The development of a trauma intervention manual for South African social workers

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The development of a trauma intervention

manual for South African social workers

HC Van Wijk

orcid.org / 0000-0003-4408-4595

Thesis accepted for the degree

Doctor of Philosophy in

Social Work

at the North-West University

Promoter:

Prof NH Ntombela

Co-promoter:

Prof M Van Der Merwe

Graduation: April 2020

Student number: 25830392

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DECLARATION

I declare that “The development of a trauma intervention manual for South African social workers” is my own work.All sources used or referred to have been specified and recognised by means of validated references.

Student: H.C. van Wijk Date: 4th November 2019

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ACKNOWLEDGEMENTS

The completion of this research would not have been possible without the support and help of several people. I thank those who invested in me to complete this study for their assistance, reassurance and inspiration:

 My promoter, Professor N.H. Ntombela, who supported and directed this research study with understanding and commitment.

 My co – promoter, Dr. M. van der Merwe, for her efficiency, encouragement and guidance in developing the trauma intervention manual.

 The research participants, without whom this study would not have been possible.

 My husband, Anton Esterhuizen, for his loving support and willingness to always listen and encourage me.

 My friend, Professor Nickey Alpaslan, for his motivation and assistance.  God, for his unwavering favour. Thank you for giving me the opportunity,

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2.10.10. Evidence-based practice ... 79 2.11. Conclusion ... 82 CHAPTER THREE ... 84 3. RESEARCH METHODOLOGY ... 84 3.1. Introduction ... 84 3.2. Type of research ... 86 3.3. Research philosophy ... 86 3.4. Research approach... 88 3.5. Research design ... 91

3.6. Population and sampling ... 93

3.6.1. Legal authorisation and role-players ... 96

3.7. Data collection ... 97

3.7.1. Data collection method ... 97

3.7.1.1. Focus groups ... 97

3.8. Data analysis ... 106

3.9. Trustworthiness of data ... 110

3.10. Research ethics ... 112

3.10.1. Confidentiality and anonymity ... 113

3.10.2. Privacy ... 114

3.10.3. Deception of participants ... 115

3.10.4. Beneficence ... 116

3.11. Conclusion ... 116

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4. DATA PRESENTATION, ANALYSIS AND INTERPRETATION ... 118

4.1. Introduction ... 118

4.2. Demographic information of the participants ... 119

4.3. Section A. The needs of the practising social worker regarding trauma treatment training ... 120

4.3.1. Themes that emerged from the discussions ... 121

4.3.1.1. Theme 1: Challenges in dealing with trauma for practising social workers ... 122

4.3.1.2. Theme 2: Trauma incidents that clients present to practising social workers. ... 129

4.3.1.3. Theme 3: Social workers current methods in dealing with trauma cases. ... 135

4.3.1.4. Theme 4: The importance of trauma intervention and the training thereof for undergraduate social work students.... 139

4.3.1.5. Sub-theme 4.1: Undergraduate training received to assist traumatized clients. ... 144

4.3.1.6. Theme 5: Needs of practising social workers on suitable training in trauma intervention. ... 149

4.3.1.7. Sub-theme 5.1: In-practice trauma intervention training attended as a social worker. ... 154

4.3.1.8. Theme 6: Contents of a trauma intervention manual. ... 157

4.4. Section B: Pilot test for the trauma intervention manual developed ... 163

4.4.1. Feedback from the focus groups ... 164

4.4.1.1. Question one: What did you learn from the presentation? ... 164

4.4.1.2. Question two: What aspects were not covered fully enough? ... 165

4.4.1.3. Question three: What other changes would you like to make? ... 166

4.4.1.4. Question four: According to you, why would a social worker be better equipped to do trauma intervention after training on the manual? ... 167

4.5. Conclusion ... 170

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5.1. Introduction ... 173

5.2. Preface... 177

5.3. The purpose of the manual ... 178

5.4. Manual intents ... 178

5.5. Directions for using this training manual ... 179

5.6. Baseline information on trauma ... 183

5.6.1. Define and explain trauma ... 183

5.6.2. Types of trauma ... 185

5.6.3. Reactions to trauma ... 193

5.6.4. The impact of trauma on survivors ... 197

5.6.5. Post –Traumatic Stress Disorder (PTSD) ... 201

5.6.6. Typical effects of post-traumatic stress on relationships ... 204

5.7. Understanding the trauma intervention process ... 206

5.7.1. Introduction to the trauma intervention process ... 206

5.7.2 Phase one (1) of the trauma intervention practice guidelines: Stabilisation (0–72 hours after the traumatic incident)... 214

5.7.3. Phase two (2) of the trauma intervention practice guidelines: Revisit the trauma and reduce the emotional charge (72 hours and onwards after the incident) ... 221

5.7.4. Phase three (3) of the trauma intervention practice guidelines: Reuniting with the authentic self ... 239

5.8. Case studies ... 244

5.9. References ... 246

5.10. Conclusion ... 253

CHAPTER SIX ... 254

6. SUMMARY, CONCLUSIONS AND RECOMMENDATIONS ... 254

6.1. Introduction ... 254

6.2. Summary and conclusions for Chapter one: Introduction to the study. ... 254

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6.3. Summary and conclusions for Chapter two: Literature review. ... 257

6.4. Summary and conclusions for Chapter three: Research methodology. ... 258

6.5 Summary and conclusions for Chapter four: Findings of the research. ... 263

6.6. Summary and conclusions for Chapter five: The trauma intervention manual 268 6.7. Summary of the findings as per objective of the study ... 269

6.7.1. Objective one: To explore the importance of trauma intervention through literature study ... 269

6.5.2. Objective two: To identify key elements of existing trauma intervention that can be adapted. ... 270

6.5.3. Objective three: To describe the needs of practising social workers on a trauma intervention manual. ... 272

6.5.4. Objective four: To develop a trauma intervention manual ... 272

6.8. Recommendations ... 273

6.9. Conclusion ... 275

BIBLIOGRAPHY ... 277

Table of Figures

CHAPTER 1

Figure 1.2.1: The parallel of the most common crimes perceived by South Africans and crimes that are feared the most in South Africa. p 6 CHAPTER 2

Figure 2.10.4.1: Stages of crisis intervention. p 72 CHAPTER 3

Figure 3.5.1: The first four phases of the intervention research design described by Fraser et al. (2009:29-34) used in this study. p 91 CHAPTER 5

Figure 5.7.1.1: The process of trauma intervention practice guidelines. p 212

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List of Annexures

Annexure A: Letter to seek permission to do research Annexure B: Permission letters:

 Department of Social Development ( Mahikeng Service point)  Suid Afrikaanse Vroue Federasie ( SAVF)

 Rooigrond Correctional Services

Annexure C: Ethical Clearance approval letter from North-West University Annexure D: Informed consent form

Annexure E: Research instrument: Interview questions

Annexure F: HREC approval letter of the trauma treatment training manual Annexure G: Certificate of First Language Editor

Annexure H: HREC change of title approval letter Annexure I: Certificate of Second Language Editor

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ABSTRACT

The motivation for this study was built on assessments that indicated at the time of the study that social work students in South Africa receive little or no training on trauma and trauma intervention. As a result, practicing social workers might not have adequate knowledge to work effectively with clients who experience traumatic incidents.

Influenced by the research problem as described above, the aim for this research was to develop a trauma intervention manual that could equip South African social workers in addressing the recovery of a traumatised person.

The following objectives steered this study towards achievement of the goal above, and these were set to:

 Explore the importance of trauma intervention through literature study.  Identify key elements of existing trauma interventions that can be adapted.  Describe the need of practising social workers for a trauma intervention manual.  Develop a trauma intervention manual for social workers.

The population for the purpose of this study included the Suid-Afrikaanse Vroue Federasie (SAVF) branch in Lichtenburg, Rooigrond Correctional Services and the Department of Social Development (Mahikeng Service Point). The three different organisations were selected to participate in the study because of their diverse exposure to trauma. All the participants work on a daily basis with traumatised people but from a different structure and location. The practising social workers of the three organisations selected formed part of a focus group discussion as a data collection method within the qualitative research approach.

Twenty practising social workers from the above-mentioned organisations participated in the study for Phase one (problem analysis) and for Phase four (pilot-testing of the design) of the intervention research process. The sample size was satisfactory for this study.

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The qualitative research approach was tailored to have focus group discussions with practising social workers concerning their needs on trauma intervention. Data were collected through simultaneous questioning of several individuals in each focus group.

The process of intervention research as suggested by Fraser, Richman, Galinsky & Day (2009:25-140) was used to develop the practice trauma treatment manual. The intervention research model consists of six phases, namely, problem analysis and project planning; information gathering and synthesis; design; early development and pilot testing; evaluation and advance development; and dissemination. For the purpose of this study, the researcher used only Phases 1, 2, 3 and 4 of the intervention research model.

Practising social workers who participated in this study confirmed that they lack sufficient knowledge in trauma intervention. The findings further accentuated the need for a trauma intervention manual in the social work profession that will equip the South African social workers to contribute in addressing the recovery of the traumatised person.

In closing, recommendations related to dissemination of the research findings, further research studies and practice were made.

Key words: Trauma; Social Work; Manual; therapeutic relationship; trauma intervention.

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CHAPTER ONE

1. INTRODUCTION TO THE STUDY

1.1. Introduction and rationale to the study

Briere and Scott (2015:1) disclose that the narrative of the human race is not only of pleasure, contentment, skill, philosophy and art, but also about conflict, oppression, cruelty, violence and tragedy. These scholars indicate that most people are likely to experience one or more traumatic events during their lives and a substantial number of people who experience trauma suffer long-term or even permanent emotional discomfort and pain. This emotional pain can vary from anxiety to a collection of symptoms that interfere, restrict and sometimes delay all facets of life.

Goelitz and Stewart-Kahn (2013: xv) confirm that trauma can take place at almost any time in life and that human reaction to trauma can be extremely complex, using September 11 and Hurricane Katrina as examples. Kaminer and Eagle (2010:1) point out that the high levels of exposure to trauma and violence in South Africa are cause for serious concern about the mental health effect of these experiences. South Africans are, in their everyday lives and through the media, frequently challenged with reported versions of traumatic incidents.

Kaminer and Eagle (2010) further outline the harsh picture in South Africa regarding trauma by noting that the term “post-traumatic stress” is commonly used without real understanding of the condition. In their 2013 article, Eagle and Kaminer (2013:85) outline the term “continuous traumatic stress,” a term coined in 1987 by Straker and the Sanctuaries Counselling team. Continuous traumatic stress is a reality for many South Africans, where they are repeatedly exposed to extreme events and do not have safe spaces to which to escape (Eagle & Kaminer, 2013:85).

The media often reports that debriefing or counselling is given to trauma victims; this suggests that trauma treatment is offered by many specialists to large numbers of

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trauma survivors. It is imperative that educated information about traumatic stress is widely distributed to enhance the knowledge of the South African public and to increase the treatment thereof. South African social workers must be equipped to work with a large population of traumatised people within the contexts of acute trauma as well as continuous trauma and complex traumatic stress.

It is clear from literature (Eagle & Kaminer, 2013, Van Rooyen, 2016) that South Africans are exposed to high levels of trauma and that such exposure could be prolonged and continuous. De la Porte and Davids (2016:49) draw attention to the South African history of political violence and contends that this history, together with high levels of interpersonal, political and community-based violence, could lead to high incidents of traumatic exposure in this country. The prevalence of traumatic incidents in South Africa is a challenge for social workers who often encounter traumatised persons in their areas of practice.

Inquiry by the researcher from a preliminary investigation on 8 August 2017 by means of a telephonic conversation with South African universities shows that currently undergraduate social work students in South Africa receive little or no training on trauma and trauma treatment. As a result they do not have adequate knowledge as practising social workers to deal effectively with clients who experience traumatic incidents. Given the complexity and high incidence of trauma in South Africa, it is imperative for social workers to have proper knowledge and professional training to identify and respond to clients who experience traumatic situations. Kawam and Martinez (2016:20) validate this by emphasising that social work is the sole profession that could privilege trauma education and take on this great service on behalf of the most exposed people. Greenstone and Leviton (2002) cited by Teater (2014:208) say that social workers with inadequate clinical experience can worsen the trauma. They underline the importance of a specific, systematic trauma intervention manual for social workers.

Teater (2014:208) further refers to Greenstone and Leviton (2002) in explaining that an all-inclusive model allows the beginner as well as the experienced social worker to be attentive in facilitating the traumatised person in the right direction. Such a model should suggest steps on how the social worker can purposefully meet the traumatised

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person, evaluate the level of danger, activate resources, and move strategically to intervention. There are already existing trauma intervention models that could provide guidance to what should be included in a trauma intervention manual for thepractising social worker.

There is also no indicator from the South African Qualifications Authority (SAQA) requirements that trauma intervention is explicitly needed for the Bachelor of Social Work degree. However, it is clear that trauma intervention can no longer be viewed as an incipient action and has now developed into an extensive social work field.

This study explores existing interventions for trauma, with the ultimate goal to develop a trauma intervention manual. This manual may equip the practicing social worker to assist, guide and empower the traumatised person to healing, growth and self-realization or as Briere and Scott (2015:79) succinctly state, to help people to “process trauma-related memories and, when possible, to move toward more adaptive functioning." Rinker and Lawler (2018:154) argue that traumatised persons should be able to deal with the reality against the backdrop of trauma, where the central nervous system becomes ‘overprotective” and can give over-active or false warnings, which must be judged against the facts of the current reality.

1.2. Problem statement and research questions

South Africa has always been characterised by violence, from the time of colonisation, through apartheid up till the post-apartheid period, with crime and traumatic experiences occurring on a daily basis. South Africa’s crime statistics was released on 11 September 2018 in Parliament for the reporting year 2017/18. The number of murders in the country was the highest ever recorded for a single year: a shocking 20,336 people were murdered in 2017/2018 according to the South African Government Crime Statistics (2018).

In his reaction to the current crime statistics, the Minister of Police, Bheki Cele, critically compared South African crime statistics over the past 10 years with deaths in the bombing of Hiroshima and the Afghanistan war. Following is a summary of the

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disturbing facts about crime in South African referred to by the South African Government Crime Statistics (2018):

Murder: The police recorded a total of 19,016 murders in 2017/2018. During this

period an average of 56 people were murdered every day.

Sexual offences: The sexual offences category covers crimes such as rape, incest,

sexual assault, bestiality, the sexual grooming of children and statutory rape. In 2017/18, a total of 50,108 sexual offences, of which the majority was rape, were recorded by the police. This is an increase from 49,660 in 2016. What is more alarming is that this total translates to 137 sexual offences occur every day in South Africa.

Rape: A total of 40,035 rape cases were recorded by the police in 2017/18, an

increase from 39,828 in 2016/17. The police verified an average of 110 rapes each day.

Assault with the intent to cause serious bodily harm:

The police recorded 167,352 assaults with the intent to inflict grievous bodily harm in 2017/18. An average of 458 such assaults was documented every day.

Common robberies: In 2017/18, there was a shocking 50,730 common robberies

were logged, down from 53,418 the year before. On average, 139 common robberies were recorded each day.

House robberies:

In 2017/18, there were 22,261 incidents of house robbery recorded. Victims were threatened and victimised in their homes. On average, 61 households were robbed each day.

House burglary:

In 2017/18, a staggering 228,094 house burglaries were recorded. An average of 625 houses per day were burgled.

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Carjacking

In 2017/18, a total of 16,325 cars were hijacked – an average of 45 cars each day.

Theft of cars or motorcycles

In 2017/18, a total 50,663 cars or motorcycles were stolen – an average of 139 each day.

Cash-in-transit heists

There were 238 cases in 2017/18, up from 152 in 2016/17 and 137 in 2015/16. De la Porte and Davids (2016:49-53) confirm that South African communities are threatened with crime and violence each day. Africa Check, a non-partisan organisation which promotes accuracy in public debate and media, (cited by De la Porte & Davids, 2016:51) indicated some key trends in South Africa for the period April 2013 to March 2014. The first category includes violent crimes such as: “47 murders per day, 172 sexual offences per day; 47 attempted murders per day; 502 serious assaults per day; 327 aggravated robberies per day and 148 common robberies per day.” The second category includes robbery with aggravating circumstances: “Carjacking – 12.3 %; Residential robberies – 7.4%; Bank robberies – 200% and non-residential robberies – 13.7 %.”

Bezuidenhout (2008:2) agrees with the general consensus that violent crime in South Africa is outstandingly high, maintaining that crime put severe threats on the South African economy and negatively affects the country’s development. South Africans are constantly threatened by crime. People are murdered, raped, tortured and robbed each day. As far back as 2008, Bezuidenhout (2008:2) postulated that many people believe that crime is out of control and consequently South Africans live in fear. This is even more accurate today with ever-rising crime and atrocities against women and children (Van Diemen, 2019, n.p.). Bezuidenhout’s 2008 point of view regarding South Africans living in fear is reiterated by Business Tech (2017) with reference to the latest Victims of Crime Survey released by Stats SA which indicates the crimes that scare South Africans. In the survey, families and people were asked which crimes they see as the most prevalent in the country and which violations terrified them the most. The outcome of the survey is outlined by Business Tech (2017) indicating the following: “The 10 crimes South Africans perceive to be the most common in South Africa are, housebreaking / burglary 58.8%; street robbery 41.5%; home robbery 38.5%; assault 19.4%; business robbery 17.9%; pick-pocketing or bag-snatching 17.9%; murder

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15.9%; livestock / poultry theft 10.9%; car theft or any type of vehicle 10.4% and vehicle hijacking 10.2%”. Business Tech (2017) also indicated the crimes South Africans fear the most are: “housebreaking / burglary 49.2%; home robbery 45.5%; street robbery 41.9%; murder 35.7%; assault 21.5%; pick-pocketing / bag-snatching 17.2%; business robbery 15.8%; vehicle hijacking 15.0%; car theft or any type of vehicle 12.8% and child abuse 10.9%”.

The South African Government Crime Statistics (2018) validate the above mentioned survey by showing a parallel presentation in Figure 1.2.1 of the most common crimes perceived by South Africans and the crimes that are feared the most in South Africa.

Figure 1.2.1: The parallel of the most common crimes perceived by South Africans and crimes that are fear the most in South Africa.

Bateman (2016) reports on an interview with trauma activist, Brian Rogers, who said that: “the toxicity of trauma reaches into our personal and societal psyche, depletes

our physical health reserves, fuels violence, traps the poor for ever in scarcity, creates barriers to learning amongst our youth – particularly the poor, and directly affects the rates of harmful addictions and substance abuse; leading to sexual exploitation and promiscuity and raising the sexually transmitted disease rate”. Importantly, Bateman

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quotes Rogers as saying: “Unresolved Trauma is the fuel for the cycle of violence in South Africa today” which underscores the importance of effectively addressing trauma.

De la Porte and Davids (2016:53) further indicate that the country is exposed to these high levels of violence as an outcome of the following factors:

 Violence became normal under apartheid and is seen as required and used to deal with conflict.

 The inefficiency of the criminal justice system and corruption.

 The dominance of inequality, lack of finances, unemployment and social rejection.  Family systems that are dysfunctional and result in children with low confidence,

poor skills and little ability to resolve conflict without reverting to violence.  Violence escalates and intensifies due to alcohol and drug abuse.

According to Bezuidenhout (2008:2) “a traumatized person and indeed a traumatized society, has become commonplace in South Africa, so much so that some of us have almost become oblivious and insensitive to its occurrence. Yet all of us, or someone we know, may have been, or at some point in time will be, touched directly or indirectly by events that have a shattering effect on our lives.”

The violent crime discussed here should not overshadow the many other forms of violence such as child abuse, wife battering, domestic assaults and rape. These "out of sight" forms of violence, which are generally directed towards women and children and the more helpless of society, affects more people than what is publicly acknowledged. Although social workers are confronted with the “out of sight” forms of violence on a daily basis, the underlying aspect of trauma is seldom addressed. The reason for that might be that the significance of trauma is not properly understood. Schnyder et al. (2017:3) are of the opinion that adult survivors of childhood abuse and neglect are hesitant to seek specialized help based on reasons of stigma, shame, fear of rejection, lack of knowledge and fear to re-experience the trauma.

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A traumatic experience hurts and results in an emotional wound (Rinker & Lawler, 2018:152). People struggle with the pain of trauma. Briere and Scott (2015:65) explain that traumatised people may appear stable at first after a traumatic incident and then unexpectedly express anxiety or experience anger outbreaks. Caring, focused attention and guidance are very important to a traumatised person after a traumatic incident.

Trauma is a subject we can no longer ignore and we therefore need professionals in the helping professions, including social workers that are equipped to address the traumatised society in South Africa. It is thus critical for social workers to have sufficient knowledge of the impact of trauma and the treatment thereof.

A preliminary investigation on 8 August 2017 by means of a telephonic conversation with the following universities (Stellenbosch University: Professor Engelbrecht, University of Limpopo: Mrs. Seloana, University of Pretoria: Dr. Spies and University of KwaZulu-Natal: Mrs. Cindy Naicker) confirmed the likelihood of inadequate trauma intervention training on undergraduate level, which could imply that practicing social workers are not equipped to work with trauma. These universities, together with the North-West University, only offers crisis intervention as part of the social work theories and no specific in-depth trauma training. None of the universities investigated have trauma intervention as a separate module that forms part of the undergraduate social work curriculum. The impression is that trauma intervention is overlooked in training social work students at universities in South Africa which could then have a negative impact on the skills of practicing social workers.

Kawam and Martinez (2016:18) clarify that social workers work with people with extended and difficult pasts of exploitation and brutality, sometimes with demanding physical and emotional needs. Social workers work every day with people who have experienced a traumatic event that has had an impact on their lives. Williams and Erlank (2019:1) confirm the problem in submitting that “Social workers in South Africa have to deal with victims of trauma on a daily basis and, with the already overstrained, limited resources available to communities, it is a significant challenge for social workers to assist traumatised victims promptly and appropriately.”

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It is clear that the existing undergraduate training given to social work students does not prepare them satisfactorily to deal with trauma in practice. The researcher is a social worker in private practice who sometimes has to refer traumatised clients to practicing social workers. Some of these social workers lack the know-how to offer trauma intervention to such clients. This problem undoubtedly suggests a dire need for better, adequate knowledge of trauma intervention strategies among social workers.

Kaminer and Eagle (2010:2-5) explain that the study of traumatic stress is a distinct, individual field of theory and encompasses a broad range of issues. In accordance with this view, the researcher was led in the current study to identify practising social workers’ needs regarding trauma intervention. This study further developed, through intervention research, an integrated manual with practical guidelines to equip social workers in trauma intervention.

Williams and Erlank (2019:1) are of the opinion that it is the responsibility of social workers in practice who deal with traumatised people to develop their knowledge and skills with regard to trauma intervention. Social workers should engage in Continuing Professional Development (CPD) as it is not possible to equip them for every possible practice challenge in a generic undergraduate course.

It is therefore clear that “a social work practice can take on many forms and regardless of the roles you fulfil as a social worker, you will need skills to master the roles and meet the needs of your clients. Each person has a story to tell and the social worker must elicit and understand that story in order to be an effective helper.” (Cummins, Sevel &Pedrick, 2014:16 -21)

In summary the research problem can be delimited saying that traumatisation of people living in South Africa is a problem with detrimental impact on the individual, communities and the country. Social workers are daily confronted with people who have experienced a traumatic event that has impacted on their lives. It is further clear that the existing undergraduate training given to social work students in South Africa does not prepare them satisfactorily to deal with trauma in practice. The development of a trauma intervention manual for South African social workers is therefore

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encouraged and should be guided by the needs and suggestions of practising social workers.

1.3. Research question

This study proposes the following key question:

What elements should be included in a trauma intervention manual to equip South African social workers to address the needs of traumatised persons?

1.3.1 Secondary research questions

 Why is trauma intervention important?

 What are the key elements of existing trauma interventions that can be adapted?

 What are the needs of practising social workers for a trauma intervention manual?

1.4. Research aim and objectives of the study

The aim and objectives of the study are conceptualized as follows:

1.4.1 Aim

To develop a trauma intervention manual that equips South African social workers to engage in trauma intervention.

1.4.2 Objectives

The objectives are set to

 Explore the importance of trauma intervention through literature study.  Identify key elements of existing trauma interventions that can be adapted.  Describe the need of practising social workers for a trauma intervention manual.  Develop a trauma intervention manual for social workers.

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1.5. Contribution of the study

It is hoped that the findings of the study contribute to knowledge by the development of a trauma intervention manual to equip practising social workers in implementing trauma intervention. Adequate education may enable the social worker to work with the “complex” and “multifaceted” individual following a traumatic experience.

A further contribution for the practising social worker is to register the trauma intervention manual developed in this study at SACSSP (SA Council for Social Service Professions) for CPD (Continuing Professional Development) points. Attending workshops and conferences is part of the CPD (Continuing Professional Development) points that every practising social worker must achieve each year, as structured by the SACSSP. This is an imminent benefit to all practising social workers.

1.6. Scope and demarcation of the study

The study was conducted in the North-West Province, focusing on three specific sites. Three focus groups of practising social workers in three areas of the North West Province were selected. The areas included the Suid-Afrikaanse Vroue Federasie (SAVF) in Lichtenburg, Rooigrond Correctional Services and the Department of Social Development in Mafikeng.

The motivation for focusing on the above mentioned three sites was that the diverse conditions at these sites provided a good representative sample of practising social workers in South Africa. The participants used in the study were practising social workers employed at the three sites, all of them dealing with a high number of people that experienced trauma on a daily basis. These social workers were therefore able to identify the practical trauma intervention needs and provided rich detail from the practice.

The sampling for this study was driven by two aims, crafted to:

1. Identify the need of practising social workers regarding a trauma intervention manual and,

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2. Perform a trial evaluation of the trauma intervention manual developed.

The same three focus groups in the three areas of the North West Province were used for both purposes.

1.7. Limitations and delimitations

There are limitations and delimitations in this study that needed to be taken into consideration when assessing the findings of this study.

1.7.1 Limitations

Price and Murnan (2013:66) describe the limitations of a study as those characteristics of design or methodology that impact the interpretation of the findings of the research.

These were the constraints in the current study:

 The participants in this study consisted only of registered social workers in the North West Province employed at three specified sites. Participants were limited to people who have already obtained a Bachelor degree in Social Work and were practising at the time of the research.

 Participants were practising social workers from the North West Province only. Generalizations and external validity of the findings might therefore be limited. Due to the lack of resources, it was impossible to test the trauma intervention manual on all social workers in all the provinces of South Africa.

 Arranging dates and times with the participants of focus group two from the Department of Social Development (Mafikeng services point) was very challenging due to a strike that was planned for all the social workers to protest for better benefits. The strike was planned to carry on for more than three months. Fortunately the strike was postponed to 2019.

 Getting permission from the national office to do research at the Rooigrond Correctional Services was frustrating. The confusion of when the committee would meet to finalise the permission left the researcher helpless and completely at the mercy of the gatekeepers. The powers to be kept on postponing the date. The

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waiting period of nine months, sending emails back and forth affected the time frame of the study but did not affect the results because eventually permission was granted to conduct the research study.

 Another limitation was that all the participants were female except for one male, thus the voice of male practising social workers were not well represented.

 Most of the participants came from the African community, followed by the white community, and none came from the coloured or Asian communities. The voice of the coloured and Asian communities were not represented.

 English was the second language of all the participants in this study. The difficulty in finding the correct wording did limit their true expression and their ability to articulate their needs and challenges regarding trauma intervention. Fortunately, all the participants were practising social workers and therefore certain terminology related to the profession was familiar to all.

1.7.2 Delimitations

This study was conducted in the North-West Province and focused on the following:  Only registered and practising social workers in the North-West Province could

participate.

 No limit on the years of experience was put on the social workers to participate in the study.

 The following participants, although also registered at SACSSP (SA Council for Social Service Professions), were excluded from the research project: social auxiliary workers, student social workers, social auxiliary work learners, child and youth care workers and student, child and youth care workers. One of the objectives of the research was to identify the needs of the practicing social worker regarding a trauma intervention manual in South Africa.

 The focus of the study was only on trauma and trauma intervention. No other issue regarding social work was considered.

The literature on the impact of trauma on an individual and the symptoms after a trauma experience were reviewed. One of the objectives of the project was to develop a trauma intervention manual. In order to apply trauma intervention, the social worker has to understand the impact and the symptoms of a traumatic incident.

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1.8. Ethical considerations

Strydom (2011:115) provide guidance with respect to ethics. A full description of ethics adhered to in this study are covered in detail in Chapter Three. The following ethical considerations were kept in mind:

 The purpose of the research study was explained to all participants. They were provided with consent forms that clarified that the focus group discussions would be recorded. (Annexure: D)

 Participants were not misled about the research study and what was expected of them.

 Participation was voluntary, and were allowed to leave the group or end participation in the group at any time.

 No harm was done to any participants (mentally or physically).

 Special attention was given during focus group meetings not to cause any discomfort in participants by asking particular questions. Nobody was forced to answer any question if they were uncomfortable with it.

 Credibility of the research was assured through correct identification and description of the topic and questions.

 The researcher made further provision for credibility by adopting a well-established research method.

 All participants were assured of confidentiality of the discussions. However, as it was focus group discussions full confidentiality could not be promised. Participants were only asked to talk about work-related aspects.

 The researcher ensured honesty by establishing rapport and stressing that it is a safe environment where the participants could talk freely.

 The researcher also ensured she had adequate knowledge to conduct the focus group and data analysis.

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1.9. Definition of terms

The following definitions are significant for this study:

1.9.1 Trauma

Most definitions concur that an experience of trauma occurs when an individual’s abilities and resources are inadequate or lacking to handle the external threat or danger, but then again some differences on how to define a traumatic event are evident. Hence, in order to define and understand trauma for the purpose of this study, more than one definition is presented.

Carbajal (2014:1-2) states that: “Trauma is a psychological or physical wound resulting from combat exposure, crimes, rape, kidnapping, natural disasters or accidents, which causes great distress and disruption in a person’s life and leaves long lasting psychological effects. These psychological effects affect the person cognitively, emotionally, and behaviourally and diminish the function and quality of life as the traumatic symptoms increase.” Carbajal (2014) further says that when traumatic symptoms develop, the recognition thereof or ability to adapt weakens. The individual starts to lose trust in self, others, and their surroundings and cannot realise any meaning in the trauma. Moreover, trauma influences an individual somatically and neurologically. The message sent through the sensory system is excessively actuated and incongruent with the experience the individual goes through. These different messages at the emotional, cognitive, neurological, and physical levels stimulate signs of trauma like the ones triggered during the traumatic event, in spite of the fact that the individual is protected and out of risk.

Tummala-Narra (2007:34; cited by Hovan, 2017:6) defines trauma as “…inclusive of a broad range of experiences that share the threat of violation and have implications for the individual’s relationships with the larger community or life context.” Hovan (2017) further debates that trauma takes account of incidents where an individual feels vulnerable and endangered and in which the result damages a person’s ability to function within his or her milieu.

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James and Gilliland (2016:146) provide another definition on trauma, influenced by Freud (1917/1963) and Erikson (1968) and submit that: “Psychic trauma is a process initiated by an event that confronts an individual with an acute, overwhelming threat. When the event occurs, the inner agency of the mind loses its ability to control the disorganizing effects of the experience, and disequilibrium occurs. The trauma tears up the individual’s anchors, which are fixed in a secure sense of what has been in the past and what should be in the present.”

Herman (2015:7) explains that trauma displays the human for evil and emphasises our vulnerability in the natural world. Therefore, Herman states: “Traumatic events call into question basic human relationships. They breach the attachments of family, friendships, love and community. They shatter the construction of the self that is formed and sustained in relation to others. They undermine the belief systems that give meaning to human experience. They violate the victim’s faith in a natural or divine order and cast the victim into a state of existential crisis” (Herman 2015: 51).

In summary, the following aspects are relevant in defining trauma:  Trauma is an emotional wound after a traumatic incident.  Trauma shatters an individual’s life.

 Trauma undermines the belief systems of a person.  Trauma tears up a person’s anchors.

 Trauma leaves people feeling out of control.  Trauma overwhelms and

 Trauma violates and diminishes a person’s faith.

1.9.2 The therapeutic relationship

Many authors refer to the centrality of a therapeutic relationship in trauma intervention (Booth & Adlem, 2016:30; Briere & Scott, 2015:88; Herman, 2015:133; Kimberley & Parsons, 2017:563; Skinner & McLean, 2017:212). Clark, Classen, Fourt and Shetty (2015:9) explain that in dealing with trauma, the social worker must be very attentive to the respect of power in the therapeutic relationship because the loss of power is one of the major symptoms of a traumatic incident. The focus must be to work together

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with the traumatised person, engaging him/her in the intervention planning and encouraging the re-empowerment of the individual. The social worker must also confirm the traumatised person’s security, freedom to choose and trust. By focusing on the strengths of the person, development of insight, finding meaning and improvement of skills, the important goal of trauma intervention to facilitate growth and change could be achieved.

Herman (2015:133) confirms that a central experience of trauma is an engendering of feelings of powerlessness and impression of being cut off from other people. Empowerment and the establishment of new associations form the basis of recovery, which cannot happen in isolation – these can only be achieved within the context of a relationship. It is for that reason, according to Herman (2015) that the therapeutic relationship is vital in restoring the trust, confidence, identity, affection and closeness that was damaged by traumatic exposure.

Fraser et al. (2009:6-9) argue that the reduction of social or health problems is generally the purpose of the interventions in social work. Therefore an intervention is an action that is premeditated to change behaviour, decrease danger and improve life expectancy.

Cummins et al. (2014:257) emphasise that the preparation of the traumatised person to receive intervention is a crucial step in the helping process. How well the individual participates and engages with the intervention is dependent on how well the social worker conducts the first meeting. It is important to make the traumatised person feel welcome, respected and worthy right from the beginning. The person should be assured of the prospect that recovery can happen and that life can become better. Attention to detail of the intervention process in the first phase of intervention helps the traumatised person to become part of the team effort to achieve recovery.

Kaminer and Eagle (2010: 82) outline three steps for trauma intervention namely:

1. Acute intervention or debriefing: This step is on the level of emergency intervention or psychological first aid.

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2. Short term intervention: This step is focused on dealing with the trauma and is normally structured in a set of four to six sessions or eight to twelve sessions.

3. Long-term intervention or psychotherapy: This step is therapy with a duration of several months or years focused on more complex cases and specific when dealing with Post Traumatic Stress Disorder (PTSD).

1.9.3 Social work

The following global definition of social work was approved by the IFSW General Meeting and the IASSW General Assembly in July 2014:

“Social work is a practice-based profession and an academic discipline that promotes social change and development, social cohesion, and the empowerment and liberation of people. Principles of social justice, human rights, collective responsibility and respect for diversity are central to social work. Underpinned by theories of social work, social sciences, humanities and indigenous knowledge, social work engages people and structures to address life challenges and enhance wellbeing. The above definition may be amplified at national and/or regional levels.” International Federation of Social Workers (IFSW) (2019).

Cummins et al. (2014:2, 3) define social work as “the art and science of helping others”. Hepworth, Rooney, Rooney and Strom-Gottfried (2017:3) refer to the definition of social work of the Educational Policy and Accreditation Standards (EPAS) namely: “Social work seeks to promote human and community well-being, enhance quality of life, and promote social and economic justice and the elimination of poverty.” The EPAS definition links with the description of the social work profession of the National Association of Social Workers:

“The primary mission of the social work profession is to enhance human well-being and help meet the basic human needs of all people, with particular attention to the needs and empowerment of people who are vulnerable, oppressed and living in poverty.” (NASW, 2008:1, cited by Cummins et al. 2014:3).

The following quote by Kimberley and Parsons (2017:567) is specifically relevant for this study: “Social workers can take pride in the claim that social work is a

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oriented profession with knowledge and skills to offer trauma-informed practice and trauma treatment, with cumulative an complex traumas, as well as social action in preventing the oppressions of preventable traumas”. It is part of the tradition of the social work profession to meet the range of human needs and helping underprivileged, needy and destitute people. Completion of the qualification of a Bachelor’s degree in Social Work (BSW) from an accredited school of social work must be achieved in order to be a professional social worker. “The profession is bound by common values and ethics that are grounded in client self-determination, respect for the individual, and helping individuals reach their potential by assisting them to function within the context of their environment” (Cummins et al., 2014:3).

1.9.4 Manual

Fraser et al. (2009:65) explain that the word manual is sometimes substituted with the term practice tools. A manual may also be called a sequence of practice procedures designed to reach specific goals, stipulating certain steps. In addition, manuals are also from time to time referred to as practice guidelines. Fraser et al. (2009:66) define manuals as “guides to practice that describe a problem, a program theory, practice objectives and program content”.

1.10. Preliminary literature review and theoretical framework

A brief summary of relevant literature is provided in this section, while a full literature review is presented in Chapter Two.

The acknowledgement that traumatic events are collective and that the impact of such can be devastating makes appropriate and suitable trauma intervention education an indispensable need in the helping professions.

There is a growing acknowledgement, according to Golightley and Goemans (2017:70), of the role of trauma as a cause of mental illness. They refer to the work of Romme and Read who established a connection between adult mental health problems and unprocessed childhood trauma in individuals.

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Bebbington et al. (2004; cited in Golightley & Goemans, 2017:70) provide examples of early untreated traumatic experiences that are related and supplementary to the development of psychosis later in life. Traumatic experiences such as sexual abuse, being bullied, taken into foster care, violence at home, running away from home are part of the contributory facets to psychosis. These are all traumatic experiences that social workers have to deal with on a daily basis.

Hovan (2017: 20) adds the following nine groups of trauma:

1. When a person is injured or experiences a loss of possessions as a result of fire or a natural disaster

2. Physical attack, stabbing, mugging or beating 3. Loss of a loved one

4. A serious motor vehicle accident

5. Sexual attack or forced uninvited sexual action of any kind 6. Robbery or theft

7. Required to leave the safety of your environment or house because of danger that is about to happen such as bad weather

8. Any other disturbing or awful experience

9. When a person’s residence, employment, or personal affairs are forced to change.

In terms of childhood trauma, Herman (2015:52) points out that the attachment process which takes place during a child’s development outlines patterns for future relationships, develops a sense of self and learning to cope with emotions. In addition, when a child, guided by a professional, learns to deal with trauma from an early age, that child develops coping strategies that can help with a more normal way of living later in life.

Beckner and Arden (2008:9) stress that “a traumatic experience will change a person’s life and force victims to face issues lying outside their boundaries of personal and collective frames of reference. As a result these [experiences], victims are compelled to confront emotional and spiritual challenges that are unfamiliar at that particular stage of development and spiritual maturation, individually or collectively.”

Describing trauma as an experience that brings an abnormal, forceful and extended stress reaction, Perry (2006; cited in Van Dyk & Van Dyk, 2010:379) points out that

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trauma often includes shock, anxiety, fright and powerlessness. It is an emotionally disturbing and painful incident that is not the natural choice of a person.

De la Porte and Davids (2016:49) explain that the reality of living in South Africa today is that a large percentage of the population has experienced trauma. South African communities are threatened with violence every day. The expectation of social workers who work within a community should therefore understand that traumatic experiences are not rare and recognise the emotional and spiritual impact on an individual. “The reality of intervening in people’s lives is that you, as the social worker, are working with something that is complex and multifaceted.” (O’Sullivan, 1999, cited in Golightley & Goemans, 2017: 71)

Clark et al. (2015:5) stress the fact that all the interventions offered may be fruitless when social workers do not understand trauma and know they are working with a traumatised person. This can lead to frustration, confusion and feelings of being overwhelmed in the social worker and leave the traumatised person feeling offended, terrified, not being understood and helpless, which points to the necessity of trauma-informed practice.

There are different trauma interventions that are recognised and some of the treatment options are outlined in the following segments.

As far back as 2004, Herbert and Sageman (2004:223) referred to the so-called ‘power therapies” in the context of trauma intervention. Masson, Graham and Langa (2016:236) remark that these power interventions are known for their speedy and effective treatment of trauma victims. The following are some of the most popular power interventions:

 Thought Field Therapy (TFT): This approach focuses on the fact that trauma harms the body’s energy levels. To correct the unsettled energy, the person must tap specific parts of the body while rolling their eyes and humming a happy song.  Emotional Freedom Technique (EFT): This seems similar to TFT but during this

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 Traumatic Incident Reduction (TIR): This technique is used by repeating the traumatic experience and that provides an opportunity to change the trauma memory.

 Eye Movement Desensitisation and Reprocessing (EMDR): This approach focuses on the generation of recurring eye movements while the person focuses on the memory of the traumatic experience until desensitisation takes place regarding that part of the memory (Welsh, 2018:35). The person must then replace negative thoughts and feelings with a positive memory.

Herman (2015:155-196) suggests that there are three essential facets to trauma treatment which should happen within a healing relationship. It is important to establish safety for the traumatized person (Kimberley & Parsons, 2017:553; Williams & Poijula, 2016:31); secondly, it is crucial to process the trauma and thirdly, it is essential to reconnect with self and the larger community. All three facets must be in place, for example, if a person does not feel safe it would be impossible to engage in the recovery process because the memory of the trauma continues to evoke much anxiety. The development of the trauma intervention manual was strongly influenced by the three aspects discussed by Herman (2015) as well as the Traumatic Incident Reduction (TIR) technique.

As far back as 1992, Janoff-Bulman wrote a seminal work about shattered assumptions in the context of trauma. Linked to this, Beckner and Arden (2008:201-233) conclude that the fact that trauma disrupts a person’s beliefs about the self, other people and the world do not necessarily have a negative ending. They assert that there is a way to change that to a positive vision by giving practical guidelines on how to confront and revise the beliefs of the victim. Beckner and Arden (2008:232) conclude by saying that because people try to make sense of the traumatic experience, they often draw unforgiving assumptions about themselves. It is so much easier to put the blame and guilt on oneself by thinking that the trauma happened because of some stupidity or bad karma. It is challenging to consider that bad things often happen to good people. Trying to ignore the negative thoughts and feelings make the experience more powerful. It is thus important to process the memory and to

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confront the negative beliefs. Beckner and Arden (2008:232) explain that the value of talking about trauma lies in the following results:

1. Talk organises the trauma memory in the brain, reducing the symptoms. 2. Talk lessens and eases the intensity of emotions connected to the memory of

the trauma.

3. Frank and open talk assists in understanding the impact of the trauma on core beliefs and gives opportunity for growth.

This study made use of the literature reviewed to support and assist in the development of a trauma treatment intervention manual suitable to train the practising social worker.

1.11. Theoretical framework

Rubin and Babbie (2011:54) accentuate the important role that theory plays in social work research and in social work practice as it helps to make sense of a phenomenon and to direct the intervention. For this study, the researcher saw it appropriate to be guided by the following theories to develop a trauma intervention manual.

1.11.1. Gestalt Theory

Congress (2011:256) indicates that the principles of Gestalt Theory are very relevant to social work. He highlights that the emphasis of both Gestalt theory and social work is to start where the client is. The second parallel is what the Gestalt therapists refer to as the “ground experience.” This is the same as the social work concept of “the person in environment ecological perspective” (Congress, 2011:250). The final association Congress (2011:250) makes is the resemblance between the Gestalt therapy’s focus on holism and the social work principle of including the entire person without isolating the physical, emotional, behavioural and cognitive constructs.

Congress (2011:248) explains that Gestalt therapy’s strives to understand the experience of the individual in their current context (here-and-now) as well as reflecting on past experiences. The restoration of the present and existing experience of a

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traumatised person is important. However, to examine past experiences and relationships as part of the trauma intervention helps the traumatised individual to gain a greater understanding of their life.

1.11.2. Cognitive Behavioural Theory

Thomlison and Thomlison (2017:54) and Teater, (2014:151) explain that Cognitive Behavioural Therapy is a combination of two therapies, namely behavioural and cognitive theories, both focusing on the impact of thoughts, feelings and behaviour on the traumatised. Cognitive Behavioural Therapy suggests that thoughts, feelings and beliefs are integrated and should not be assessed separately (Teater, 2014:150).

The goal of the Cognitive Behavioural Therapy is to replace negative thoughts in order to change negative behaviour to positive. The role of the social worker is to facilitate the process by guiding the traumatised person through exercises that modify the thinking and behaviour of the traumatized person. In assisting a traumatised person to change the negative traumatic experience into a personal growth, self-realisation and ultimately a positive conclusion, the thoughts and the behaviour must be altered.

Van Rooyen (2016:160) indicates what trauma-focused Cognitive Behavioural Therapy may be good for reaching the following goals:

1. To assist a person after a traumatic event to understand the symptoms.

2. To assist a person to find perspective by understanding that there is nothing wrong to experience these symptoms.

3. To assist a person by re-igniting traumatic memories to uncover stimuli that might aggravate and intensify anxiety.

4. To assist a person to find new practical, important and essential patterns and thinking related to well-being and security.

Van Rooyen (2016:161) further guides the process by stressing the importance of initially understanding certain aspects of the individual before undertaking Cognitive Behavioural Trauma Therapy. The initial step of understanding is the most important trigger that causes intense responses such as people, objects, sounds, smells or places; secondly, to understand the most important thought changes, for example,

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how the person looks differently at himself or others and thirdly, to understand the traumatic stress symptoms that a person is experiencing. Thomlison and Thomlison (2017:60-61) discuss basic premises of cognitive behavioural intervention, namely that problematic behaviour should be identified and challenged; that behaviour is often shaped by cognition and that a systemic approach facilitates behaviour change.

1.11.3. Strengths Perspective

Van Breda (2019:244) points to the roots of the strengths perspective in the work of Hamilton and Hollis and that of Perlman from the 1950s. When thinking about the strengths perspective in social work, the work of Saleebey (2008; 2011) easily comes to mind. Van Breda (2019:245) refers to the 1992 seminal work of Saleebey where he outlined the strengths perspective. Teater (2014:39) argues that the essential belief of the Strengths Perspective lies in changing the focus from the individual’s shortfalls or restrictions to the individual’s strengths. Instead of focusing on the problems only, the identification and application of abilities, resources, accomplishments and strengths becomes the centre of the therapeutic process. Van Breda’s (2019:245) view of the strengths perspective is worth noting as “... an approach in social work that centres on the social worker’s perception of people as possessing or having access to the strengths and capabilities to deal with their lived challenges.”

One of the principles of the Strengths Perspective described by Kisthardt (2013) (cited by Teater, 2014:42) is that all human beings have the essential ability to learn, develop and change. Traumatised people have that same inherent capacity. The trauma intervention process can assist people to discover their own strengths and abilities to heal and provide an opportunity to alter the negative traumatic experiences to a positive conclusion.

Hassim and Herbst (2016:206) and van Breda (2019:245) refer to the following six principles of the strength based perspective conceptualized and described by Saleebey (2011:483):

1. Everybody has inner strengths. The role of the social worker is to help a person to identify and develop their strengths to deal with the trauma.

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2. All types of adversities and trauma in life hold the prospect to become a birthplace of something new, progress and evolution.

3. The social worker must believe that all people have the capacity to develop and to mature, even with trauma. The social worker must constantly make the effort to give hope and empower the person to grow.

4. In the intervention process the social worker must work with the traumatized person. The social worker brings knowledge, understanding and skills and the individual brings feelings, reactions, views and actions. Teamwork between the social worker and the traumatised person involves exerting effort from both sides through communication and participation.

5. Every environment is full of resources; people have the strength to overcome trauma. Even though some are not able to do it alone, by standing together anybody can survive.

6. The social worker must take care of themselves, the community and the traumatised people. To ensure workable care after termination of trauma treatment, the social worker should assist in establishing on-going care within the family and community.

1.11.4. Person-centred Approach

Rowe (2017:37) is of the opinion that the person-centred approach has a significant influence on the field of counselling and psychology. This person-centred approach is incorporated by many therapists as an appropriate substitute for traditional analysis. The concept suggests that the person is an active participant, who volunteers to take responsibility for the envisaged positive change. The Person-Centred Approach is especially suitable for the social work profession because of many of the values similar to the social work values. Mbedzi (2019:199) describes the person-centred approach as “... a non-directive and empathic approach to social work practice that cultivates a therapeutic environment that is conducive to personal growth.”

The Person-Centred Approach is appropriate for trauma intervention because of the shared goal indicated by Rowe (2017:36) to liberate an inner ability that already exists in an individual for personal growth. This goal is based on the expectations highlighted by Rowe (2017:65) that, given specific settings, the individual has the ability to adjust,

The development of a trauma intervention manual for South African social workers