African Journals Online
Southern African Journal of Child and Adolescent Mental Health

Volume 14 No 1 2002
Abstracts

TALKING WITH INFANTS: A BRIDGE TO CROSS-CULTURAL INTERVENTION

Astrid Berg

Infant-led psychotherapies are receiving increasing attention. Talking to the infant directly has proven to be a useful way of engaging the infant as well as the mother, particularly in a cross-cultural setting. The setting of a community clinic is described with attention given to the manner in which the political and economic contexts of the local circumstances affect the clinician. The intensive psychoanalytic psychotherapy given to a 6-month-old infant is recounted in order to illustrate the ability of the baby to use the therapeutic space. This is followed by two brief cases from the clinic which illustrate similar points and which underscore the therapeutic impact that can be made when personhood is conferred on the infant.

ASSESSMENT OF CHILDREN FOR PSYCHO DYNAMICALLY ORIENTED PSYCHOTHERAPY

R. B. H. Anderson,

The ideas presented for consideration are based broadly on Object Relation Theory. According to this theory, development and disturbance are essentially the outcome of the inherited potential helped or hindered by the facilitating environment. Therefore any assessment must comprehensively explore both the child's external as well as internal environment. This combined information helps to give an estimate of the strengths and vulnerabilities in both the child and his / her environment. It is on the balance of these factors that psychotherapy may or may not be recommended.

A PSYCHODYNAMIC UNDERSTANDING OF TRAUMA AND ADOLESCENCE - A CASE STUDY

Jodie L. Mackay

This paper explores the unique ways in which trauma affects adolescents as opposed to children and/or adults. This is an area of research that has not received sufficient attention. The various approaches in defining the concept of trauma are outlined. Developmental challenges and difficulties regarding the period of adolescence are discussed. Emphasis is placed on particular vulnerabilities evoked during adolescence and the importance of looking at a case in its developmental and environmental context. The impact of the environment, which forms the backdrop to the study, is addressed with reference to the South African context. It is observed how trauma and underlying conflicts augment stress already present in adolescence and complicate successful resolution of developmental tasks, such as autonomy in late adolescence.

The research takes the form of a case study of an adolescent female, who experienced a traumatic assault when she was already struggling with the demands of an unplanned pregnancy. The study illustrates the manifestations in late adolescence of the adverse effects of violence-induced trauma as well as the impact of secondary trauma on the family. The adolescent was seen in the context of exploratory family therapy, which was conducted weekly for 8 months. This offered an opportunity to gain insight into the ways she presented symptoms of trauma to other family members. In this respect a psychodynamic approach is shown as a useful way to explore the emotional features after trauma, such as loss, guilt and difficulties with trust, intimacy and safety. This approach highlights the subjective experience of unexpected violence-induced trauma that overwhelms the ego and produces a state of helplessness. Psychodynamic phenomena, such as regression, defenses and the inner world of the adolescent are discussed in relation to trauma and provides the context in which the meaning of trauma can be understood.

Freedom and Authority: a conceptual focus in work with violent adolescents

Barrie M Biven

In all societies there is a cohort of young people whose anti-social behaviour places them at the interface between mental health considerations and the criminal justice system. This paper describes some of the psychological and biological factors that predispose these adolescents to becoming offenders. In Britain, these youngsters are admitted to Secure Units and psychotherapy forms part of an attempt at resocialising inmates. The author presents a case example and makes recommendations regarding how psycho-analytically informed work with offenders could be adapted in order to respond to the particular demands encountered in therapeutic endeavours.

Brief-term Group Psychotherapy with Late Adolescents

Birgit Schreiber

Using the White Paper for Higher Education as released by the National Department of Education (1997) as a reference point, this paper explores the implications for psychologists working with late adolescents at a university counselling service. The author argues that students are in a developmental phase which is particularly receptive to group interventions and uses developmental theory and psychodynamic principles to support the suggestion that brief-term group psychotherapy is an appropriate intervention for late adolescents.

CONFERENCE ABSTRACTS

Abstracts from the First Annual Forum of the
Centre for the Study of Violence and Mental Health,
University of Cape Town

VIOLENCE IN CHILDREN'S WORLDS
PATHWAYS TO VIOLENCE: A SOUTH AFRICAN RESEARCH AGENDA

A Dawes

The purpose of this contribution is to provide a basis for discussion about the development of a South African violence prevention research agenda. The paper will commence with a brief overview of some of the main theoretical models and findings that guide contemporary research on the development of violent behaviour. Significant developments in the field of violence prevention research will then be highlighted. It will be argued that ecologically informed transactional models of development hold the most promise for research and practice in this area. The final section of the paper will pose some challenges for South African violence prevention research.

DOMESTIC VIOLENCE AND LEGAL REFORM: TEETHING TROUBLES OR SYSTEMS FAILURE

L Artz

Since 1999 the South African government has attempted to address the interests of children in abusive domestic situations through legislative measures. The first measure, the Domestic Violence Act (116 of 1999), was put into effect to improve the accessibility and levels of protection afforded to victims of domestic violence by introducing protection orders. The Act not only contains a comprehensive definition of what constitutes domestic violence, but also ensures that a wide range of domestic relationships is covered by the Act. The second major initiative to deal with child victims of abuse is the recently released discussion paper by the Law Commission that reviews the current Child Care Act. The Commission's vision of this new children's statute is based on two fundamental principles, namely, enabling a child's growth and development within a family environment and protecting children in vulnerable situations. Both legislative reforms are commendable in terms of their substantive content, but leave much to be desired in terms of the capacity of the criminal justice and social welfare systems to implement them. This paper sets out some findings from the Domestic Violence Act monitoring research conducted by the Gender, Law and Development Project over the past two years. It briefly describes the methodological tools and indicators used to monitor the implementation of the Act and will highlight the findings relevant to child victims of domestic violence. It is argued that the current approach by the judiciary is to treat the child victim as an addendum to protection granted by the protection order. Police and judicial interpretation of the Act as well as “exposure” to violence are the two primary interests of this discussion. Finally, considerations for law and mental health research in terms of the forthcoming Child Care Act are discussed.

SAFE SCHOOLS PROGRAMME

G Ziegler

The legacy of Apartheid has permeated all levels of South African society and continues to contaminate and pervert social organizations, the quality of life and the values of many South Africans. The resulting political, socio-economic and educational inequalities have exposed South African children to a multitude of forms of violence.

The Safe Schools programme was established in 1997 in response to a shooting incident at a high school that resulted in the death of a learner. Subsequently, a further twenty learner deaths have been reported. The aim of the Safe Schools programme is to eradicate the root causes of crime and violence by transforming schools into centres of excellence with strong community links, and by enhancing quality learning and teaching with effective governance and management.

The basic strategy underpinning the Safe Schools model is that the intervention needs to be owned by the community and the school. By building positive partnerships and strengthening community participation, the problems of violence and crime will eventually be reduced. The practical application of the Safe Schools strategy is evidenced in the environmental, behavioural and systemic programmes:

Environmental programmes consist of providing infrastructural support to the learning institutions of the Western Cape Education Department. For example, because schools are often vandalized, the programme provides alarms, mesh wire, fencing and panic buttons to the school authorities.

Behavioural programmes such as training in behaviour modification strategies are used to engage with the learners to address truancy, gangsterism, bullying and abuse. Peer mediation, conflict management and self-defence are some of the intervention programmes that are used.

Systemic programmes are aimed at transforming schools at risk. For example, the Whole School Development Programme is the basis for effecting systemic changes such as governance, organizational development, capacity building and classroom management.

The effects of violence on children include feelings of personal vulnerability, loss of control, guilt and remorse, grief, anger, denial, and fears that the traumatic event will be repeated. To address these negative effects, the Safe Schools programme makes provision for Safety Committees at schools. These committees consist of representatives from the community, NGOs, religious and sports bodies, the South African Police Services, business, parents, educators and local government. A representative is elected to be a part of and to serve on a geographically formed cluster committee. The Safety Committees develop safety plans focusing on prevention, intervention and response strategies. The clusters collectively identify projects that address the social, economic and political imbalances in the community. Through these innovative programmes learners are enabled, and parents and educators are encouraged to take ownership of and responsibility for their lives. This in turn facilitates the development of more effective coping styles to deal with daily challenges.

VIOLENCE IN CHILDREN'S WORLDS

A Jackson

The issue of violence in children's worlds can be understood from a structural perspective. Several examples of the way in which violence is perpetuated by structural means are discussed. This is followed by a brief description of some of the programmes that have been launched or are being planned by Cape Town Child Welfare in order to address these problems.

Children have no voice in that they do not have the right to vote or have access to large amounts of money, yet there are few structures which provide ongoing representation for them

Corporal punishment has been abolished, but little has been done to help adults to discipline children in the context of sound relationships

South Africa has one of the highest infant mortality rates in the world, but little is done to equip young mothers with the necessary knowledge and support to avert this tragedy

An estimated three million children are raised in dire poverty resulting in social disintegration, crime and unemployment, yet these children are expected to be concerned about those around them

The South African constitution promises a utopia for children, however, there are insufficient human and material resources to render these principles workable

Politicians launch campaigns designed for short term media coverage, but spend little time designing and maintaining sustainable programmes

An AIDS pandemic has been unleashed on children, yet not enough has been done to minimize the physical and emotional effects of the disease

Many ex-Apartheid activists have either been co-opted into new state structures or are too nervous to speak out against these systematic abuses

Cape Town Child Welfare and its affiliates do not have the answers for all these problems. However, a number of projects have been developed that do contribute towards dealing with these difficult issues. These interventions include:

An holistic street-children programme that provides accommodation, nutrition and care for homeless children, encourages family re-unification and provides life- and job-skills training

A home-visiting programme for mothers of infants at risk in which community development workers are trained to provide support services and model good infant care

A parenting training programme that teaches caregivers about relationship building and positive disciplining

Building community capacity to care for children infected and affected by HIV/AIDS by training community volunteers in Guguletu to support and keep families together for as long as possible

• Building community capacity to tackle child abuse and neglect in the form of the Isolabantwana (eye on the children) programme which trains community volunteers to detect and investigate child abuse and take whatever action is appropriate to protect the child.

PROPOSED PROGRAMME FOR SECONDARY AND TERTIARY PREVENTION OF SERIOUS VIOLENT CRIME BY 14 TO 18 YEAR OLDS

B Robertson

A recent study of 14 to18 year old awaiting trial and sentenced youth found that the following six factors were associated with serious violent crime: gang involvement, emotional connectedness to adults and peers, cognitive impairment, emotional and behavioural competence, mental health disorders and substance abuse. A situational analysis of service provision for violence and crime in the Western Cape revealed that the assessment and management of juvenile offenders was limited, and was not addressing the complexity and intensity of the risk factors involved. The presentation will propose a comprehensive screening process and intervention programme aimed at improving the psychosocial adjustment of young offenders, keeping youth out of the criminal justice system, reducing recidivism, and interrupting the cycle of violence and crime. The intervention could be applied at the level of secondary prevention, e.g. to high risk youth identified at school or in the community, and at the level of tertiary prevention, e.g. to youth at the point of entering the criminal justice system.

THE SAYStOP DIVERSION PROGRAMME: A FIRST LINE OF INTERVENTION FOR YOUNG SEX OFFENDERS IN SOUTH AFRICA

C Wood

SAYStOP (South African Young Sex Offenders Project) was formed for the purpose of developing innovative and effective interventions to treat and manage young sex offenders. As a first line of intervention, SAYStOP initially focused on developing a diversion programme that could be used at the point where the sexual offending behaviour first to came to the attention of the courts with the aim of preventing recidivism. The programme was designed to be relevant and appropriate for the South African context. In this regard, it needed to take into account context specific variables such as poverty, rural/urban disparity, cultural differences, language barriers and varying levels of literacy. A brief description of the process involved in the development and implementation of the SAYStOP diversion programme is provided. The content and structure of the programme is outlined. After a four year period, SAYStOP has completed the development of a basic diversion programme; trained approximately 90 facilitators in the Western Cape and Eastern Cape; developed an implementation strategy that appears to encourage sustainability and self-sufficiency and remained committed to on-going research and evaluation of the project. During this period, however, the project has also encountered numerous challenges. These difficulties are briefly described for the purpose of encouraging discussion around future programme development, managerial issues and policy direction.

NICRO'S APPROACH TO YOUNG VIOLENT OFFENDERS

F Brey

NICRO has been actively involved in providing diversion programmes for young people in conflict with the law since the early 1990s. At present, only offenders who are regarded as being “low risk” are diverted from the formal criminal justice system. As such, the selection criteria for a candidate to be diverted is that the young person admits guilt; he has a contactable address; and the offence is of a less serious nature (e.g. shoplifting, petty theft). However, experience indicates that although the majority of young people are arrested for less serious offences, a large percentage of these children have in fact committed violent offences such as rape, assault and murder, but were never arrested.

For many in the criminal justice field, it appears that an offender is regarded as being “low risk” if he has committed a less serious offence. Thus more emphasis is placed on the type of offence committed rather than the risk profile of the client It is estimated that 55 000 young offenders will be diverted annually. NICRO will be diverting approximately 24 000 offenders in the next financial year and the numbers increase annually. The Child Justice Bill necessitates that organizations such as NICRO provide services that are appropriate to the needs of the violent young offenders. It would therefore be useful to assess how many of these young people have committed violent offences so that we are able to design our interventions appropriately.

During 2001 a national training programme was conducted with the NICRO workers to highlight the gaps in our programmes and interventions. Consequently, the following needs were identified as key elements to be incorporated into our programmes:

To develop an holistic assessment and diagnostic tool to be implemented by all NICRO workers and probation officers

To build partnerships with other professionals in order to work as a multi-disciplinary team, for example, criminologists, psychologists, homeopaths, and educators

To replace generic programmes with those designed around the needs of the clients

To design prevention programmes for children younger than 10 years of age

To clarify NICRO's role in working with offenders who have also been victims of physical and emotional abuse.

Proposed areas for collaboration between NICRO and the Centre for the Study of Violence and Mental Health are:

To assist in the streamlining of programmes to suit the needs of the clients. This will include dealing with unresolved trauma, learning difficulties, impulse control, anger management, and ADHD. Research on the underlying causes of violent behaviour will have to be conducted to inform programme development and implementation

To evaluate NICRO's current interventions, for example, the wilderness therapy programmes for “high risk” youth, and to make recommendations for improvement

To assist in the design of a crime prevention programme for children below the age of 10 years old for possible implementation in the schools or pre-schools.

CHILDREN IN CONFLICT WITH THE LAW

N Nilsson

The issue of children in conflict with the law is complex and controversial. The first part of this discussion will provide a brief description of the current procedures relating to the arrest and detention of child offenders as outlined in the Criminal Procedure Act, the Correctional Service Act and the Constitution. The second part of this presentation relates to some of the practical issues faced by the South African Police Services in their attempts to deal with young offenders. Experience indicates that most children in conflict with the law have psychological problems that are not adequately addressed by the present criminal justice system. There are several issues that require the careful consideration of those involved with juvenile justice and mental health:

Children who have been traumatised should be debriefed to prevent the development of further behavioural problems

The psychological needs of a first time offender must be dealt with as soon as the child enters the criminal justice system

Police officers should receive training that will enable them to deal more effectively with children with behavioural problems

A one-stop youth justice centre that will deal with all aspects of the reception and referral of juvenile offenders in a centralized location is being planned for the Western Cape. There is a need for mental health workers to be represented in such an environment.

CARING FOR CARERS: REFLECTIONS DRAWN FROM A SUPPORT GROUP FOR HEALTH CARE PROFESSIONALS WHO WORK WITH AND CARE FOR PERSONS WITH HIV/AIDS

P Mayers

South Africa is dealing with two major epidemics, violence and HIV/AIDS, both of which have left no field of health care untouched. Health professionals, in particular medical practitioners, already challenged with providing quality care in a context of diminishing resources, limited pharmacological treatments, and lack of social support structures, are finding that their role is changing. Increasingly there are demands on medical practitioners to move beyond the traditional, biomedical role to a far more comprehensive role, for which many health professionals are ill prepared. The need for appropriate support of health professionals working in this field has become apparent, yet this is often viewed as a time-consuming luxury. Over the last year the author has been conducting a support group for a small number of medical practitioners working with HIV/AIDS patients at the community/primary care level. Reflections from this experience are discussed. Initial themes arising from this work include the need to unburden, feelings of loss, helplessness, anger and frustration, particularly with “the system”. Health professionals in South Africa are seldom able to specialize in a narrow area of health care provision, and the issues faced by this group may be useful in identifying the stresses faced by health and welfare workers working with children impacted by a violent society. The need to create appropriate support structures for health professionals will be discussed.

PREVENTION OF SECONDARY TRAUMA IN CARE PROVIDERS

CL Ward

Secondary or vicarious traumatisation is a well-known phenomenon that results from care providers' exposure to the traumatic material experienced first-hand by those for whom they care. The symptoms are similar to those of PTSD, although no diagnostic criteria have been developed to describe it. The essence of vicarious traumatisation is trait-like changes to values, beliefs, and behaviours that result from exposure to another's traumatic material. It has been documented in emergency service personnel, health care providers, those who teach and research trauma issues, jurors, clergy and those preparing exhibits for the United States Holocaust Memorial Museum. A small intervention to support mortuary workers through the use of peer support and opinion leaders showed some promise for remediating the effects of the traumatic stress that they experience. This intervention trained opinion leaders (respected peers) in a broad range of stress management techniques, including those specifically useful for dealing with traumatic stress. Opinion leaders were asked to disseminate this information to co-workers, and to offer support to co-workers who appeared troubled by their work. Results showed that opinion leaders made significant changes. It is possible that similar stress management programmes and peer support systems may be an effective means of protecting other care providers against the negative effects of their work.

WORKING WITH TRAUMA IN THE BURNS UNIT OF THE RED CROSS HOSPITAL: AN INTERVENTION WITH NURSES

L Frenkel

The Burns Unit at Red Cross War Memorial Children's Hospital was established in 1956. Up to this point there has been no assistance from a resident psychologist for the staff or patients in the Unit. This discussion offers some thoughts about the multiple levels of trauma that occur on the ward and how the nurses in particular have attempted to deal with it. The work of Menzies Lyth on nursing in Britain in the 1950s and 1960s provides a useful psychodynamic framework for understanding the psychological impact on the nurses working with children who have sustained burns. The initial stages of an intervention with the nurses in the form of a weekly support group, is described.

TRAINING IN TRAUMA MANAGEMENT AS AN INTERVENTION FOR CAREGIVERS

N Mkontwana

South Africa has one of the highest rates of violence in the world. In recent research undertaken by the South African Institute of Race Relations (1999), it was found that the Western Cape is the only province that showed an increase in serious crime. This places a great demand placed on frontline workers in different sectors to render mental health services to survivors of violence. Dealing with survivors of violent acts such as murder, assault, armed robbery and rape has an exponential emotional impact on the frontline worker/caregiver. This paper suggests that training is but one form of intervention that can help to address this emotional impact.

From a Human Resources perspective, training may be defined as a process of developing the individual's knowledge, skill and attitudes (including feelings) to a desired level of performance in order to reach personal, social and organizational objectives. Through training, organizations and societies invest in their human resources. In the organizational context, training provides opportunities for employees to optimize their performance in pursuit of the organization's goals. This paper demonstrates the Care for Caregivers training module of the Trauma Centre in building the capacity of frontline workers to acknowledge the emotional impact of their work. The essential components of this model draw attention to the following dimensions of training:

Placing violence in context

Recognizing the post-traumatic stress reactions

Recognizing the signs and symptoms of vicarious trauma, stress and burnout

Developing effective mechanisms to deal with these features

The paper concludes with questions reflecting upon the efficacy of such a model, and its implications for further research.