1. EDITORIAL
2. NEWS: WHAT'S HAPPENING IN THE TRAUMA FIELD IN SOUTH AFRICA
Themba Lesizwe Victim Empowerment conference
Interview with the new director of Themba Lesizwe
3. trauma and women
New baby in the field: Ikhaya Lethemba
4. news:
international field
5. SAITS ACTIVITIES
7. links to useful resources
EDITORIAL
The last issue of the traumatic stress newsletter received positive feedback from practitioners who felt they needed a newsletter that provided them with up to date information on the issues in the trauma field. SAITS would like to thank all those who responded to the newsletter and encourages other people who have comments, recommendations, articles or news to forward them to saits@saits.org.za
In this issue, we give you a peep through the window of the happenings in the field of trauma in South Africa. We focus on the new developments at Themba Lesizwe, the biggest national coalition for trauma service providers in South Africa. We take a look at the new director and his plans, and we also explore what this organization is about and where it is going.
The next important event is the 2nd Annual National Conference on Victim Empowerment that is taking place beginning of September. It is one of the biggest national events in the trauma field and we discuss its objectives and themes.
In the international field arena, we highlight the cutting edge issues in the trauma field and point you to up-coming conferences.
There is also a section updating you on the activities at SAITS, which we believe are crucial for your development as a trauma practitioner.
The interaction between HIV/AIDS and trauma in South Africa has complicated the grieving process where many people are now exposed to continuous traumatic stress. It is therefore important to develop services appropriate for this context. Johanna Kistner's article "grief and healing in the context of continuous traumatic stress" addresses this.
Finally, in this article we also refer you to useful website for information related to trauma.
NEWS: WHAT'S HAPPENING IN THE TRAUMA FIELD IN SOUTH AFRICA
Themba Lesizwe (TL) has become an important stakeholder in the South African trauma field. It is seen not only as a potential source of funding but also as an organisation providing a platform for interaction, networking and collaboration for those who work in the trauma and victim empowerment fields. TL is one of the most successful national structures created in the victim empowerment field. Liaison and interaction with this organization is important for anyone who works in the field.
Themba Lesizwe, previously called the The South African Network for Trauma Service Providers (SANTSEP) has gone through major growth and changes since it was first established in 2000.
SAITS had an interview with Ashley Green Thompson, the new director of TL to get a sense of what this important organisation is about and its plans for the future. This article is based on an interview with him.
HOW WAS THEMBA LESIZWE STARTED?
TL was the baby of four trauma service providers; the Trauma Center in Cape Town, National Peace Accord Trust, Sinani Survivors of Violence in KwaZulu-Natal and the Trauma Clinic in CSVR. When the organization was started, all the founder members formed part of the board and they employed a director- François Dronnet. As founding members these organisations got their co-funding from Themba Lesizwe. members will give up their status as board members. For the first time in the history of the organisation the affiliates will participate in electing board members. This will take place in the 2nd Annual Victim Empowerment Conference in Durban. These founder members will have to apply like all affiliates in order to get funding.
Also this year François Dronnet has given the directorship of TL over to a South African: Ashley Green-Thompson.
WHAT ARE THE OBJECTIVES OF TL?
Themba Lesizwe exists to support service providers in the victim empowerment field. This objective is expressed in five programme areas, which are: Institutional strengthening of the sector: This section focuses on building strong national and provincial networks amongst service providers. The national victim empowerment conference is one of the projects under this programme.
To enable and promote accessible services to poor and vulnerable groups: This is accomplished through supporting TL affiliates in providing such services. TL is aware that ideally service provision should be government's responsibility but is aware of its limitations and thus TL promotes accessibility of services to the poor and vulnerable. One of the projects under this programme is the provision of funding for projects in service provision.
Providing capacity building and training for service providers: This section looks at standards setting and quality control in the victim empowerment field. TL has set up and is supporting a standards generating body for victim empowerment. Themba Lesizwe chairs this body, Zuzell Pretorious, the deputy director of Themba Lesizwe is involved with the project. TL also looks at capacity development programmes for the sector.
Facilitating and coordinating policy development and implementation: TL provides support for service providers to be involved in policy development, monitoring and implementation. TL is also involved in ensuring that the policies developed by government in victim empowerment sector are implemented.
Facilitation and coordination of research: TL is concerned with information dissemination and the types of research taking place in the sector. TL is currently in the process of developing a research audit looking at where research is being done and at where fresh ideas are coming from. TL encourages CBO's and smaller organisations to also contribute to research.
The client tracking system also falls under this programme.
Developing collaboration with SADEC region. TL is currently looking at moving beyond South Africa and developing the Southern African coalition for victim empowerment service providers.
WHAT ARE THE ACCOMPLISHMENTS OF TL?
TL has been successful beyond its wildest expectation with now over 200 affiliates.
In 2003 Themba Lesizwe managed to host a national victim empowerment conference. This year another conference is taking place in September and is co-hosted with the Department of Social Development. This kind of collaboration with government is major achievement for Themba Lesizwe.
TL is finding that service providers are starting to work in collaboration creating more opportunities for networking, which is the core objective of the organisation.
TL has also managed to fund over 160 projects in the past three years totaling to the amount of R20 million.
WHAT ARE THE CHALLENGES FACED BY TL?
TL is struggling to keep in touch with smaller CBO's which are not visible or high profile. TL therefore plans to encourage the organisations in the remote areas to be part of the mainstream in victim empowerment sector.
There is a major public relations challenge where TL has to look at how to communicate more effectively and encourage more people to use its resources and networking.
WHAT CHALLENGES ARE TRAUMA SERVICE PROVIDERS FACING IN SA?
The provision of efficient and high quality services is a challenge for trauma service providers. The other major challenge is the availability of resources. NGO's are finding that resources are becoming scarcer. NGO's have to therefore learn how to access government resources, e.g. developing a relationship with the municipalities and finding out if there is budget for service provision in the area.
Service providers still need to learn how to tap into indigenous ways of working and use this information to assist clients. Most service providers need to move away from just providing services, and towards challenging government to assist and provide resources for this service provision.
WHAT ARE YOUR PLANS FOR THEMBA LESIZWE?
Currently the challenge is to get more funding to ensure the sustainability of TL. The success of the conference is currently a major short-term challenge for TL.
The past 2-3 three years were based on innovative ideas to start and establish the organisation. The challenge now is to consolidate those ideas and ensure their sustainability.
The future plans are to move Themba Lesizwe from a national network to provincial networks; this process has already started in KwaZulu-Natal and Limpompo. This will therefore ensure that TL members meet more frequently and have greater networking and collaboration.
TL and service providers in general are faced with the challenge of selling the
idea to the government that Victim Empowerment is an important sector in the development of the country. With a government that is invested in bread and butter issues this is a major challenge. It will require aggressive lobbying, advocacy and collaboration amongst all service providers.
CONCLUSION
In the past three years, TL has managed to establish itself as a key strategic player in the trauma field through offering networking and collaboration, which is crucial for service provision. Organisations providing services in the victim empowerment field can join Themba Lesizwe as affiliates for free. As affiliates, organizations get access to TL's resources, including information and networking. Affiliates are also eligible to apply for the grants that Themba Lesizwe provides yearly to service providers. For more information contact TL at 012 344 6301 or its website on www.santsep.co.za. SAITS wishes Ashley and his team all the best and that the next three years be even more fruitful and contribute to the improvement of trauma service provision in South Africa.
The 2nd annual Victim Empowerment conference The 2nd Annual Victim Empowerment Conference is the biggest local event in the trauma field. It is an event that will see about 500 delegates from all over South Africa including service providers, policy makers, community based organisations, faith based organisation, psychologists and other mental health workers, communicating about issues that affect victims in South Africa. It is an opportunity for service providers all over the country to converse about the interventions that they use, the training they offer and the key research areas they are focusing on. It will also cover other issues critical to victim empowerment such as law, advocacy and lobbying.
One of the major strengths of this conference is the involvement of government in the conference. Unlike the first annual conference, which was organised mainly by Themba Lesizwe, this year the Department of Social Development, is to be the partner in conference. This points to the move towards cooperative work between government and non-governmental organisations.
The strength of the conference is its integration of academia and practice with presentations ranging from very
academic work to work from practitioners, policy makers and community-based interventions. This contributes to bridging the gaps between grass root and academic work that exist in the trauma field.
SAITS promotes local initiatives such as this as they enable the sharing of information that is appropriate to South Africa, which is something that is desperately needed by the trauma field in this country. In support of this initiative SAITS is sending 10 of its students to go and present posters of the projects that they presented in SAITS training courses. SAITS is assisting the students to write up the posters and will be covering some of the students' costs. Craig Higson-Smith from SAITS has also been actively involved in the planning process for the conference and, SAITS will also have people to present papers and chair sessions in the conference.
SAITS encourages everyone who is in the trauma field to attend this conference and we hope that there will be more locally organised conferences like these in the country. For more information on the conference contact www.santsep.co.za
TRAUMA AND WOMEN
This month we are commemorating Women's Day in South Africa and saluting all the women who fought for the struggle.
In this month that recognizes and appreciates women, it is important to focus at the initiatives done in the traumatic stress field to address women's issues. This newsletter looks at the initiative by government and NGO's to provide an integrated and holistic service to women survivors of domestic violence and sexual abuse through Ikhaya Lethemba (IKLT). Ikhaya Lethemba "the home of hope" is the baby of the Provisional Department of Safety and Liaison. The organisation was launched this year in March and has been operating for only five months but its value is already evident, with over 400 people having been referred to the organisation in these months alone.
SAITS has had the opportunity through a project led by the CSIR-Crime prevention unit, to work with this exciting organisation. This article explores what IKLT are about and the role it is likely to play in the trauma field.
ABOUT IKLT
Ikhaya Lethemba is a one-stop centre for women and children who are survivors of domestic violence and sexual abuse. The center was started with the purpose of providing a place where women and children survivors could get the services they needed under one roof.
Services available for victims include; medico-legal services, counseling and therapy services, court preparation, the FCS and temporary residential services.
This is one of the organizations that highlights the importance of collaboration between government and NGO's. At IKLT there are about five NGO's that work on site to offer their specialized services to victims of trauma and four government departments.
This initiative can pave a way for developing a best practice model on how to maximise the country's resources -both government and non-government- to assist victims of trauma.
SAITS salutes IKLT and all its staff for the hard work that they do and wishes them all the best and hope they can be able to develop a centre of excellence where other people who want to conduct similar projects can learn.
For more details about IKLT and how to refer clients to them, please contact Mashadi at 011 242 3000.
NEWS: international field
4.1. Cutting Edge issues:In most of these countries, people tend to be exposed to multiple traumas and they are looking for interventions that can deal with this kind of trauma. Here at home this kind of trauma was recognized as early as the 80's and was called continuous traumatic stress. Internationally, there is an exploration of the nature of this trauma and the interventions appropriate for addressing it.
The cultural context of trauma
The international trauma field is prioritizing the study of the culture's role in how countries handle trauma. For example, this year in the Zurich conference speakers were invited form South America, Japan and South Africa to look at how these countries experience and deal with trauma. Dr. Merle Friedman who is the founder and board member at SAITS represented South Africa in this conference.
Journalism and trauma
This is becoming a topic of interest both internationally and here at home. Topics of interest include a look at the impact of trauma reporting on the journalist and the general public. There is also an exploration of the guidelines on how traumatic stories should be reported so that they do not re-traumatised people. The DART foundation is leading this process. The CSIR-Crime Prevention programme will also be hosting a workshop on this issue. The role of media reporting in the recent Iraq war has also contributed to this increasing interest
Trauma and war
For a long time wars have been central in trauma work. Actually, most of the trauma literature on PTSD was developed from war experiences. With the current war on Iraq, there has been a renewed interest in trauma and war; and trauma and terrorism.
4.2. International conferences on traumatic stress
2-5 December 2004 - Psychological Health after Disasters: Prevention, Treatment and Organization, The Marmara Otel, Istanbul, Turkey.
http://www.adobe.com/products/acrobat/readstep2.html
The 6th Annual Conference of the German Speaking Society of Traumatic Stress Studies (DeGPT) will take place from 3rd to 5th September, 2004. (No translation). Vienna, Austria.
11th Annual ASTSS Conference Advancing Traumatology: From Violence, Trauma & Human Suffering...to Healing & Hope. September 10-11, 2004. Sydney, Australia
ISTSS Annual Conferences - the next one (the 20th) is scheduled for New Orleans, USA November 14th -17th, 2004.
ISSD International Fall Conference November 18th-20th, 2004, New Orleans, USA.
III Psychological Trauma Meeting December 2-5, 2004. Istanbul, Turkey
ESTSS Conference: The 9th ESTSS European Conference will be in Stockholm, Sweden June 18th-21st, 2005. For more general information about these ESTSS events, which take place every other year, please consult http://www1.sotocon.se/WMS/9/12734/asp.
For more details on these conferences check on the UK trauma group: http://www.traumaclinic.org.uk/conferen.html.
SAITS ACTIVITIES
5.1. SeminarsSince the last publication of the newsletter, SAITS has had four seminars, which highlighted crucial issues in the trauma field a brief summary of the seminars is presented here. For detailed papers please see our website on www.saits.org.za or call at 011 648 7376.
HIV/AIDS and Trauma
Pierre Brouard, a clinical psychologist who has been working in the field of HIV/AIDS for over 18 years presented this seminar in April. His seminar provided a rich perspective on the links between HIV/AIDS and trauma. He discussed the different stages that people who have HIV/AIDS go through, drawing from his own clinical practice. He then explored whether there is trauma in each of these stages. People's feedback was very positive and it is a useful seminar for anyone working in the field of HIV/AIDS and/or trauma. (For the article go to http://www.saits.org.za/seminars.html)
The Arts therapy and trauma
Kistern Meyer, a drama therapist and Linda Souchon, an art therapist presented this seminar. Both of them were our students in the Advance Treatment of Trauma Survivors Course and graduated this year March. They had shown in the course how they integrated the trauma training with the wealth of information they already had on the arts therapy.
During the seminar, they both illustrated very well how the arts therapy could be used in working with trauma. Kistern explored the history of drama therapy and showed some techniques of drama therapy that could be used in working with trauma. Linda on the other side presented a case study in which she used the arts to work with children who were HIV positive in a hospital. She also showed us the techniques she used in her work and differentiated between art therapy and using art in therapy. This a worthy article to read if one is looking at alternative ways of dealing with trauma (To get the articles call Rina at 011 648 7376).
Child trauma Interventions:
Exploring the South African reality
Stacey Liebowitz-Levy, a clinical psychologist, lecturer at Wits University and board member at SAITS presented this seminar. She presented a research that she conducted in exploring the interventions available for working with children in South Africa. In her seminar, she showed how most child interventions focus on exploring the story without integrating it into the child's life experiences. She then proposed and discussed a short-term model, which uses both the exploration of the story and its integration. This is a definite must for people who use brief term interventions in working with children who are survivors of violence (To get the article go to http://www.saits.org.za/stacey.html)
Traumatic Bereavement: Siyabakhumbula (we remember)
Johanna Kistner a clinical psychologist, the director of Ekupholeni mental health and board member at SAITS presented this inspiring and eye-opening seminar on the work that Ekupholeni is doing with people who have lost their loved ones through political violence and/or HIV/AIDS. She showed how the interaction between violence, HIV/AIDS and stressors such as poverty and joblessness make bereavement work complicated. She used the concept of continuous traumatic to explain the impact of these interactions. She further discussed the interventions they use in the project called Siyabakhumbula-We remember them- which initially started as a project for people who lost their loved ones through political violence in the late 80's, early 90's but is now also dealing with bereavement as a result of HIV//AIDS. Part of this presentation is included in this newsletter. A definite must for people who are finding that traditional therapeutic methods are not sufficient in enabling them to assist victim of continuous traumatic stress.
5.2. TRAINING COURSES
Certificate in Trauma Treatment:The majority of the trainings in the trauma field have been on early interventions. Such trainings are themselves limited as they focus mainly on debriefing. This method of intervention has been thoroughly discredited in the research literature.
In addition to this limited training in early interventions there is also very limited training on trauma counseling and therapy. What is of even more concern is that this lack of expertise is found amongst professionals such as social workers and psychologist. There are therefore very few places where people who need treatment beyond early interventions can be referred.
Most of the people and organizations that attended SAITS courses were very keen to learn and committed to their work. Therefore, there seems to be a willingness from the service providers' side to develop their skills. The main challenge is that trauma counseling needs more specialized courses. Some of the service providers who desperately need such training find that they cannot afford it. SAITS is honoured to be able to contribute by offering such training courses at affordable rates and offering bursaries to those who cannot afford the courses.
Certificate in Trauma Treatment:
Advanced level II
SAITS was also able to for the first time offer this advanced course to practitioners. This course was targeted at people who had already had extensive experience and training on trauma and now needed to specialize in the field. Most of the participants in the course were the students who attended SAITS' level 1 courses and it was exciting to see how much they had learned.
The attendee's ranged from university lecturers to clinical psychologists, educational psychologist, psychiatric nurse, art therapists and social workers. The course is based mostly on working with case studies and linking them to specific themes in the trauma field.
What this course confirmed for SAITS is what we have always advocated for. The trauma field needs to have specialists. It was of concern to us just how few people were actually specializing in trauma work. In South Africa, there are only about 3 to 4 organisations that specialize in trauma counseling and therapy. This means that as a country, we have very little service available for people with PTSD or subsyndromal chronic traumatic stress.
It also became apparent during the course that the generalized training that social workers, psychologists and other mental health professionals get in the university does not prepare them to do this specialist work.
SAITS is targeting to develop a pool of trauma specialist in the country. If anyone is interested in specializing in trauma as a field please contact us at 011 487 1348 and we can forward information on the courses we have available and how we can assist you to specialize in the field.
Community Course
Since the 80's, there has been a school of thought that has challenged the appropriateness of the traditional one-on-one counseling interventions for the South African context. This field now called "community psychology" highlighted the importance of offering interventions that are at a community level and that consider the socio-cultural context of the people to be assisted. This is particularly important in trauma work where it is difficult to separate people's reactions to trauma from their socio-economic and cultural contexts. Despite this, the trauma field in South Africa continues to train practitioners on one-on-one counseling without due reference to culture.
Since offering the community course last year, SAITS has seen just how far South Africa is from offering appropriate community interventions in the trauma field. Firstly, there are very few mental health professionals involved in community interventions. Secondly, most people who are doing community work are volunteers who themselves have had little or no training. Those who have had some training, have only been trained in one-on-one victims support work or debriefing, which does not equip them to offer quality community work.
There have been three community oriented courses that SAITS has offered so far, one in Namibia and two in JHB. Those who attended the courses found them very helpful in enabling them to be active participants in the community and in mobilizing community resources to address issues of trauma. This is therefore a very necessary and crucial course and SAITS hopes that in the future it could offer the course in other provinces and have more mental health professionals engaging in this form of intervention.
Training of trainers course
One of the major problems in the trauma field is the lack of quality straining for service providers. Quality training depends on the availability of trainers who have themselves received quality training. One of the ways of addressing the crisis is through developing trainers who specialize in the field.
SAITS aimed to address this by offering such training for the trainers. SAITS offered its first training of trainers course last year. However, in offering this course we realized just how few trainers are available who actually focus on trauma treatment. There are therefore a lot of people conducting trauma work but very few trainers, suggesting that most people in SA who are doing trauma work do so with little or no training. This lack of trainers in the field is of major concern and any organization doing work in trauma has to consider developing trauma trainers and ensuring that they get trained.
What we also discovered is that most people who offer trauma training are people who do so due to their years of experience but have not received any training on trauma training. Mostly however, organisations employ professionals such as psychologists and social workers and expect them to be able to train volunteers on trauma. Unfortunately, in general, the university training does not equip people to conduct quality training for volunteers. It is imperative that anyone who does trauma training should get the appropriate training and it should not be assumed that varsity training prepares people to do trauma training.
ARTICLES
GRIEF AND HEALING IN THE CONTEXT OF CONTINUOUS TRAUMATIC STRESS by Johanna Kistner. (Johanna is a clinical psychologist. She is the founder and director of Ekupholeni Mental health. She also serves in the board of directors of SAITS)
INTRODUCTION
South Africa is a nation of bereaved individuals, families and communities with no time to grieve. The struggle against the apartheid and other forms of oppression has cost many lives. Economic and political conflicts have escalated into wars which took hundreds and thousands of more lives. Criminal violence continues to take its toll, as does violence against women and children. HIV/AIDS has invaded our homes and the dying has reached unprecedented proportions. Families mourn not for one but for many loved ones, taken often in the prime of their productive lives, leaving the survivors in conditions of abject poverty and material deprivation. The burden of care is enormous. Elderly relatives nurse the dying and are left with the responsibility for children, many of whom themselves may carry the deadly disease. The struggle for survival leaves little time for tears, for the treasuring of memories, for the rituals that speak of love and belonging. A nation that cannot grieve cannot move on, cannot affirm life and move into the future with a sense of optimism.
This article highlights the difficulties that are experienced by people who live in the context of continuous traumatic stress. These difficulties are drawn from group sessions and retreats of the project called Siyabakhimbula (we remember them). Siyabakhumbula is a community-centred model of intervention with families affected by multiple and traumatic bereavement that was developed at Ekupholeni.
1. Vigilance
Grief is associated with the traumatic experience of violence, displacement, loss of income, shelter, family and community ties. The immediate need for ensuring the survival of self and family takes precedence over the emotional processing of the experience of loss. Traditional mourning rituals often need to be put indefinitely on hold as survivors have neither the means nor the safe context within which these can be practiced. Grieving processes are culturally defined and require safe spaces within which the individual and family can withdraw. In situations of ongoing threat to life, however, such withdrawal cannot take place, as the individual needs to maintain a constant state of physical and psychological vigilance. S: You are asking me to cry. Yes, I want to cry but I cannot. When I cry, I cannot see. And I need to be able to keep my eyes open so that I can see clearly when they come to attack me. I need to be able to protect myself.
The demands of coping with other losses, associated with violence and/or disease Almost inevitably the loss of an adult in the family is associated with other losses, most notably the loss of income. Violence and HIV/AIDS tend to target the breadwinning generations of young and middle aged adults- people who still have young families to feed, clothe and educate. The despair associated with the loss of income often tends to overshadow the grief for the person who has gone. People living with HIV/AIDS who are in receipt of a disability grant may represent the only form of income in a large family. When they die, the family is first and foremost bereft on the income which kept them alive.
Bereavement may also be associated with the loss of status in the community, especially for women. A story that we hear again and again is that of a young woman whose husband was able to provide a relatively comfortable life style for his family. When he dies, the in-laws claim his property and other assets and leave the young woman and her children penniless and homeless on the street.
P:
I made a dish. I was touched by the poverty in the story. I felt you were talking about me. My husband died, leaving me with eight children. The family took his body. The family took everything. I had to beg with an empty dish. It always stayed empty. We slept without food. I did not know that children can get used to hunger…..I found friends who told me that smoking would make me feel less stressed. I started drinking
3. The burden of care
During the period of violent political conflict many families lost two or three or more of their adult children. Each of these may have left a number of grandchildren. The situation is even worse with HIV/AIDS pandemic which may claim the lives of both parents, leaving grandmothers to care for large numbers of orphaned children. The bereaved grandmother has little time to grieve for her children, as she immediately needs to take on the task of providing for the children they have left behind.
A:
I remember my six children. They left 13 children who do not have fathers. I am left with two sons. My grandson was killed mercilessly by my neighbours. Since I joined Siyabakhumbula my one daughter died on 23 January 2003. My other daughter died in February 2003. My grandchild died in March 2003 because he was bewitched by my neighbours. I hope God will give me strength to bring up my remaining grandchildren.
Multiple bereavement and emotional blunting Grieving and the process of recovering from a traumatic bereavement requires psychic energy, time and a great deal of support and tolerance from family and friends. Where people have been through multiple bereavements, often one following after the other, the energy required to process each loss soon dries out, as does the ability of family and friends to provide support. Organizing and financing funerals alone becomes such a drain on the material and emotional resources of the family, that there is little energy left to grieve for the person herself.
N:
We were always crying. The tears would have filled dams, but they would not have helped us. You cannot drink salty water.
G:
When a person dies, you are supposed to bring him home with a branch. I was so powerless, I could not do it.
Bereavement and grief in the face of one's own pending death Many people who have lost loved ones are themselves infected with HIV and need to deal with their own pending death. Often they have nursed to death siblings, partners or children, and are acutely aware that they too have to face the same agonizing death. Intense feelings of guilt and shame may further complicate the grieving process, especially in the case of mothers who have lost their young children to AIDS.
Z:
I thought about my boyfriend, who will be two years dead next week. I blame myself for giving birth to a sick child. If I had known, I would not have married. Here I drew my husband. He was bleeding through his eyes. I am afraid that I may bleed to death. I ask myself why this happened to me. I looked after them without any support. Both died within a month of each other. I had hopes for my boy. I already completed a form for him at the preschool. Now I am waiting for death. I want to be next to them. ...
6. Individual grief in the context of mass dying
Just as individuals are overwhelmed by multiple bereavements, so are communities. In many neighbourhoods community resources have been stretched beyond endurance. Group members report that they can no longer collect money to assist with the cost of funerals, as they used to do in the past.
J:
Ubuntu is dead. AIDS has killed ubuntu. Everybody is busy with their own loneliness.
A funeral can be a logistical nightmare. The undertaker will no longer wait for the funeral service to finish before removing the body from the home to the cemetery. Ceremonies are rudely interrupted by impatient undertakers who schedule funeral arrangements by the hour. Five to eight funeral services may take place in a single row of graves no more than 20 meters long. The hymns sung by the one group are drowned out by the voices of six other groups. The words of the pastor cannot be heard. Back at the home of the family hungry strangers join the queue, hoping to get a free meal. They do not know the deceased person and have no relationship with the family. Funerals are no longer ceremonies to help the bereaved come to terms with the finality of death. Big business has turned them into mass arrangements for the disposal of dead bodies. Under such conditions, people struggle to find the emotional space for grieving:
R:
In our churches there is no time to share. People look at you strange when you go on about your own problem.
7. Generational and gender differences in the process of grieving
Women:
Women tend carry the burden of grief, the burden of care for surviving families members, as well as the burden of ensuring that cultural requirements in terms of mourning rituals are carried out appropriately. In some respects, this means that women are given the most space to express their emotions, to elicit support and to engage in meaningful healing rituals. It is the woman who sits on the mattress, is supported by other women from the neighbourhood or church, and is socially recognized as the chief mourner. On the other hand, once the immediate rituals leading up to the funerals have been completed, women are usually left very much on their own, and often have additional restrictions imposed on them. They may have to wear clothing which identifies them as mourners and which isolates them from the mainstream of social and community life. It is usually the woman who incurs huge debts in preparation of the funeral, which may take her years to pay off. She may be hounded by undertakers and debt collectors. It is the woman who needs to see to it that orphaned children are fed and able to continue schooling. It is the woman, who seeks out help from service providers, often spending months or years queuing in government offices, desperate to attain the right kind of documentation, and access the right kind of people, that maybe could eventually result in material assistance. It is the woman who is usually turned away, and is expected to find a way of coping with no formal assistance. It is therefore no wonder, that despite the support women are able to elicit in the very early stages of the grieving process, they are in the long term the ones most likely to present with symptoms of post traumatic stress, major depression, anxiety disorder and the like.
R:
I look fine but deep down in my heart I still have a pain. I had to be strong for my family. I tried to protect others rather than deal with the pain.
Children
Children, on the other hand, are largely excluded from the grieving process. They are often sent away or left in the care of neighbours. Very few adults talk to children about the circumstances surrounding the death of a loved one, and even fewer can acknowledge the feelings of guilt, distress, sadness and anger the child is likely to experience. Children as old as 10 or 12 years are considered "too young to understand." Left to deal on their own not only with overwhelming feelings of loss, but also often with dramatically changed life circumstances which have not been properly mediated, many children therefore may later present with behavioural or learning problems. These often then force the family to seek help from social workers, counselors or psychologists. Thus it is often the children who finally open up the possibility for the entire family to deal with their grief.
Adolescents
Adolescents also do not have a direct role in the grieving process but are often expected to take on the burden of care, especially in the context of HIV. Nobody discusses feelings with them. They do not sit on the mattress, nor do they mix with adults. While younger children may be taken in by relatives, adolescents are generally left to fend for themselves, emotionally as well as materially. They do not tend to seek help directly, but are desperate for attention when this is solicited by service providers. In increasing numbers adolescents are becoming caregivers and bread winners in orphaned families.
Men
Men are the least likely to seek help and have the most difficulty in expressing grief, especially in situations which are dominated women. The reality is that in the home grieving rituals are organized by women and center around the bereaved women. Men meet in separate spaces and tend to resort to alcohol. Men report that they deal with their bereavement by looking for distractions. " I take my bereavement to soccer". They are the least likely to seek out support from each other, from community structures of formal sources of help.
PRINCIPLES OF HEALING
As mental health professionals we need to be able to translate our understanding of the dynamics of survival under conditions of continuous traumatic stress, into practical and meaningful strategies of intervention. At Ekupholeni our interventions are guided by the following principles drawn from our understanding of the context within which we work:
Grief and mourning take place in a particular social context. Where the social context is overburdened by massive trauma and large numbers of deaths (with all its attendant economic consequences), traditional rituals of mourning become eroded and the individual or family no longer has the necessary support in the emotional process of grieving. Alternative social support mechanisms need to be developed to assist people through the grieving process
Grieving is an intergenerational process. Women in effect carry the burden of grief for an entire family. Grief needs to be shared across the generations within a family or community.
R:
This is my family- myself, my younger sister, my two brothers holding each other. Here is an angel of my father's spirit. I hope that it is still with us and that we will find a way.
Rituals are critical elements of the grieving process.
In the context of mass dying traditional funerals and other rituals may be too expensive to implement, and/or may lose their healing power through over use. How to bury becomes more important than how to grieve. Cleansing ceremonies are complex and expensive. Priests and other spiritual leaders are burnt out by excessive demands for funerals and these are then at risk of simply becoming meaningless repetitions, devoid of the spiritual support they are intended to convey to those who are grieving. People need to explore and develop rituals that they can imbue with refreshed spiritual significance.
E:
With this leaf I remember my son who planted, pruned and picked the grape vines at our home. During spring they are so full of fruit that I can share them with all my neighbours.
Celebration, play and laughter have healing powers Celebration, play and laughter are critical components of the healing process. Celebrations can be of the life of the deceased person or, even more importantly, of the lives of survivors. Play and laughter bring people in touch with the inner child and evoke childhood memories. They also open up the emotional body, making space for other feelings to rise, find expression, and be processed. On arrival at a retreat center the first activity always involves active outdoor play. Women especially tend to resist this at first, but once they have been drawn into it, they loose themselves in the joy of movement, noise, playful competition and the triumph of mastery.
God is a miracle. I came to Ekupholeni being mute, unable to speak. But now I am able to speak, share and laugh.
Transitional objects symbolize support and love Transitional objects which have become invested with symbolic meaning can assist people whose lives are continuously disrupted by trauma and deprivation in accessing memories of support, caring and love, even when they are on their own. Transitional objects consist of small gifts, which are given to participants at the end of a family day, retreat, or on special occasions during group sessions. They are inexpensive everyday objects which have become embued with symbolic meaning through the group process: a candle, a cup, a note book and a pen, a red plastic rose, a plate. Candles have become particularly powerful transitional objects and many clients use them for meditation or prayer in the home, feeling that they have a special power because they are associated with the group and with Ekupholeni. Clients often come between sessions to request another candle, claiming that an ordinary candle can simply not give them the spiritual strength they need. Other transitional objects consist of clay sculptures, drawings and other works of art the person may have produced during family days or retreats. On home visits we often find these objects in a special place, even in the poorest shack. Over time, these objects in all likelihood loose their meaning, as people find the resources within themselves to cope with the challenges of their daily lives. However, in times of crisis, they may be called in again to evoke memories of support, caring, love and spiritual growth.
P:
This is the candle of hope. I have seen a lot of destruction but in the end there is a solution.
Physical and emotional cannot be separated All of our clients come from backgrounds of extreme poverty and deprivation. Food is a central issue in people's life and most women's lives revolve around the daily struggle to find food for at least one family meal a day. Special meals are associated with funerals, cleansing ceremonies, and life-affirming celebrations. While we cannot deal with the crisis of hunger and poverty at Ekupholeni, we make every attempt to acknowledge the fact that people's basic needs are not being met, and that these take priority in any process of recovery and healing. All clients are provided with tea and bread. For group meetings there are usually special food items, like fruit or hot dogs. Family days are associated with cooked meals. The highlights are the retreats, with three full meals a day, and snacks and tea in between.
E:
When I think of my husband something pulls my neck. I become a beggar. I made a cup. I came to Ekupholeni very hungry. At the end to the meeting they poured tea and gave me bread.
The power of healing lies within each other In the communities within which we are working groups are powerful healing tools. Groups can, to some extent, take over the role of family and kinship structures, where these have become too eroded to provide consistent support. Participants usually see the group as an alternative family where it is safe to share narratives, express feelings, exchange ideas and explore coping strategies.
E:
I went outside and when I came back I made a sculpture of a person. This is my daughter who was helping me when I was sick. She is the one who brought me to Ekupholeni. I also made an African pot. In it I will put the mealies to share with other people to show support. I want the group to do the same: to share love and ideas, and be one family and get rid of the problems we had.
Often group members discover in the group that they know each other from the community, and the collective group experience can strengthen personal relationships outside the group context. Members who have been attending retreats and group sessions for a long period of time and have internalized rituals of support and caring, often take on a very active support role for new members, who have been very recently traumatized. They model ways of communicating support, and are encouraged to place the current emotional experience of the newly traumatized member, into a time frame of healing. By doing so, they themselves re-trace their own journeys of healing and build into it increasingly more hopeful and positive narratives. There are many group members who have been attending sessions and functions over several years. Within a context of continuous trauma, the event that brought the client into the group in the first place, is highly unlikely to be the only traumatic experience that needs to be processed. Group members continue coming to the group (or return to it at intervals) because of ongoing traumatic experiences in their lives. For them the initial experience of healing and support, and the internalization of rituals, provides a framework within which they can then process other traumatic events.
7. A healing environment lightens the step into the future
Taking people out of their ordinary environment for a couple of days and conducting therapeutic interventions in a comfortable, home- like atmosphere, has proven to a critical element in the healing power of retreats. All of Ekupholeni's clients are living in conditions of abject poverty and deprivation. The struggle for survival, takes precedence over the need to deal with grief and other emotional processes. Much of a poor woman's time, especially is spent searching for food, begging from neighbours, or scavenging the various dumps of waste. By taking people out of this environment of extreme stress, and ensuring that all their basic needs a met for a number of days, the psychological urgency of the survival instinct, can be put on hold, even if only temporarily, allowing time and space for other activities and processes. Opportunities for play, meditation and prayer, music and drama, sharing of memories, empathy and exploration can then be all the more powerfully utilized.
N:
I know that when I get back and enter the gate of my yard, nothing will have changed. The children will still be hungry and I still cannot pay the school fees. But I have changed. When I open the gate of my yard, I will know that I have changed, that my step is lighter.
Resilience is the partner of despair While therapeutic interventions clearly need to access extremely traumatic narratives of suffering and despair, these need to be juxtaposed with narratives of "hope, courage, and togetherness" (see Siyabakhumbula story). The power of Siyabakhumbula lies not only in the fact that people are given the opportunity to tell and share their stories of suffering, but also that they are helped to tell and re-discover stories within the story, of coping, resilience, hope and courage. The Siyabakhumbula story effectively draws out of people two intertwined threads- the thread of suffering and despair and the thread of resilience and coping. Clay is a particularly powerful tool in this regard. It does not evoke the anxieties associated for a lot of illiterate or semi-literate people, associated with paper and pencil or even paint and canvas. Instead it is deeply associated with early childhood play and often evokes very early childhood memories of positive experiences. In sharing the images evoked by the sculptures which arise from working with eyes closed and the non-dominant hand, people often are put in touch with experiences they had long forgotten, and which they can they weave into their narrative.
M:
I remember my husband with this basket I made. When he comes from Johannesburg the basket is full, the children are smiling. Now it is just a hole. But I am still alive, still strong. There are people showing me the way. Things are improving.
Another way of exploring sources of resilience lies in activities structured to help people think about their support system. Through the bead activity members often discover that there are people in their lives on whom they could rely for support, or whom they could approach for support. This is often followed by a more active engagement with the immediate environment.
The healer is wounded too
None of the counselors and therapists at Ekupholeni have been left untouched by traumatic grief. In fact, it is the experience of our own loss and grief, consciously acknowledged, that continuously contributes to the vitality and creativity that make this programme so special to us. All of us have lost family members, colleagues and close friends, and almost all of us are caring for orphaned children within our families. We therefore do not deny our own grief during sessions and retreats, and do not hesitate to share it within the larger group experience. This also gives group members to the opportunity to support us, which can be a powerful healing experience for them. However, to ensure that the group process remains focused on the group every session or retreat is facilitated by at least three experienced counselors. Team members who have been recently bereaved at times may choose to attend a retreat as a "client". They then relinquish their role of counselor for the period of the retreat. This may be very controversial in terms of conventional psychotherapeutic practice, but in our experience it has been very growth enhancing for both the "healer" and the" client". The boundaries between "us" and "them" are broken down, perhaps more congruently reflecting the current South African reality: We are all affected by our violence of our past and present. We are all affected by HIV/AIDS.
... Some group members later told us that it had been a life changing experience for them- to be able to support someone they had always considered as different- a healer, but not of them. We had become one, the boundaries erected by history and society, torn down in the shared experience of grief. Five years later, group members still light a candle for J's sister in the monthly candle lighting ritual.
CONCLUSION
Finally, it is clear that in the face of overwhelming trauma and loss, psychology can never be enough. Grief goes beyond what can be accessed through conventional approaches to psychotherapy, reaches into the world of the spirit, draws on deep and age-old interpretations of the meaning of suffering, life after death, life with death. To help people experience and process profound grief we need to have the courage to go with them on a spiritual journey. It is a journey on which the client takes the counselor, those who suffer take those who have made it their mission to heal. It is a journey into worlds that may be strange to us, alien at times, but often also very safe and comforting, as we discover the elements of a universal spirituality that transcends the boundaries of religion and dogma.
Perhaps most important of all is the recognition that people living in situations of continuous traumatic stress require continuous and multi-layered opportunities for healing.
7. links to useful resources
The importance of gaining information and catching up with the increasingly developing field of traumatic stress could not be over emphasized. Studies show that there are about four articles published daily in the field of traumatic stress.
The trauma field is one of the fastest growing fields in psychology and there is constant updated information on what interventions work and which ones do not. Interventions that were seen as effective and popular a decade ago are now challenged and shown to not be helpful.
Getting and updating information is therefore crucial for delivery of quality services in this country.
Outlined below are the most useful websites in the field of trauma. Practitioners and students in the field are encouraged to forward us information on any book, articles or website that they have come across which they think will be valuable for trauma practitioners.
WEBSITES
http://www.istss.org/This website belongs to the international society for traumatic stress. It has useful update information on trauma including information on the conferences held annually that discuss cutting edge issues in the field of trauma. In here you can also get links to other useful trauma sites
A must for getting practical updated information on interventions ranging from groups such as ex-combatants, children and general trauma. It also provides definition on different trauma terms. The website belongs to The National Centre for PTSD.
David Baldwins trauma Information pages If you are looking for the papers that have been published in the field of trauma, this is the website to go to.