Introduction
Research data on the prevalence of trauma suggest that most adults will experience a traumatic event in their lifetimes (Magruder et al., 2017). Occurrences of trauma in the general population have been described as high and pervasive as experienced by “virtually everyone” (Tebes et al., 2019, p. 494). On the prevalence of trauma exposure nationally, the Substance Abuse and Mental Health Services Administration (SAMHSA) notes that 61% of men and 51% of women report exposure to at least one difficult or painful lifetime event, and 90 percent of clients in public behavioral health care settings have experienced trauma (Substance Abuse and Mental Health Services Administration [SAMHSA], 2014). On the prevalence of adverse childhood experiences in the general population, Liu (2017) found that 53.4% of adults had experienced at least one form of childhood adversity before age 18. The literature is expansive on the early and enduring effects of trauma on the mind, body, and development of children as result of trauma exposure early in the life course. Described as particularly detrimental in childhood, trauma exposure for children has been found to disrupt various aspects of health, identity, and development, including cognitive functioning (Magruder et al., 2017; Truskauskaite-Kuneviciene et al., 2020). As understanding of trauma impact has increased, and acknowledgment of the public health implications and consequences has grown, professionals across multiple fields have worked to adapt and evolve service delivery models (Tebes et al., 2019).
From 1995 to 1996, approximately 8000 adults seeking treatment at a San Diego-based health clinic were asked to participate in a study and answer ten questions regarding adverse childhood experiences (Lacey & Minnis, 2020). The ten experiences included across the questions encompassed: emotional abuse, physical abuse, sexual abuse, emotional neglect, physical neglect, witnessing domestic violence, household substance abuse, mental illness in the household, parental separation or divorce, or a household member who had spent time in prison (Felitti et al., 1998). This groundbreaking and influential study examined the impact of childhood trauma occurrences on the life course and adult health (Maguire-Jack et al., 2020). A significant impact of the study was the shift in thinking across many fields of study, including medicine, public and mental health, social work, and others, regarding the impact of trauma and its connection to racial and gender experiences, physical and mental health, life course development, and cognitive functioning, to name a few (Maguire-Jack et al., 2020). As found in the dose-response relationship, as Adverse Childhood Experiences (ACE) scores increase, so too does the likelihood of increased associations with diminished resilience, poorer adult conditions, and lower socioeconomic standing (Nurius et al., 2015). Among human services professionals, research suggest that these professionals tend to report higher scores on the ACE questionnaire and can show higher levels of maladaptive behaviors impacting career success (Hiles Howard et al., 2015; Steen, 2017). Every year, thousands of human services professionals, who have experienced some level of trauma, including complex traumas, deliver social services to millions of the country’s most vulnerable residents, who have also experienced trauma (Bryan & Brown, 2015; Substance Abuse and Mental Health Services Administration, 2014). Program and agency outcome measures for services provided by human services organizations go far beyond merely demonstrating and validating service delivery models; the measures reflect how many lives were changed due to program participation. The well-being and ability of human services professionals, specifically case managers, to understand how their childhood experiences shape their professional practice is paramount to an organization’s ability to increase positive programmatic outcomes (Hiles Howard et al., 2015).
The research on the intersection of trauma and the workforce demonstrates a traumatized workforce, whereby many professionals who work in the human services field have experienced trauma exposure all their own (Hubel et al., 2020). ACEs impact on specific professional groups was consistently found in the literature. Research inquiries into ACEs impact on child welfare, or child welfare adjacent, professionals occurred most frequently in the literature. While not observed as frequently, ACEs impact on career choice was a related theme in the literature on ACEs and their impact on specific specialized professionals. In discussing childhood trauma exposure and career choice, researchers identified a relationship between the exposure and the life course and concluded that findings validated the career construction theory (CCT) (Bryce et al., 2021). By this, it is understood, through applying a CCT lens, that a person’s trauma experiences and how meaning is made of those experiences can profoundly influence career choice (Bryce et al., 2021). Researchers validated these assumptions, and findings suggested that factors like family origin dysfunction, child abuse and neglect, and individual characteristics and traits developed through adversity were all associated with career choice (Bryce et al., 2021). Furthermore, the responses to these factors and life events shape professional progression and direction (Bryce et al., 2021).
A review of the body of literature concerning the research study demonstrates findings across the following subjects: (a) the lasting effects of trauma exposure (Alameda et al., 2015; Dunn et al., 2018; Nurius et al., 2015), (b) trauma histories among human services and child welfare professionals (Bryan & Brown, 2015; Flinchbaugh et al., 2017; Hiles Howard et al., 2015), (c) secondary trauma occurrences in the helping and child welfare professions (Dombo & Whiting Blome, 2016; Middleton & Potter, 2015; Mittal et al., 2015), (d) potential interventions to address trauma occurrences among social service professionals (Damian et al., 2019; Jaffe et al., 2019; Sippel et al., 2015), and lastly (e) the neurobiological effects of trauma exposure (Corrales et al., 2016; Easton, 2013; Jedd et al., 2015). Taken together, the research literature on adverse childhood experiences among human services professionals demonstrates that child welfare professionals tend to report higher scores on the Adverse Childhood Experiences questionnaire (Bryan & Brown, 2015; Flinchbaugh et al., 2017; Hiles Howard et al., 2015), as well that ACE exposure may present long-lasting functional impairment (Alameda et al., 2015; Dunn et al., 2018; Nurius et al., 2015); however, the literature is incomplete as to how case managers, who have experienced childhood traumas, perceive the role those events play on the services they provide to their clients. The intention of this study was to further explore the gap in the literature related to how human services case managers, who have early childhood trauma experiences, perceive the role those events have played in shaping their professional practice.
Purpose of the Study
This generic qualitative inquiry aims to answer the research question of how human services case managers perceive how adverse experiences during their childhood have shaped their professional practice. The literature overwhelmingly addresses the perspectives of child welfare professionals, and several ways adverse childhood experiences impact these individuals, both personally and professionally. Researchers note how in a rapidly changing professional landscape, where expectations for positive client outcomes are only increasing, centering the perspectives of case managers provides organizations with the best opportunity to meet client need head-on and consistently produce positive results (Tahan et al., 2020). While the perspectives of case managers working in the child welfare field are firmly established in the literature, a specific focus, however, on the perspectives of human services case managers is lacking; the intent of this study is to fill that gap. Exploring the perceptions of human services practitioners expands the body of knowledge concerning the intersection of adverse childhood experiences, professional practice, and behavioral system service delivery.
Broader Community Need for the Study
Research findings into the profound impact of trauma exposure make clear the physical, emotional, cognitive, mental, and social impacts of traumatic experiences (Dunn et al., 2018; Germine et al., 2015; Mittal et al., 2015; Porter et al., 2020; Sullivan et al., 2019). The pervasive nature of exposure among the general population, and children in particular, highlights the critical importance of research into the implications of childhood traumatic exposure across the life course (Magruder et al., 2017; Maguire-Jack et al., 2020). For the broader community, the study’s research findings allow for behavioral health systems, whereby individuals seek treatment for harm, to be better designed, informed, and staffed by a workforce with a competent understanding of how their own traumatic childhood experiences shape their professional practice. Behavioral health consumers may not always be aware of how past traumas they have sustained impact their daily lives; however, the research detailed that as trained professionals come into a clearer acknowledgment of the impacts of trauma exposure, they demonstrate a deeper understanding of the complexity of trauma responses, a deeper sense of empathy, primarily for children who have experienced trauma, and most importantly, a heightened ability to see behavioral responses through a trauma-informed lens (Dublin et al., 2021).
Methodology
Research Design
The choice to utilize a qualitative research methodology must be closely aligned with the purpose of the research. At the core, qualitative research seeks to communicate, describe, and explain the subject matter in its real-world complexity (Bloomberg & Volpe, 2018). To fully understand the perspectives of human services case managers, the current study solicited the perspectives of human services case managers in their natural professional settings, where they experience the phenomenon under study. As an inductive process, qualitative research utilizes the voice of the participants to understand the phenomenon under study in its naturally occurring environment (Edmonds & Kennedy, 2017).
As a member of the qualitative research methods class, the generic qualitative inquiry, while falling outside of the classification as a traditional qualitative method, is designed to uncover and understand a phenomenon from the perspective of the people involved (Caelli et al., 2003). Oriented toward issues external to participants, the generic inquiry is designed to understand how research participants make meaning of previous experiences (Kahlke, 2014; Percy et al., 2015). To achieve methodological and research design alignment, semi-structured interviews, as the method for data collection, must be aligned to the theoretical framework, the associated area of discipline, and the researcher’s prior knowledge and awareness of the gaps in the research literature (Merriam & Tisdell, 2016).
Population
Established in 1992, the Commission for Case Management Certification (CCMC) is a nationally accredited case management certification organization (Commission for Case Management Certification, n.d.). Responsible for the oversight of case manager and disability management specialist certification, CCMC currently has over 50,000 board-certified professional case managers and disability management specialists (CCMC, n.d.). In 2019, CCMC commissioned its Role & Function Study; an evidence-based study exploring the knowledge, skills and activities performed by case managers (CCMC, n.d.2). Key statistics from the study’s findings provide insight into characteristics of the larger case management population. According to findings, over half (52.68) the of the respondents were care or case managers (CCMC, n.d.2). 61% of study respondents have been in case management for 10 years or more, and nearly all (94.6%) case manager respondents were women (CCMC, n.d.2). While primarily utilized in the health care setting, case management practice fields were diverse and included, ambulatory and disease management, community, and military and veteran settings (CCMC, n.d.2). Professional backgrounds include registered nurses, social workers, and worker compensation professionals (CCMC, n.d.2). CCMC national personnel received study recruitment materials for distribution amongst members.
With service roots dating back to as early as 1955, ACHSA represents over 85 nonprofit community agencies that provide a wide range of human services for individuals and families in Los Angeles County (Association of Community Human Service Agencies, 2019). Local members of the ACHSA received study recruitment information for dissemination amongst their members. Additionally, executives from two human services non-profit organizations, one located in Los Angeles, Ca and another in Pontiac, Michigan received study recruitment information for dissemination amongst their respective staff members. Lastly, the researcher’s social media and professional networking platforms were used to disseminate study recruitment materials.
The study’s inclusionary criteria included human services case managers who self-reported experiencing at least one incident of an adverse childhood experience and believed that those same adverse experiences in childhood shaped their case management practice. Of the ten areas included across the ACE questionnaire, for study purposes, adverse childhood experiences were limited to include the following three experiences: economic hardship, for example, the participants’ family found it hard to cover the costs of food and housing; living with anyone who had a problem with alcohol or drugs; or being a victim of violence or witnessing any violence in his or her neighborhood (National Center for Injury Prevention and Control, Division of Violence Prevention, 2021). Exclusionary criteria included case managers in a child welfare organization or program. The study was designed with the child welfare exclusionary criteria specifically because of the over-saturation in the research literature into the impacts of trauma experiences on child welfare professionals. Additionally, any individual who was currently experiencing major depression, major anxiety, PTSD, suicidal ideation, or a psychological diagnosis in which psychosis was a symptom was ineligible to participate in the study.
Sample
The study sample was drawn from Association of Community Human Service Agencies (ACHSA) member organizations in Southern California and one human service nonprofit organization in Southern California. The sample included adult case managers who provided support services in several disciplinary fields, including homelessness, mental health, domestic violence, and senior services. Participants were all employed with human services organizations at the time of their participation in their research interview. The sample population included both male and female individuals, from varied socioeconomic backgrounds, at the time of the study and during their childhood. All participants self-reported experiencing adverse events during their childhood and agreed that they believed those events played a role in shaping their professional practice. Case managers in the sample possessed varied years of professional experience in the case management field, from those newly practicing to those with more senior-level case management experiences and duties. The participants’ race and ethnicity varied and included representation from several racial and ethnic groups. Members of the sample all shared related perspectives regarding the impact of their adverse childhood experiences into adulthood and, subsequently, on their professional practice.
Participant Selection
Purposeful and snowball sampling techniques were used to recruit participants for the research study. Purposeful sampling, a common sampling technique utilized in qualitative research, was selected to ensure that participants possess appropriate information-rich data that meaningfully allows the selected individuals to answer the researcher’s interview questions (Bloomberg & Volpe, 2018). The study’s recruitment plan, including additional recruitment announcements on several of the researcher’s social media platforms, the language of the recruitment email solicitation, and the study recruitment flyer, with language regarding the potential receipt of an incentive, were approved by the research institution’s Institutional Review Board (IRB). Following contact and preliminary screening for study eligibility, participants who met inclusionary criteria were offered the opportunity to participate. Informed consent was obtained from all research participants.
Steps of Recruitment
Each association or organization listed in the recruitment plan was requested to provide the recruitment email and associated study recruitment flyer to their members and/or employees. The recruitment flyer contained study details, a dedicated contact phone number, and the researcher’s designated email for individuals interested in participating. Interested individuals utilized either the email address provided or the contact number and reached a voicemail message instructing them to leave their best contact number, day and time. When the researcher returned the call, study screening questions were used to determine if the individual was eligible to participate. If the individual was not eligible to participate in the study, they were informed that they did not meet eligibility criteria and were thanked for their time and interest in participation. If the individual was eligible to participate, the study was explained in more detail along with what would be required of study participants, including requirements for receiving the study completion incentive.
Data Analysis
The data were obtained through semi-structured interviews with 12 human services case managers who met the study inclusionary criteria. The goal of utilizing semi-structured interviews as the data collection method was to capture content-rich data from individuals who can provide relevant insight into the study phenomenon, particularly because of their situational positioning to and awareness of the research problem (Percy et al., 2015). Interviews were conducted virtually utilizing the Zoom platform. Interviews were recorded, and the audio files only, without the video, were securely transferred to a paid service for transcription.
Inductive thematic analysis was used to analyze the research data. While more of a process than a design, inductive thematic analysis is driven by what the data reveals rather than an attempt to fit the data into any predetermined categories (Percy et al., 2015). The process calls for each interview to be analyzed individually; then, once completed, the researcher can identify repeating patterns among the collective to draw larger themes in the context of the research study. Percy et al. (2015) prescribed a 12-step data analysis process.
Trustworthiness
Given the nature of qualitative research, the potential for an outsized role and influence of the researcher is probable. As the researcher is the primary tool for data collection and analysis, the possibility of an impact on the participant, their reactivity, and the incorrect interpretation of study outcomes is present (Bloomberg & Volpe, 2018). In a discussion on identifying and avoiding bias in research, Pannucci & Wilkins (2010) outline several suggestions to avoid bias in the research process, including before participant recruitment, during data collection, and during data analysis. As defined in research, bias is any feeling or inclination which prevents objective consideration of a question. Qualitative research is often considered to be the methodological approach most threatened by researcher bias (Jones & Donmoyer, 2021). As the primary tool for research in the qualitative approach, the researcher brings their thoughts, beliefs, values, and feelings to the research study. Awareness of these values and beliefs is not always readily apparent to the researcher because they are cultivated over spans of time and across multiple dimensions, including mental, physical, social, and emotional interactions and experiences (Creswell & Poth, 2018). Researchers must not consider bias exists but to what extent bias influences the conclusion(s) of the research inquiry (Pannucci & Wilkins, 2010). To address bias in the research process, researchers are encouraged to clearly define the study’s risk and outcomes at the onset of the study design. Researchers should endeavor to standardize participant interaction as much as possible during data collection. During data analysis, researchers are encouraged to publish all results, even those unfavorable to the inquiry (Pannucci & Wilkins, 2010).
To address potential researcher bias, bracketing was utilized to minimize the influence of bias throughout the research process (Creswell & Miller, 2000). More specifically, bracketing was utilized during the data collection process, including during the development of the interview questions, during the research interview, and finally, during data analysis. Bracketing methods included writing self-addressed memos throughout the data collection and analysis process and journaling and note-taking before finalizing research questions (Tufford & Newman, 2012). All bias mitigation tools, including memos, journals, and notes are securely stored in the researcher’s home in a locked file drawer.
Results
An inductive thematic analysis was conducted to examine the data and uncover underlying meanings. Seven themes and 20 patterns were identified due to the data analysis process. The themes were: (a) perceived development of case management Superpowers; (b) recognition of the use of empathy as an essential job skill; (c) a perceived effect on self and career and resulting diminished capacity; (d) a perceived effect on career progression; (e) a perceived effect on professional competency and resulting unique skills and enhanced capacities; (f) development of coping mechanisms as a way to mitigate workplace stress; and (g) centering the sensory power of the lived experience as a means of elevating case management practice.
Theme 1. Perceived Development of Case Management Superpowers
Three patterns were identified that contributed to the emergence of the first theme. Participants’ perspectives reflected their innate ability or characteristic beyond their experiences or professional training and education. In many cases, participants expressed a beyond-earth ability or a connection to a greater sense of meaning or purpose, a connection that participants sometimes had trouble putting into words. Lastly, participants demonstrated a uniqueness, often appearing to be set apart from their colleagues because they possessed these superpowers; it was a characteristic coveted by employers for its effectiveness. Participant comments that demonstrate the patterns of Theme 1 are provided as follows:
Okay, so one of the biggest things that I didn’t mind doing was I didn’t mind hanging out with my clients. I didn’t mind going to their encampments, hanging out right there. It didn’t bother me. I felt at home. I felt comfortable for some weird reason. (Participant 1)
I was scared. But no, as much as it’s scary, I’ve been through enough pretty, pretty scary situations, to where it just makes me feel like I was supposed to overcome those. My whole experience of everything makes me feel like, there’s no way that you went through all of these experiences for nothing. There has to be a purpose. (Participant 10)
Theme 2. Recognition of the Use of Empathy as an Essential Job Skill
Three patterns were identified that contributed to the emergence of the second theme. Participants expressed possessing this skill by way of their unique experiences. The ability of participants to employ this skill was connected to a feeling and deeper understanding of where their clients were on their road to success and the support they needed to navigate challenges. For the participants, these feelings of empathy provided a sense of legitimacy and connection that elevated their case management practice. Participant comments that demonstrate the patterns of Theme 2 are provided as follows:
[Clients say,] “Man, this person don’t get it. He don’t understand [what it’s like to] not have any help at all.” So that keeps me every day knowing what I got to do, how I got to do it. And if I don’t know how to do it, [I] learn how to do it. So, everything that happened in my life is the stuff that keeps me motivated and keeps me grounded to never forget what it feels like to be at the bottom. (Participant 6)
“Hey man, you hungry?” And I was like, “Hell yeah, I’m hungry. How you know?” And he gave me, I’ll never forget it. He gave me two Styrofoam things full of sliced beef, one with barbecue, one with no barbecue, a loaf of bread, and a 99-cent thing of fruit punch. And I never forgot that feeling. (Participant 11)
Theme 3. A Perceived Effect on Self and Career and Resulting Diminished Capacity
Three patterns were identified that contributed to the emergence of the third theme. Participants expressed that aspects of past experiences shaped their perceptions of their own case management competencies, skill sets, or worthiness of upward professional progression. Several participant comments demonstrated how the lingering impacts and re-experiencing of adverse exposures show up in practice in ways that impact interpersonal interactions with colleagues and clients. Lastly, consistent in the participants’ reports were impacts on their
self-esteem and a pattern of disclosing negative character traits they believed they possessed due to their adverse exposure. Participant comments that demonstrate the patterns of Theme 3 are provided as follows:
So, this is the bad thing about being in prison. The bad thing about that and using that out here is in prison, you never want to be responsible for anybody else but yourself. You don’t want to cosign nobody. You don’t want to do none of that stuff. Be responsible for yourself, because if you make a mistake or you mess up, you make a bad call, you’re going to get it. Unfortunately, I still look at life like I’m in prison. I still use all my whatever I was indoctrinated with, all my dumb ideologies. I use that and I incorporate that in my everyday life, whether it’s work or personal or whatever. Sometimes it’s not good, but hey, a lot of times it’s not bad. (Participant 1)
My experiences as a child, honestly with relationships, taught me that I couldn’t trust people. I have to recognize it, and I have to be able to forgive it and move on from that so it can make me have better relationships with people in the work setting.
(Participant 10)
Theme 4. A Perceived Effect on Career Progression
Three patterns were identified that contributed to the emergence of the fourth theme. Participants expressed perceptions that reflected an initial desire to move forward on a career path or pursue a position or education, only to be discouraged by other individuals or adverse circumstances. Several participants reported hesitation or discouragement in pursuing career advancement opportunities. Lastly, participants reported finding inspiration and motivation to move forward after experiencing initial discouragement or hesitation. Participant comments that demonstrate the patterns of Theme 4 are provided as follows:
Man, they be tripping on the background. So, I kind of got discouraged. I’m like, “Oh, shit.” Because I was like I’d be perfect for that because that’s where I come from. I know what it’s like to be in those group homes. (Participant 2)
Then, again, dealing with my childhood traumas, my mental health, I’m getting out of that where I’m finding my voice. I’m not quiet anymore. I’m not just going to be in the back. And that’s helped me a lot. It’s helped me speak up for what I deserve, speak up for what’s not right. What is right. And it has allowed me to progress. I started off as a case manager. I’m now lead. I’m now looking to promote even more. And I just got lead like six months ago. (Participant 4)
Theme 5. A Perceived Effect on Professional Competency and Resulting Unique Skills and Enhanced Capacities
Three patterns were identified that contributed to the emergence of the fifth theme. Participants reported possessing an enhanced skill set or capacity not readily available to other colleagues, a skill set coveted by their employers. The skill set included a boldness, a fearlessness, and a willingness to go where other colleagues won’t go and do what other colleagues may not be willing to do. Participants reported an increased capacity to navigate and resolve client and programmatic challenges. A key characteristic of participants’ capacity included operating at a level of effort to resolve challenges utilizing less bandwidth and under less stress than what seemed to be experienced by colleagues who did not possess the same experiences and histories of adverse exposures. Participant comments that demonstrate the patterns of Theme 5 are provided as follows:
I mastered the survival tactics in the streets, and how to read people, how to maneuver without getting myself killed or getting into a wreck. They loved the fact that I was from the community because I was getting them in places that they couldn’t get in. Yeah, you’re from the street. You’re doing great. (Participant 2)
And I use that to motivate myself, to show not only myself, but to show people that people do change for good. And when you get that shot, you take advantage to make sure you create something positive so that the next person doesn’t go through what you went through and use what you went through as a guide to better yourself.
(Participant 6)
Theme 6. Development of Coping Mechanisms as a Way to Mitigate Workplace Stress
Three patterns were identified that contributed to the emergence of the sixth theme. The first pattern was identified as a result of participant reports expressing how, as a result of their experiences, they identified a positive coping mechanism used during workplace-related stress. Participants reported an awareness of their workplace trauma triggers and how utilization of positive coping mechanisms became incorporated into their routines. Lastly, participants expressed the personal benefits experienced as a result of utilizing positive coping mechanisms and strategies. Participant comments that demonstrate the patterns of Theme 6 are provided as follows:
I work out. My thing is when I’m mad, when I’m having a bad day or whatever’s going on, I just leave my desk, and I leave. I’m like, “I’ll deal with this tomorrow. I can’t do it no more.” I go home and I start working out or I go hiking. That’s my main thing, working out is what relieves all my stress. So that’s my main thing. Like now, when I work out, I feel good. And I used to feel some type of way, it was either being part of the neighborhood gang, the violence stuff. That actually made me feel what I feel now with working now. I feel good. (Participant 6)
I bake, I bake, I bake. I go to church. I used to retreat a lot into my creative mind, which I still kind of do. I think baking has substituted that in a lot of ways because my baking becomes art. (Participant 8)
Theme 7. Centering the Sensory Power of the Lived Experience as a Means of Elevating Case Management Practice
Two patterns were identified that contributed to the emergence of the seventh theme. Unlike empathy, participants reflected on how they use the power of their sensory experiences to build relationships and connect with clients. The participants’ perspectives on the sensory power of their experiences reflected their belief that those experiences serve as a mechanism that informs their practice, specifically their professional use of self and the disclosure of their personal stories. Participant comments that demonstrate the patterns of theme seven are provided as follows:
I try to use the little bit of experiences, not everything, but the little bit of experiences that I’ve suffered. I have slept out in the streets, so I know what that’s like. I have slept in my car. I know what that’s like. I know what it’s like to go to the gym and wash your clothes and hang them up on a bus bench and start the whole day again. (Participant 1)
I have serviced some of the same people that I have sat on the same milk crate with, who I lived in the same alley with. I have convinced them to go into shelters, and now, some of them have their own shared room or shared living or whatever they have done. (Participant 11)
The semi-structured interviews provide insight and perspectives of the case managers regarding how childhood traumatic events have shaped their professional practice. While the descriptions of each theme reflect a composite picture of research participant interviews, the detailed discussion of each theme, which includes direct quotes from the research participants, tells of their unique perspectives regarding how adversity they have faced in the past influences their case management practice today.
Discussion
The literature focused on a discussion of five general theme areas: (a) the evolution of trauma and its growing prevalence; (b) the impact of adverse childhood experiences; (c) trauma impact in the workplace; and (d) trauma and mental health and well-being. The gap identified in the literature was defined as the absence of perspectives of human services case managers concerning how early experiences of childhood trauma have shaped their professional practice. Seven themes emerged to shape study findings. The themes included: (a) perceived development of case management superpowers; (b) recognition of the use of empathy as an essential job skill; (c) a perceived effect on self and career and resulting diminished capacity; (d) a perceived effect on career progression; (e) a perceived effect on professional competency and resulting unique skills and enhanced capacities; (f) development of coping mechanisms as a way to mitigate workplace stress; and (g) centering the sensory power of the lived experience as a means of elevating case management practice. The findings of the study support areas of the established body of literature, including the impact of adverse childhood experiences, the impact of trauma exposure, mental health and well-being, and trauma impact in the workplace.
The literature demonstrates the severity of the dose-response relationship between adverse experiences and adult development (Nurius et al., 2015). Specifically, researchers note the impacts on the execution of self-sufficiency tasks and occurrences of substance abuse, cognitive disassociations, and mood disorders, such as avoidant problem-solving (Sheikh et al., 2016; Spinazzola et al., 2018; Tran et al., 2019). These findings in the literature are confirmed by participant stories illuminated in the theme dedicated to the sensory power of the lived experience elevate case management practice. Participants shared past stories in vivid detail that left an indelible mark on their lives, both personally and professionally. Participant stories included a range of experiences, including substance abuse and addiction, homelessness, and mental health challenges, including moments of dissociation in the workplace.
The idea of posttraumatic growth was demonstrated in the literature in the context of trauma and adverse childhood experiences. In discussions on empathy and resilience, the literature demonstrates how trauma provides the opportunity for growth, specifically to the opportunity to learn from trauma processing (Greenberg et al., 2018). As part of the themes on both the development of case management superpowers and utilizing empathy as an essential job skill, participants voiced stories of how as a result of making meaning of past trauma experiences they were able to find purpose in life and career selection. Participants discussed how they felt they were specifically prepared for a job in case management, particularly because of their childhood trauma experiences. The participants’ superpowers reflected a fearlessness and a boldness to do whatever was necessary to ensure the success of their clients. Throughout many interviews, participants reflected on their experiences and voiced feelings of familiarity with their client’s experiences. For participants, the ability to authentically connect with their clients because of shared experiences represented a special tool in their case management toolbox that set them apart from their colleagues. For participants, while their experiences of childhood trauma were indeed unpleasant, terrifying, and in many instances disappointing, all participants were able to find deeper meaning, direction, and connection because of their meaning-making processes. These findings add to the developing body of literature related to posttraumatic growth; specifically in areas related to the idea that people can transform traumatic experiences in a manner that both makes meaning of past experiences and fosters wisdom, personal growth, and positive personality changes (Saakvitne et al., 1998). As well, it further reinforces the work of Tedeschi and Calhoun (1996), and their conceptualization of the five-part posttraumatic growth model, inclusive of the exploration of new possibilities, a deeper ability to relate to others, development of personal strength, experiencing spiritual change, and appreciation of life (Saakvitne et al., 1998).
An area of notable distinction, in that it expands the current body of literature concerning posttraumatic growth, is found in the study’s multiple findings related to posttraumatic growth and resiliency. As discussed in the literature, when an individual experiences a traumatic event, impairments to individual capacity and the questioning of fundamental needs and beliefs can occur (Pearlman & Saakvitne, 1995). Study findings highlighted, thru multiple illustrations, instances of posttraumatic growth and resiliency development despite impaired individual capacity because of trauma exposure. Study findings, as established through participants’ meaning-making processes, highlight not only posttraumatic growth and resiliency development as a means of trauma processing for the participant, but their capacities to transcend that process and utilize aspects of trauma growth and resiliency development in their professional capacity for the betterment of their clients.
Research into the area of childhood trauma impact demonstrated that childhood traumas are recorded and reflected in the adult schema and experienced adversity and can lead to neurological distortions, including impacts to memory and free recall as well as impairments to social problem-solving and social adjustment (Ahmadi Forooshani et al., 2021; Grégoire et al., 2020; Pilkington et al., 2021). As part of the theme on participants’ struggle with perceived effect on self and career and the resulting diminished capacity, participants voiced feelings of professional inadequacy compared to their peers. Participants discussed having to “play catch up” to perform comparably to their colleagues. Participants shared stories of impacted self-esteem, self-agency, and confidence in their ability to carry out case management functions and duties. One participant shared how, as a result of previous experiences in prison, his capacity for conflict resolution was diminished, and the steps he must now take to react differently in a professional setting than he otherwise might have in a prison setting. These findings bolster findings within the related body of literature, specifically in the areas related to the impact of adverse childhood experiences and trauma impact in the workplace.
In the area of trauma impact in the workplace, literature findings demonstrate that in addition to managing the impacts of prior trauma exposure, human services professionals must also navigate the additional challenges that come with a consistent sustaining of persistent workplace stressors, a concept termed toxic stress (Valeras et al., 2019). As part of the theme on positive coping mechanisms as a way to mitigate workplace stress, participants voiced their identification, and in some cases, development, of positive coping mechanisms; first as a way to process trauma, then as a way to mitigate workplace stressors. Participants discussed utilizing physical, creative, spiritual, and mental outlets to process workplace stress. Participants identified exercise routines, baking, art, prayer, and music creation as regular practices to handle the stress their job creates. Several participants discussed their process for identifying their trauma triggers, understanding when they are experiencing elevated stress levels, and recognizing when it was time to engage in their stress-relieving practices.
Taken together, the literature concerning childhood trauma and neurological impacts and trauma impact in the workplace, bolstered by current study findings related to perceived impact of self and career and positive coping mechanism, raise several implications for career progression, sector training and professional development. Lessons outlined in the literature encourage practitioners and organizational leaders to acknowledge that among the workforce, there is generally a deficit of individuals who have been trained to provide services to individuals who have experienced complex traumas (Kumar et al., 2019). There must also be an acknowledgment that understanding the detrimental effects of early childhood trauma exposure, and ACEs specifically, is essential to providing meaningful trauma-informed service delivery (Sherfinski et al., 2021). A particular element of that ACEs knowledge must include an understanding that, for individuals, ACEs exposure includes an environment wherein individuals may operate in a state of toxic stress, meaning their stress response, cognitive, and cortisol circulation systems are constantly activated. Creating a trauma-informed system is identified in the literature as a best practice to help individuals and organizations understand and respond to the impact of trauma (Oral et al., 2016). Organizations must integrate trauma awareness and concepts into their principles, policies, procedures, and practices to fully realize a trauma-informed service delivery system. Trauma-informed service delivery systems also reflect an understanding of the impact of trauma along with intentional efforts to continually build awareness among their teams so that their screening, assessment, and treatment delivery practice are meaningfully transformed (Oral et al., 2016).
Implications for Practice
The study’s findings further inform the body of literature concerning the impact of early childhood experiences. The study provides a specific lens on that topic by providing the perspectives of human services case managers. In addition to the contribution to the literature, study findings carry practical implications for the case management profession in the human services field.
The study’s practical implications are centered on benefits to human services professionals and organizations. Leaders of human services organizations will benefit from research participants’ reflections regarding how past experiences of childhood trauma have shaped their professional practice. The study findings demonstrate the value of seeking out the perspectives of human services case managers and the implications those perspectives can have not only for informing and enhancing practice, put transforming organizations and larger behavioral health systems. As highlighted in the research, the goal of a trauma-informed system is to integrate trauma awareness and concepts into an organization’s principles, policies, procedures, and practices (Oral et al., 2016). Findings from the study allow for the opportunity to heighten awareness among human services leaders and provide concrete examples and recommendations for how decision-makers can transform principles, policies, procedures, and practices, including, for example, the design of workplace environments and self-care and well-being employer initiatives, (Grist & Caudle, 2021). Practical implications of the study also include the identification of workplace experiences, interactions, and conditions that can either exacerbate, mitigate, or as demonstrated by study findings, beneficially translate the impacts of ACEs (Trinidad, 2021). Participants’ reflections related to workplace interactions, specifically with colleagues, reveal conditions that can exacerbate the effects of early childhood trauma exposure; this finding is reflected in the theme related to perceived effects resulting in diminished capacity. Professional competency and coping mechanism themes demonstrate how participants, as result of early childhood traumatic experiences, developed tools and skills which allow them to mitigate and process negative workplace experiences and interactions. The themes related to case management superpowers, empathy and case management practice demonstrate how workplace experiences and conditions, including colleague and client interactions, are made better and elevated to the benefit of the organization and associated programs. Lastly, while the research expands the knowledge concerning posttraumatic growth and resiliency development, it also confirms previous findings regarding the detrimental impact of early childhood trauma exposure. Practical implications include outlining how organizations can provide mental health resources and training opportunities to address areas of diminished capacity as they show up in case management practice.
In a more expansive macro context, the study’s findings provide insight for leaders of educational institutions preparing future human services professionals. In the areas of curriculum development, professional identity formation and competency, study findings add to the growing understanding of the impact of childhood trauma in the professional context. Specifically, how an increased understanding and awareness of childhood trauma impact can prove beneficial in aiding professionals in mitigating workplace triggers, processing vicarious re-traumatization, and avoiding re-victimization of clients as they begin and advance in their professional practice.
Limitations
This study into the perspectives of human services case managers’ perceptions on how their past experiences of childhood trauma shaped their professional practice produced findings with professional and practical implications. The study, however, is not without its challenges in the form of limitations. The following provides discussion of the limits of the study, along with suggested improvements.
A contributing element to the study’s limitations is the use of participant self-report (Goldenson et al., 2020). In the current study, participants were allowed to self-report experiences of adverse trauma occurrences during their childhood. Relatedly, questions during the participants’ interviews required recall of past trauma experiences and participants’ interpretations of their connection to their professional practice presently. This aspect of the study design could lead to participant misinterpretation of researcher questions or general discomfort with self-report. Both the use of participant self-report and the need for participants to recall prior childhood experiences can result in recall bias, a phenomenon that can threaten study findings, along with the validity or dependability of the research (Dombo & Whiting Blome, 2016; Jia & Lubetkin, 2020; Middleton & Potter, 2015; Mittal et al., 2015).
To address these issues, future studies aligned with the research topic may consider either a mixed-methodological approach or an alternate data collection method, like a self-administered survey rather than a participant interview (Goldenson et al., 2020). Another limitation of the study design was the sampling method selected. The current study utilized purposeful and snowball sampling techniques to recruit study participants. Twelve case managers were ultimately selected to participate in the study and provide their unique perspectives. Frequently, with the selection of a qualitative research approach, along with a generic qualitative design, sampling procedures and size are cited as nonrepresentative limitations that therefore threaten the generalizability of the study across larger populations (Flinchbaugh et al., 2017; Ivandic et al., 2017; Juurlink et al., 2018; Lee et al., 2017). Additional notable limitations of the sample include the disproportionate number of female participants and the centralization of the geographic location of the research participants (Nuttman-Shwartz & Green, 2021; Truskauskaite-Kuneviciene et al., 2020). To address this limitation, future studies aligned with the research topic should consider alternative sampling methods and recruitment of larger study samples so that findings might be generalizable to larger representative populations.
Additional limitations that fall into a general category include both age of trauma experiences and demographic analysis of study findings. The inclusionary criteria of the study provided that participants experienced traumatic events during childhood and adolescence. While the study considered the influence of childhood experiences into adulthood, the study did not specifically assess the impact of trauma experiences exclusively after age 18 (Rokita et al., 2020). The occurrence of trauma experiences after age 18, and the exclusive influence of those experiences on professional practice, represents a limitation of the study and an area for future study. Future studies aligned with the research topic could consider trauma occurrences in childhood and adulthood, with special consideration of the influence of trauma from each period in the life course. Finally, although limited demographic data were collected for research participants, the study did not analyze results with specific consideration of influence by demographic categories (Grist & Caudle, 2021). To address this limitation, future studies with larger sample sizes may want to consider analysis along specific demographic categories, including age, gender, race, or ethnicity.
Conclusion
This study began with the researcher’s interest, sparked by a training in New Orleans, Louisiana, to better understand the implications of trauma exposure for professionals who have sustained their own experiences of adverse childhood experiences. A review of the literature concerning the research topic demonstrated that child welfare professionals tend to report higher scores on the Adverse Childhood Experiences questionnaire (Bryan & Brown, 2015; Flinchbaugh et al., 2017; Hiles Howard et al., 2015), as well as that ACE exposure may present long-lasting functional impairment (Alameda et al., 2015; Dunn et al., 2018; Nurius et al., 2015); however, the literature was incomplete regarding how human services case managers, who have experienced childhood traumas, perceive the role those events played in shaping their professional practice. A generic qualitative study was designed to elicit the perspectives of human services case managers who could answer the research question, "how do human services case managers describe their perceptions of how adverse childhood experiences shape their professional practice? Study conclusions expanded the body of literature concerning the perspectives of human services case managers.
Study finding highlights include, first, the concrete recognition of unique skills & abilities offered to organizations by case manager with ACEs histories. Second, findings provided clearer insights for the leaders of human services organizations regarding the kinds of challenges faced by human services professionals with ACEs and the ways in which they can cultivate a work environment and employee experiences that fosters a trauma informed workplace. Thirdly, a bolstering of the literature furthering the understanding and applicability of ACEs in a new (human services) professional context. Additionally, study findings continue to confirm previous findings in the literature, including the relationship between early trauma childhood experiences, career choice, and heightened processional skills and competencies. Finally, study findings contribute to the present body of knowledge dedicated to centering a macro systems perspective in the improvement of customer and consumer experiences within the behavioral health system at large; a system designed with the manifest intent to heal those seek repair from past harms.
Overall, the study’s conclusions demonstrate a new understanding of early childhood trauma exposure’s positive and negative effects on case management practice for human services case managers. By adding to the literature demonstrations of posttraumatic growth, resiliency development, and meaning-making, particularly in the professional context, the study builds on the current understanding of posttraumatic growth and resiliency development. Furthermore, several examples in the study demonstrate how these professionals have processed their trauma experiences and have transformed those experiences to find a deeper meaning and purpose in their professional roles. The research literature is clear on childhood trauma’s mental, physical, emotional, and social impacts. The current study’s findings align with the body of literature and offer additional perspectives, by way of human services case managers, on the tangential impacts for adults in the professional setting. Practically, study findings highlight the professional implications associated with instances of posttraumatic growth in the development of enhanced professional skills, abilities, and competencies.
Further research is recommended into posttraumatic growth and resiliency development in the professional context and potential implications for case management practice and client outcomes. Additionally, future researchers may also consider conducting a comparison study on the impact on case management outcomes for case managers with childhood occurrences of trauma as compared to a set of their counterparts who have not had childhood trauma experiences. The continued investigation into these areas and the current study findings ultimately help transform behavioral health and social service systems into trauma-informed systems. The kind of systems created with the understanding of and accommodation for trauma exposure are designed to prevent the re-traumatization of individuals, all while centering understanding, recovery, and resilience (Tebes et al., 2019).