, I need motivation! Help me see the goal. Because I felt, in the group too, I need help to see the goals! ‘What does this do?’ ‘What does it help me?’ ‘Where are we going?’ ‘What is happening?’” (p. 576).102 Even when tied to a need to understand the point of treatment, the focus for motivation here is situated around that act of change rather than the aftereffects of that change. While these concerns are indeed distinct, they are not in opposition. The first seems primarily to be oriented toward those “techniques of self” necessary to successfully engage with treatment, but the second situates the development of these techniques within a larger plain of relations. Both ask questions about that relationship one has with one’s self, but one drags the relationship with one’s self out into the way therapy could have an effect both within one’s self and the world.
Descriptions of how one’s relationship with one’s self is implicated in treatment becomes important to thinking through the use of iCBTs for PTSD in a few ways. On the one hand, this relationship was actively tied to the techniques or tools one needed to be ready to engage in certain forms of treatment. Studies oriented around PE and CPT qualified this as “affect management skills.” As exposure is often a component of iCBT, it is important that individuals engaging in the exposure elements of iCBT have appropriate affect management skills. This is valid and, according to our reading, would seemingly be appreciated by providers and patients alike. The development of and ability to apply these skills in one’s daily life could be liberating and can open the door for those living with PTSD to begin “relat[ing] differently to their problems.” (p. 577).102
This relationship also comes to bear when thinking through the relationality of interventions like iCBT. As interventions existing and being engaged within the lived worlds of patients, iCBTs and the asks associated with successful completion of an iCBT program do not stand in isolation from these lived worlds. The techniques and tools being developed, or exposure elements being worked through, in these programs only have practical effect when applied to the lived worlds of those patients engaging with them. As such, it would be helpful to remember that notions of “motivation” apply to more than a willingness “to do” an iCBT. Knowing that one is ready and motivated to engage in treatment is not the same as knowing what happens once one has completed treatment.
The importance of understanding this situating in the world was also prevalent in Reeves and Stewart’s110 study with Indigenous counsellors, healers, and Elders. Some expressed the wounds of trauma as a broken spirit. While it was first important to understand the context of their Indigenous clients (situated within histories of colonial violence) it is then important to understand how this can play out on their daily lives with new, non-historical, traumas. If one such wound is a broken spirit in which a lost connection with the spiritual worlds around them is manifested, one Elder asks, “So how do you re-Aboriginalize ourselves [sic]? In terms of utilization of spirit? Which is probably the weakest part of ourselves that we didn’t grow with and nurture… Healing has to reflect the cultural paradigm.” (p. 69).110
Content
Given that there were no studies found engaging with either patients’ or providers’ experiences of iCBT for PTSD, the thematic category of “content” as taken from the previous report on the use of iCBT for major depressive disorder and anxiety required some adaptation to meet the objectives of this review. As the studies included in this review engage with therapies ranging from skills training in stabilizing groups to more intensive ones like PE or CPT, it was neither possible, nor practical, to capture the breadth of commentary surrounding intervention-specific content concerns as was done in the prior report. Rather, “content” for the purpose of the current review was explored from a high-level reading that considered how participants described the value, rather than makeup, of the types of content being engaged. As such, content here highlights the value placed on skill building programs and the importance of a program’s content to be adapted to patient needs.
The importance of a strong set of tools or skills with which to face the daily stressors of life with PTSD was widely recognized among both practitioners and patients.100,102,104,107 Such skill building programs were highly valued as a way of reorienting an individual to the world around them and their life with PTSD. These programs were described as helping to foster a sense of control over affective responses by building a connection between understanding the “cause of their problems” and how tools might help them enact that desired control.102 “My feelings have controlled me a lot… I have, in a way, existed. Floated along. And that is a really big difference from now, when I see that I have a choice, and if I choose that it has a consequence, and if I don’t choose that it gets another consequence.” (p. 575).102 As described previously, the importance of this control was reiterated by providers situated around treatments like PE or CPT.100,104,107 Providing iCBT programs with approachable content that helps to deepen an individual’s knowledge of PTSD, while articulating the relevance of how that specific treatment is meant to address PTSD, would seem important.
Similarly, homework was described as helpful, though could be difficult to engage with at times due to time constraints or inappropriate language.102 For example, some individuals described that it could be difficult to relate to some of the language used in treatment. “I used this safe place [but] What the hell, safe place, what is a safe place? I didn’t really experience a lot of safety, so it became: ’Hm…ok, yes. I like to be outdoors, in the nature, it helps me relax. Calm place. So rather that.” (p. 576). While the term “safe place” itself may have been useful for others engaging in this treatment, for this individual it was difficult to identify what a safe place could be as they had not experienced the feeling of safety very often in their own life. As such, they needed to adjust the language to suit their own situation and needs. Though it seems as if this individual was able to do this successfully, it is possible that it may be restrictive for others102 and could prevent them from successfully engaging with treatment. While this is a minor example, it does reiterate the potential importance of tailoring iCBT programs to the individuals engaging with them that has been noted throughout this review. Ensuring that appropriate language throughout iCBT modular work and homework activities would seem important when deciding whether a particular program is appropriate for the patient.
Traditional counsellors, healers, and Elders included in Reeves and Stewart’s110 study, spoke to the importance of providing healing oriented around an understanding of spirituality as “a cornerstone of wellness” for their Indigenous clients. Similarly, while these providers unanimously considered Western and traditional forms of healing as compatible, it was important that clients decided which content was considered important to their healing. As such, they noted the value of being able to track back and forth between traditional and Western forms of healing. One counsellor noted that this could take the form of “doing some basic psycho-educational training with clients and maybe using some grounding techniques and tuning into the fives senses, and then we suggested praying with a grandfather or rock, help to ground them when they’re triggered.”110
Process
Similar to the way in which the thematic category of “content” did not directly fit into this review from the previous review of iCBT for major depressive disorder and anxiety,38 the thematic category of “process” likewise needed refinement. Again, as it was neither possible nor useful for this report to engage in the details of each intervention, we present here a high-level understanding of the important procedural pieces for successful treatment of PTSD. As such, process here highlights the value placed on buy-in to treatment and flexibility in things like scheduling or location of treatment.
Across interventions, respondents repeatedly commented on how difficult it could be to engage in treatment for PTSD.99–102,105 Recognizing, responding to, and treating PTSD is neither intuitive nor as simple as following a series of steps. A host of relational (as previously described) and practical issues can complicate the procedural quality of therapy. As such, an initial buy-in to therapy was described as dramatically helping improve the likelihood of successful engagement with therapy. Buy-in, in large part, can be motivated relationally through the development of strong therapeutic relationships built on trust and empathy,106,108,109 peers vouching for particular modes of treatment,101,105 or individual alignment with the goals, ideals, and problems couched within treatment protocols.99,101,102,108 Again, while buy-in to (or collaborative agreement upon) suggested treatment may happen through relationships with providers or others, for an iCBT to be successful it is likely that those engaging with the program would need to agree with the reason for engaging in the program.
More practically, some patients spoke to the difficulties of attending face-to-face therapies. Being unable to take time off of work, the difficulties associated with the frequency and distance of travelling to therapy, and poor scheduling flexibility could mitigate any effect treatment might have.99,111 This could be further exacerbated in care settings where patients’ had previous negative experiences. This was particularly true in settings like VA hospitals where US veterans receive the majority of care for their medical needs. “I’ve got everything wrong with my back, but you can’t even give me a damn MRI. That’s why I’m done with the VA…the doctor telling me that it costs too much for him to put in a order for me to have an MRI… My trust is not there with the VA.” (p. 540).99 Others could feel out of place or simply uncomfortable in their particular care setting. “I despise going to the VA like with every fiber of my being. There are people everywhere, just hordes of people everywhere. I think that I was the only female in there, and I was just, I almost left… Usually I sit there with my purse clutched like I’m at the subway station in New York or something.” (p. 540).99 As iCBTs are able to be engaged with at one’s convenience, and in one’s own home, their value in potentially alleviating these concerns would likely be appreciated by individuals engaging with them.
Clear access to and communication with providers was also considered a helpful component of treatment.111 For some patients, the opportunity to communicate with their providers online was understood as helping provide a more detailed and thorough description of their day-to-day lives. “When I was on active duty my psychiatrist and psychologist used email and it was good for them when I could express how I felt at that time; for them to gauge my overall health status and not just what I say when I’m sitting in their chair.”111 Even when replies from their provider were asynchronous, being able to reach out and describe what was happening in the moment was understood as a valuable addition to treatment. The features of most iCBT programs may already be well suited to this form of communication and could provide further benefit for those who might find expressing themselves in person daunting.111
Context
Unlike content and process, it was appropriate to port the thematic finding of “context” into this review from the previous report on iCBT for major depressive disorder and anxiety.38 In the previous report, context was understood as involving experiences with the ways in which both personal (e.g., severity of condition) and structural (e.g., availability of intervention) situations influence engagements with treatment. While both of these have been previously articulated and are highly relevant to thematic categories like relationality and process, there is more nuance to ways that context influences experiences with treatment.
Providers repeatedly articulated the ways in which the presence of psychiatric comorbidities could limit the effectiveness of interventions like PE or CPT.100,104,107 One way of approaching comorbidities was to address them prior to treatment for PTSD, “Whether it may be substance-related issues or severe personality pathology or bipolar, they probably need a degree of stabilization in those areas before they can really focus in and do the type of trauma-focused work that we would need them to do in a CPT or PE.” (p. 138).107 Another was to potentially treat them together, “Maybe PE and a combination with other things but PE alone, when you’re dealing with more than one psychiatric condition, you have to treat all of them.” (p. 138).107 Some patients experiencing both first-episode psychosis and PTSD found treating them together difficult even if eventually valuable.103
Though minor, some patients did note that treatments that they would have liked to engage with rather than those available through their care provider (e.g., PE and CPT) were unviable and one reason for not engaging with treatment.99 Implicit here is that iCBT could provide another option to the standard treatments available.
Traditional Indigenous healers, counsellors, and Elders described the exploration and understanding of context as a primary need when thinking of healing from trauma. Context was largely presented in conversations around “loss” that included themes of colonization, “trauma as a constellation of losses,” and “wounds.” Participants described colonization as the policies and systemic injustices meant to assimilate Indigenous culture into Western culture and was understood as a fundamental driver in many of the mental health issues facing their clientele. Forms of colonial oppression like the residential schooling system and adoption policies of the Sixties Scoop were described as having been disruptive to the transmission of culture across generations and were considered responsible for a host of negative outcomes, including complex trauma and sexual abuse.
As such, participants described their clientele’s traumas as situated within a “constellation of losses” rather than the result of a single event. Whether referring to poor social determinates of health or the notion of “historical trauma,” this constellation of loss was considered important for participants to acknowledge as it allowed them to demarcate the complexity that would need to be spoken to. “I can show you four generations of residential school issues, where, you know, the kid hasn’t gone, his parents haven’t gone, his grandparents never went, but his great-grandparents did. But the kid has all the same symptoms that the great-grandparent had…because no cycle was broken.” (p. 66–67).110 The manifestations of these ongoing and reinforced cycles of trauma as well as any new traumatic experiences were described as “wounds.” One of the forms a wound could take was described as a “broken spirit.” (p. 67).110 A broken spirit was someone who was “lost spiritually…and I think that’s what people feel, is that general sense of loss and not feeling connected to anything around them. And people can get stuck in there for years and years — their whole lives!” (p. 67).110
