In Their Own Voices

It is estimated that child abuse and neglect result in direct (e.g., health care, law enforcement, judicial system) and indirect (e.g., special education, lost productivity to society) costs of approximately 103 billion dollars each year. Why do some abuse survivors display healthy functioning as adults while others display a variety of physical and psychological health problems? It was the goal of this study to discover what positive influences, both internal and external, that individuals relied on to overcome childhood trauma. Five main themes emerged from the data. The five themes are as follows: Spirituality/Faith in God, Supportive Others, Therapeutic Relationships, Self-Determination, and Expressive Writing. A description of these themes and selected quotes from participants are described.


Overview of Problem
It is estimated that approximately 2.8 million children are abused each year in the United States. More than half are neglected, one quarter experience physical abuse, 11% are sexually abused, and 6% are psychologically abused. This is considered to be a serious underestimate of the extent of the trauma that occurs to children while they are growing up (Myers et al., 2002). It is estimated that child abuse and neglect result in direct (e.g., health care, law enforcement, child welfare system, judicial system) and indirect (e.g., special education, juvenile delinquency, lost productivity to society) costs of approximately 103 billion dollars each year (Wang & Holton, 2007). With the rising costs of health care, it would be prudent for researchers and practitioners to create and implement prevention and intervention programs to address this topic. What enables a person to overcome a traumatic experience? Why do some abuse survivors display resiliency or healthy functioning as adults while others display a variety of physical and psychological health problems? Knowledge of what influences a victim to successfully recover from his or her traumatic experiences will make it possible for effective prevention and intervention programs to be created.

Positive Influences
There are multiple theories (e.g., Bonanno, 2004;Werner, 1990) regarding why and in what specific ways protective factors (e.g., resiliency, social support, intelligence, spirituality) affect an adult's recovery from trauma. In some cases, theories point to a direct relationship, an indirect relationship (mediation), and/or a moderating relationship between a variety of protective factors and a trauma survivor's psychological functioning. Research has shown that various protective factors can impact the relationship between childhood trauma and adulthood functioning (Aspinwall & Tedeschi, 2010;Dervic, Grunebaum, Burke, Mann, & Oquendo, 2006;Morrow, 2001;Perkins & Jones, 2004;Reinert, & Smith, 1997;Rutter, 1987;Werner, 1989). Perkins and Jones (2004) found in a sample of 3,281 adolescents who reported that they had experienced physical abuse that religiosity and support from family or other adults predicted lower levels of alcohol use, tobacco use, and sexual behavior. Morrow and Smith (1995) found that women relied on two core strategies, keeping from being overwhelmed and managing helplessness, powerlessness, and lack of control, to cope with childhood sexual abuse. Regehr, Marziali, and Jansen (1999) found that the need for support, positive self-views, and a sense of control were influential in women's recovery from sexual assault. Much of the research thus far has been conducted utilizing samples of female childhood trauma victims and/or individuals who have experienced sexual abuse. There is scant research, however, that has looked at males' experiences with trauma as well as studies that focus on what survivors perceive as important protective factors and their helpfulness in their own recovery.

Goal of the Study
To obtain a more comprehensive understanding of the various positive influences that enable trauma victims to overcome and deal with their trauma, a qualitative methodology was used. Qualitative research is characterized by a focus on obtaining a depth of understanding, providing insight into the meanings of decisions and actions, and viewing social phenomenon holistically, and involves respondents as active participants rather than passive subjects (Ulin, Robinson, & Tolley, 2005, p. 6). According to Ulin and colleagues (2005), "Qualitative methods are adding a new dimension to the ongoing search for answers to complex questions" (p. 6). The specific method that was used for this research was a Grounded Theory approach (Glaser & Strauss, 1967;Strauss & Corbin, 1998) with unstructured, open-ended interviewing (DiCicco-Bloom & Crabtree, 2006) as the means of data collection. Grounded theory refers to theory that is discovered from the data; the theory emerges from the data collected and is not predetermined. Unstructured interviewing does not impose any of the restrictions that structured interviews impose (Denzin & Lincoln, 2000). During the interviews, no set questions were asked; instead topic areas were introduced and the conversation was allowed to flow freely. This allowed participants to tell their stories "in their own voices" and not be compartmentalized into categories as a structured interview or a survey methodology would. There are numerous strengths of conducting qualitative interviews in trauma research compared with quantitative methodologies such as greater insight into the situation and a deeper understanding of the "total picture" (Brzuzy, Ault, & Segal, 1997). It was the goal of the study to discover what positive influences, both internal and external, that individuals relied on to overcome childhood trauma.

Participant Recruitment
To achieve a diverse sample of both female and male trauma survivors', flyers announcing the study were placed in various locations throughout a southeastern, urban university and the surrounding community (e.g., YMCAs, libraries, community bulletin boards). Flyers contained a brief description of the study, inclusionary criteria for participants, and contact information for the principal investigator (PI). Potential participants contacted the PI and each was briefly interviewed over the phone by the PI to ascertain if he or she met the qualifications of the study. To participate in the study, individuals had to meet three criteria: (a) must have a history of trauma during childhood. Trauma was defined as any type of abuse (physical, psychological, sexual), witnessed violence between adults in the home, and neglect by caregivers. The trauma could have occurred just once or multiple times; (b) must define themselves as having successfully dealt with their trauma; and (c) must be 18 years of age or older. Twenty-four potential participants contacted the PI and 22 met the qualifications of the study and were scheduled for interviews. Recruitment of participants ceased when it was felt that the study reached saturation, as recommended by Lincoln and Guba (1985) and Jones (2002). According to Morse (2000), saturation (i.e., when no new information is garnered during the coding process and no new categories or themes emerged) depends on the quality of the data obtained, the scope of the study, and the amount of useful information obtained from each participant, among other factors. Recruitment of participants stopped at a sample size of 22 even though we had only 6 males, due to the fact that saturation was obtained and the number of males expressing interest in participating was scant. The university's Institutional Review Board approved this project and the American Psychological Association's ethical principles (2002) were adhered to.

Characteristics of Participants
Twenty-two individuals completed interviews for this project. The sample consisted of 16 females and 6 males. Among the females, 11 were Caucasian and 5 were Black/African American. Among the males, 5 were Caucasian and 1 was Black/African American. The participants ranged in age from 18 to 60 years with the majority of participants (62%) being 30 years of age or younger. A more detailed description of the participants can be found in Table 1.

Procedure
After individuals contacted the PI and were deemed acceptable for the study, a mutually convenient time was scheduled for the one-on-one interviews. All interviews were conducted by the PI in a small, private office at a university. A written informed consent form was given to the participants and discussed prior to the interview. After participants signed the informed consent form they chose a pseudonym for themselves that would be used during the interview. This pseudonym was not linked to their true identity; this was done to ensure complete confidentiality of the participants. Participants were informed that anytime during the interview if they felt uncomfortable they could stop and if they chose to end participation at anytime they would have their responses discarded. All interviews were audiotaped and lasted anywhere from 30 to 90 min in length. At the beginning of the interview, demographic questions (i.e., sex, age, marital status) were asked and two topic areas were posed to the participants: (a) Describe any traumatic experiences that occurred during your childhood and (b) discuss what positive influences, both internal and external, helped you overcome and deal with your traumatic experiences. The conversation was allowed to be free flowing and the interviewer asked questions only for clarification or to probe further to gather more details. The interviewer recorded important points into a journal during the interview. Participants were encouraged to end the interview when they felt they had told their story in as much detail as possible. Once the interview was completed, participants were given contact information for a variety of organizations (e.g., National Coalition Against Domestic Violence) and US$20.00 for their participation. All interview tapes were labeled with the pseudonym chosen by the participant and the date of the interview. Interviews were conducted until saturation, separated by gender, was achieved as determined by all three coders.

Coding
Three trained individuals, one of whom was the PI of the study, coded each interview transcript. After each interview, a graduate research assistant transcribed the interview verbatim into Microsoft Word. Transcribing of interviews occurred concurrently with the interview process, which was done to monitor saturation. After the research assistant transcribed all the interviews, the PI then listened to all audiotapes to verify the accuracy of the transcripts and to delete any references (i.e., names and locations) that could potentially identify participants. Once each tape was transcribed and verified, the audiotape was destroyed. The transcriptions were then exported into NVivo, a qualitative analysis software package. NVivo is the most used qualitative software package and it allows researchers to perform a multitude of tasks which enable them to enter, code, and sort their data more effectively (see Bazeley &Richards, 2000, andRichards, 1999, for a detailed description of the software). All transcriptions and interviewer notes were coded, sorted, and analyzed using the NVivo software. Grounded theory (Glaser & Strauss, 1967;Strauss & Corbin, 1998) was used to code the transcriptions. First, open, line-by-line, coding was performed on all the transcripts by the PI Then, axial and selective coding was performed by the PI to link and integrate subcategories formed during open coding. This multistep process resulted in an extensive list of codes. Two additional coders then coded the transcripts independently using this list of codes and noted on the transcripts other possible codes. The three sets of coded transcripts were then compared and discussed among the group of three coders and a final set of coded transcripts was created. During the analysis process, when no new data and analysis uncovered any new themes or new information, then it was determined that there was evidence of saturation and data collection ceased (Bowen, 2008). The results for this study are based on this final set of transcripts.

Description of Traumatic Experiences
The participants described a variety of traumatic events that they experienced as children. Some of the events occurred only once, as in the case of a rape, but many of the experiences they described occurred numerous times throughout their childhood. A few described their experiences as "no big deal"; however, the majority of the participants declared that their experiences were very traumatic to them. The most frequently described traumatic experience (45% of participantsincluding one male) was sexual abuse, usually by a family member (i.e., father, brother, male cousin). The sexual abuse ranged from fondling to frequent and sadistic sexual penetration. Another common traumatic experience was witnessing violence in the home (36% of participants). Many participants recalled being raised in a home where frequent physical and psychological violence occurred between the adults. It was discussed by many of these participants that this occurred when one or both of the adults were under the influence of alcohol or drugs. More than one third of the participants reported experiencing physical and/or psychological abuse from their parents while growing up. Many reported getting spanked or hit with a belt when their parents thought they were bad and others described frequent psychological abuse that resulted in feelings of demoralization and low self-esteem. Last, one fourth of the participants reported being abandoned by their father, mother, or both during childhood. Many expressed that frequently they had to fend for themselves and younger siblings when their parent would leave them-sometimes for days or weeks at a time. Others were abandoned by their parent at a young age and never got the chance to form a relationship with them. Although these participants each described very different traumatic experiences while growing up, they all had one thing in common-they felt that they had dealt with it successfully, they were resilient.

Positive Influences
Five main themes regarding positive influences in overcoming trauma emerged from the data. The five themes, in order of most reported by participants to least reported, are as follows: Spirituality/Faith in God, Supportive Others, Therapeutic Relationships, Self-Determination, and Expressive Writing. On average participants reported 2.2 types (2.3 for females, 2.0 for males) of positive influences that they experienced in overcoming their trauma. Participants reported anywhere from 1 to 4 different types of positive influences; no one reported all five of the positive influences. A description of these themes and selected quotes from participants are described below.
Spirituality and Faith in God. The majority of participants (14 out of 22) stated that spirituality or faith in God was an important influence in rising above their traumatic experiences. In this theme, the participants discussed how they relied on their faith both during and after their traumatic experience(s) had occurred. For many, it was the most important influence in their dealing with their trauma. "Angela," a middle-aged woman stated that spirituality was the number one thing that got her through her ordeal.
The greatest thing that's helped me has been prayer, my spiritual, my spirituality. It's become the strongest direction in my life.
"Michelle," a young, college student also felt that her religion was a big factor in dealing with her trauma.
I pray that God can just get me through the day and that he can just take over and just take control of my life and just guide me through the day and that he can just take over and take control of my life and just guide me and put me in every situation. It's helped me to realize that maybe my dad, maybe that was just a blessing in disguise.
"Barbara," a young college student, felt that even though sometimes her troubles were overwhelming her, she knew she had God to rely on.
The biggest influence I think was just probably my, my religious beliefs. I think that if I didn't believe in God, I'm not saying that I wouldn't have been able to deal with it, but I would have dealt with it in a different way and the outcome wouldn't have been as positive. I just think that believing that there's somebody there who is always going to be there to support you and won't ever let anything bad happen to you and um, will only give you what you can handle and I think that helped a lot.
While some individuals stated that they prayed on their own, many were very involved in their church and this helped them through their trauma. "Kim," a middle-aged male, found solace in the church and in his pastor.
My pastor became like my dad, you know. He had a big influence because, you know, I could ask him questions, you know. The church really was my family . . . they really supplemented what I didn't have at home, you know, it stopped me from doing what my brothers did, even though I was younger, it stopped me from going to hang out, you know, on the streets.
Supportive Others. Many of the participants (12 out of 22) stressed the importance of having at least one person they could turn to when they needed them. This theme deals with how participants sought support from family, friends, and other adults in the community. Many participants sought help from their family members and were welcomed with open arms. "Jean," a 28-year old recreation specialist, discussed how after she was abandoned by her mother, her grandmother took care of her.
My grandmother was there 24/7, um, took care of me, uh, gave me beautiful things. I can describe her . . . she was my soul mate. Definitely my soul mate.
"Barbara" declared how her mother was one who always was there for her even when she did crazy things such as get a tattoo.
My mom was a big help. My mom is my best friend and sometimes she doesn't know how to maybe word things right or she can't always give me the answer to what I need, but um she's just always there and she's very supportive of everything.
A common avenue of support for many of the participants was neighbors and other adults in the community. They were able to escape their family situations and seek out support from someone outside their family. "April," an unemployed nurse in her late 50s, related how she would go over to her neighbor's house as a way to escape the psychological abuse her mother inflicted on her.
My next-door neighbor, she would let me stay at her house. I would baby sit for her. I stayed over there a lot with her . . . actually that was, um, that was the first time that I had been close to a person.
"Betsy," a full-time waitress and college student, who felt neglected by her mother who often left for long periods of time, found comfort from a friendly neighbor.
My neighbors were helpful. I remember one in particular . . . this was when my mother was leaving for quite a while and one of my neighbors gave me a full-time job to watch her son. I was making, like, back then, I think it was about $40 a week, which was a lot for me.
Many of the participants sought support from their friends. For some, they were the only ones that they could confide in. "Ben," a young college student, would discuss the abuse that was going on in his home with his friends.
I'd go to my friends and talk to them about it. They'd give me advice like, "Don't worry about it, you know, it will stop eventually." "Kate," a young college student, also found support not only from friends but from their families as well.
There were two friends. One who had like the all American dream house . . . His parents actually, um, kind of helped me out too. Um, they actually taught me how to hug. Um, I didn't grow up in a family where you had contact with one another because my parents had made that agreement.
One issue relating to this theme of seeking support was the rejection that many of the participants experienced. This was particularly distressing because they wanted to discuss with others what was happening or had happened to them. For some of the participants, this caused them to not disclose their abuse while others were forced to go and seek support elsewhere. "Dorothy," a married, part-time student, tried to talk to her dad about the violence that was occurring in their home and how it was impacting her. Her father was less than helpful.
I mean my dad is not, um, the easiest person to talk to when you have a problem because he's that typical male, let me solve it. I don't want to hear you, just let me give you advice. And if you don't follow it, then shame on you.
Therapeutic Relationships. Many of the participants (11 out of 22) went to a school counselor or therapist either during childhood or as an adult. This theme contains descriptions of the participants' experiences with therapists and counselors. Some felt that their therapy really helped them deal with their traumatic experience(s). "Angel," a middle-aged, substitute teacher, went to numerous therapists during her lifetime and found a few of them very beneficial.
I've probably been through 10 and I probably could say that 3 or 4 were beneficial. That I can really say impacted my life. The ones that were straightforward with me, the ones that didn't, uh, the ones that could read through me because I was a manipulator, see? They, in other words, they were unconditional, uh, therapists, meaning that, you know, they did care, care about me.
"Dorothy" found her therapist extremely helpful.
Extremely, yeah. I really loved her, I mean we got along great, and she just, she really helped me get through a lot of the, you know, why were you doing these kind of things, well let's move forward and how are you going to shape your life. She actually gave me a tape recorder and said, you know, when you have something that you're really upset about, just break it out and talk.
While some of the participants stated that therapy was very beneficial to them, others however, did not have a positive experience in therapy. Some felt that their counselors minimized their traumatic experiences when they attempted to share them with their therapist/counselor. "Ben" tried to go to his school counselor to discuss the severe bullying by his brothers and older kids in school but was ignored by his counselor. I went to the counselor and he just said you know there's a couple of things you can do about it, you can tell me their names or you can just ignore them until they stop.
"Kate" also went to her school counselor and one of her teachers but did not receive support from either one of them.
I went to my school counselor and he, um, he didn't really know how to handle the situation and he ended the conversation with, uh I've gotta go run . . . I was very upset when I left that conversation.
In fact, talking with her teacher resulted in more distress: I also went to one teacher and um within a week everybody, all the teachers knew. And I had gone to her to confide in her. So I was pretty pissed about that.
Other participants did not feel connected or safe enough with their therapists to open up and discuss their experiences. "Linsey," a young college student, went to a counselor after she was sexually assaulted but received little benefit.
I did go to a counselor for a short period of time. It didn't really help me at all because I didn't really know what to do when I went to the counselor. So I would go there and I would just sit and expect her to ask me questions or get me to talk, but I would just not know what to say so I wouldn't say anything and she would just stare at me.
Self-Determination. More than one third (8 out of 22) of the participants declared that it was their own fierce determination that enabled them to survive their trauma. In this theme, participants detail how their own internal resources led them to be resilient, healthy adults. For many, it was this belief that they were strong enough to deal with their situation that got them through their traumatic experience(s). "Barbara": I've kind of always had, um, this philosophy I guess that everything happens for a reason and whatever happens will end up teaching me something in the end and kind of having this philosophy helped me deal with it.
"Steve," a middle-aged salesman, just knew inside that he was going to survive this. He believed that he was going to be okay. I guess it was my internal, you know, being somewhat rational, and, you know, knowing that, you know, I'm going to survive this and, and, be ok by it. I'll survive I guess.
Many felt it was their strong personality that enabled them to deal with their trauma. Their strength and courage helped guide them and their self-determination helped them work through their trauma.
"Angela": Yes, I think some part of me knew inside that good was coming, and it is. I was a fighter. I was a scrapper.
Expressive Writing. A few of the participants (4 out of 22) dealt with their problems by writing down their feelings. This theme describes how participants kept a written record of their ordeal and how they coped with it. Some wrote poetry and others kept a journal. While some participants initiated writing on their own, as a way to cope with their problems, others were instructed by their therapists to engage in this activity. "Sandy," a young college student, wrote down what she was feeling because she was too uncomfortable to discuss her experiences with others. I used to write a lot of poems and stuff just about like darkness and whatever. Cause it was like an English class in the eight grade and at that point that's when it started to change. That's when I started to get that confidence . . . You know I can be good at something and no one else can touch me.
"April" started writing as a teenager when she was still in her abusive situation. She has continued it as an adult as a way to manage her feelings.
I'm putting together a book of poems right now. Writing can be a very cathartic experience . . . I like it, you know, well it's a gift, but also it helps you, you know, to get things out.

Summary of Findings
The individuals in this study utilized a variety of coping mechanisms to deal with their traumatic experiences. Consistent with previous research (Davis, 2002;Dervic et al., 2006;Regehr et al., 1999;Todd & Worell, 2000;Valentine & Feinauer, 1993), spirituality, social support, and self-determination were found to be common positive influences in helping individuals cope with their childhood trauma. The majority of the individuals in this study found inner strength through spirituality as a major influence in them becoming resilient. As found by Davis (2002), many trauma survivors' assert that spirituality helps individuals get past their traumatic experiences. However, research on whether religiosity (i.e., church attendance, prayer) or spirituality (i.e., inner strengths) is more predictive of healthy functioning still needs to be studied, especially among other religious groups in addition to those self-identifying as Christians, which the majority of this sample represented. Are individual's views regarding spirituality/religiosity more protective or less protective for individuals from other religious backgrounds?
Seeking support from others was also a major influence that our participants reported utilizing. Perkins and Jones (2004) found that support from family members was significantly related to lower levels of alcohol and drug use among abused adolescents; however, they also found that higher levels of social support from other nonrelated adults was correlated with higher levels of alcohol and drug use as well as increased levels of other risky behavior. Research on who trauma victims seek support from and the quality of that support needs to be investigated in more depth.
One interesting finding from this study was the influence of therapy as a mechanism for achieving resiliency. For some individuals in this study, they reported that therapeutic relationships were extremely important in their path to overcoming their trauma. The supportive connection that they felt with their therapist enabled them to work through their experiences and move on. Others, however, stated that therapy was not helpful due to negative feedback from counselors and/or lack of connection with their therapist. Horowitz, Putnam, Noll, and Trickett (1997) found that many of the sexually abused girls in their study terminated therapy or sought another therapist for reasons such as dissatisfaction with the therapist, poor relationship between child and therapist, and confidentiality issues. Research on what methods of therapy, types of relationships with therapists, and amount of therapy are related to successful outcomes needs to be studied further. Research on what does and does not work in regards to therapy and the therapeutic relationship would be beneficial to victims of trauma in helping them find a therapy modality and a therapist that fits their individual needs.
Self-determination was an influence that some individuals in our sample reported as enabling them to overcome their traumatic experiences. Himelein and McElrath (1996) found that women who engaged in positive reframing and did not dwell on the abuse displayed higher levels of adjustment compared with those who did not have these inner strengths. How therapists can increase these inner strengths in abuse victims still needs to be examined.
A few participants stated that expressive writing was a way for them to deal with their traumatic experiences. This is a novel area of research that has been explored in areas such as dealing with medical problems (e.g., de Moor et al., 2002), coping with employment issues (e.g., Spera, Buhrfeind, & Pennebaker, 1994), and adapting to stressful events (e.g., Lepore, 1997) but is limited in published research with childhood trauma survivors'. Studies that investigate the utilization of expressive writing as a positive influence in overcoming trauma need to be performed.

Limitations
One major limitation of this study that needs to be considered when interpreting the results is the relative homogeneity of the sample. Our sample was primarily female (72%), Caucasian (73%), Christian (64%), college students (78%). Our participants also self-identified themselves as both survivors' of childhood trauma as well as resilient adults. Thus, these findings cannot be generalized to all individuals who identify themselves as trauma victims as well as those who have experienced trauma but do not consider themselves victims. Also, individuals who did not define themselves as one who had successfully dealt with their traumatic experiences were not explored here. Some of those individuals may utilize other ways of coping with their trauma not found in our sample of trauma survivors. Researchers need to recruit larger samples of men and women who do and do not define themselves as resilient to fully understand the concept of resiliency.
Another limitation of the study was the fact that no effort was made to tease out the impact of specific types of abuse (i.e., physical, psychological, sexual) or relationship to perpetrator (i.e., son, daughter, stranger) on types of positive influences utilized by these individuals. Are there different coping mechanisms utilized by trauma victims depending on type of abuse and relationship to perpetrator? This question has yet to be thoroughly explored.

Importance of Study and Practice Implications
A strength of this study is it's utilization of an in-depth, descriptive qualitative methodology, one-on-one interviews, to garner information from participants. One-on-one interviewing gives researchers the ability to "give voice to survivors" (Reinharz & Chase, 2002). Participants were allowed to share their stories in their own words without the restrictions of specific questions and/or closed-ended response categories. We were able to achieve a more valid understanding of the topic than what could have been achieved through a more rigid approach (Carr, 1994;Duffy, 1986).
One practical implication of this research is that it furthers the understanding of the factors that help individuals overcome traumatic experiences. Knowledge obtained from this study would be valuable to clinicians who treat victims of childhood trauma, in giving them an inventory of resources (both internal and external) that their clients can utilize to help them work through their traumatic experiences. Therapists and counselors can implement these tools in their therapy and would be better able to treat their clients with similar issues.

Conclusions
Each of the individuals who participated in this study displayed enormous courage and resiliency. They experienced at times horrific and unimaginable traumas, yet were able to move past these traumatic experiences and in their perception function as relatively psychologically healthy adults. Understanding how these adults were able to work through their experiences with childhood trauma will enable practitioners to devise more effective treatment plans for their clients who exhibit health problems as a result of their trauma. Finally, focusing on the positive (i.e., self-determination) rather than the negative (i.e., psychopathology) outcomes of individuals who experienced childhood trauma will stimulate research in areas that improve the quality of life of these individuals rather than research that focuses on their limitations.

Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding
The author(s) received no financial support for the research and/or authorship of this article.