Counsellors' Appraisals of the Wits Trauma Counselling Model: Strengths and limitations.

Counsellors' Appraisals of the Wits Trauma Counselling Model: Strengths and limitations.

Hajiyiannis, H. & Robertson, M. (1999). Counsellors' Appraisals of the Wits Trauma Counselling Model: Strengths and limitations. Paper presented at the Traumatic Stress in South Africa Conference hosted by the Centre for the Study of Violence and Reconciliation in Association with the African Society for Traumatic Stress Studies, Johannesburg, South Africa, 27-29 January 1999.

 

Helen Hajiyiannis & Mary Robertson

Paper presented at the Traumatic stress in South Africa – Working towards solutions conference, Johannesburg, South Africa, 27-29 January 1999.

Helen Hajiyiannis is a former Researcher in the Trauma Clinic at the Centre for the Study of Violence and Reconciliation.

Mary Robertson is a former Manager of the Trauma Clinic at the Centre for the Study of Violence and Reconciliation.

This paper presents counsellors' appraisals of the Wits Trauma Counselling Model which is used for the treatment of psychological trauma. The study was conducted with counsellors working at the Trauma Clinic of the Centre for the Study of Violence and Reconciliation. Based in Johannesburg, the Trauma Clinic offers a range of services to victims of violence and trauma. The clinic was established in 1992 in response to an increasing awareness of the need for such a service in Gauteng.

Individual and group counselling, as well as debriefing interventions are among the services offered by the clinic. Counselling is offered to individuals who have experienced criminal, sexual, political or domestic violence, as well as other traumas, such as motor vehicle accidents, natural disasters and traumatic bereavement. Other interventions offered by the clinic include training in trauma management, counselling and support, psychiatric assessment and referral, advocacy, lobbying and research.

These services are provided by a multidisciplinary team of clinical psychologists, social workers, a psychiatric nurse specialist, interpreter and research psychologist. Volunteer counsellors who are trained and supervised by staff at the clinic, as well as sessional clinical workers assist with counselling and debriefing. There is regular supervision and consultation with staff from the Psychology Department of the University of Witwatersrand.

Since the formal process of political transition and democracy, there has been a transmutation of political violence into random criminal violence. As a result, the clinic's client base has changed over the years from initially dealing primarily with survivors of political violence to the present situation, where the majority of clients seen are victims of violent crime. See figure one (next page) for prevalence and types of traumatic incidents referred to the clinic during the period January to June 1998. During this time a total of 679 clients were referred to the clinic.

Figure One
Type of TraumaIncidence 
Armed robbery
Workplace
Home
Public
Total number:
Work place
Home
Public
252
185
43
24
Car hijacking
Resulted in injury
Resulted in death
Total number:
Injury
Death
144
13
1
Traumatic bereavement
Homicide
Suicide
Natural causes
Motor vehicle accident
Total number:
Homicide
Suicide
Natural causes
Motor vehicle accident
109
70
23
11
29
Child sexual abuseTotal number:50
Motor vehicle accidentsTotal number:34
Rape
Individual rape
Gang rape
Total number:
Individual
Gang
24
19
5
Assault with Grievous bodily harmTotal number:20
Domestic violenceTotal number:14
Political ViolenceTotal number:14
Other (kidnapping, vicarious trauma etc)Total number:18

Review of the Literature

A vast literature exists documenting the psychological sequelae of traumatic events and the treatment of post traumatic stress. The destabilisation and reconstruction of meaning structures is identified as one of the key factors which influences an individual's response to trauma (Janoff-Bulman, 1992). Janoff-Bulman and Frieze (1983) argue that victimisation results in the shattering of three basic assumptions about the self and the world. These are the assumption of personal invulnerability, the perception of the world as meaningful and orderly and the perception of the self as positive. Clinicians dealing with trauma survivors advocate that recovery must include working through the meaning that the individual has attached to the traumatic event/s (Herman, 1992; Roth & Lebowitz, 1988). Factors which impact on the way an individual makes sense of an event include his/her life history, personality, social support and the nature of the traumatic event itself. In addition, Lebowitz and Roth (1994) highlight the critically important role of the broader sociocultural context in which the individual lives and is traumatised. Herman (1992) also emphasises the need to locate an understanding of trauma within a sociopolitical context. These factors are of particular relevance to counsellors working in the South African context, where there has been a legacy of political violence and social conflict (Straker & The Sanctuaries Team, 1987; Straker & Moosa, 1994).

In a review of treatment literature, Sherman (1998) found that individual psychotherapy is the most common approach taken to the treatment of post traumatic stress disorder. Prout and Schwarz (1991) argue the benefits of using a short term integrated therapeutic approach. They identify five strategies common to a range of different treatment modalities: supporting adaptive coping skills; normalising the abnormal; decreasing avoidance; altering attributions of meaning and facilitating integration of the self.

Eagle (1998) advocates an integrative approach combining psychodynamic principles with cognitive-behavioural interventions in the treatment of psychological trauma. The cognitive approach aims at facilitating the development of coping skills and in assisting the individual to identify and correct cognitive distortions and attributions of meaning (Sherman, 1998). The goal of psychodynamic interventions is to facilitate the integration of the trauma and to prevent the use of repression as a defense. The influence of dispositional variables on the individual's response to the trauma and therapy is acknowledged and insight into the conscious and unconscious meaning of the symptoms is encouraged (Sherman, 1998; Eagle, 1998).

A dearth of empirical research evaluating the efficacy of proposed treatment strategies characterises the literature in this area (Brom, Kleber, & Defares, 1989; Sherman, 1998).

The Wits Trauma Counselling Model

The Wits Trauma Model is a brief term integrative psychotherapy intervention used for the treatment of psychological trauma. The model has been conceptualised within the integrative psychotherapy paradigm, and Eagle (1998) describes the benefits implicit to an integrative approach. The model was developed by staff of the Psychology department at the University of Witwatersrand. The model was formulated using case material from hundreds of clients presenting with various forms of post traumatic stress. Methodologically, therefore, the model was developed out of an empirical multiple case study approach derived within the South African context. The model integrates psychodynamic and cognitive-behavioural approaches for the treatment of psychological trauma. From this perspective, it provides an explanation of how psychodynamic and cognitive-behavioural processes interact to influence the development, maintenance and/or prevention of post traumatic stress symptoms. The epistemological philosophy underpinning the model is perhaps its greatest strength. That is, an explicit recognition that trauma impacts on both internal and external psychological functioning, and thus requires a treatment approach which addresses both internal, psychodynamic processes, as well as intervention which is structured and problem-oriented.

The Wits model utilised at the Trauma Clinic is ideally suited to the South African context where the enormous demand for such services necessitates a time limited and cost effective approach. The model is applied in cases of acute stress and post traumatic stress disorder. It is not considered appropriate for use in cases of complex post traumatic stress (Herman, 1992), nor in cases of continuous traumatic stress (Straker & The Sanctuaries Team, 1987; Straker & Moosa, 1994), where a longer term psychotherapeutic intervention is required. The model is short term in nature, ranging from two to fifteen sessions. In our experience, improvement is noted after four to six sessions in the majority of cases.

Outline of the model

The model consists of five components which can be introduced interchangeably depending on the needs of the client. The authors acknowledge the use of Eagle's (1998) description of these components.

1. Telling/retelling the story

This involves the client giving a detailed description of the traumatic incident in sequence, including facts, feelings, thoughts, sensations, as well as imagined or fantasised aspects. This allows the client to give expression to the often unexpressed feelings and fantasies connected with the trauma which are often adaptively inhibited during life-threatening situations. Within the safety of the therapeutic context, this expression is usually made possible. In telling the story, a useful question to ask the client is, "what was the worst moment for you?" This provides both the client and counsellor with more information about what was the most difficult part of the experience and often points to what needs further exploration. The benefits of telling and retelling the story are many: the sharing of feelings and fantasies prevents their repression and displacement into other symptoms; in telling the story the client is able to impose a time sequence onto the event, and thus transform what are often sensory and episodic memories to the realm of processed thought and symbolism; in psychologically accompanying the client through the traumatic event, the therapist is able to demonstrate the ability to tolerate horrific or overwhelming aspects of the trauma, thus serving as a positive model to clients when the memory is evoked in the future; the detailed telling of the story encourages confronting rather than avoiding aversive stimuli and this serves to reduce anticipated anxiety associated with the stimulus.

2. Normalising the symptoms

This comprises obtaining information about symptoms as well as anticipation of symptoms. The client's symptoms are discussed and empathised with, while at the same time providing education about post traumatic stress symptoms. Therapists make links between the traumatic event and symptoms experienced, as well as reassure clients of the normality of their experience. That is, that their symptoms/reactions are normal responses to abnormal events and that they will diminish in time. Reassuring clients that their responses are normal reactions to an abnormal event, as well as educating clients about what symptoms to expect, serves to both reduce the fear that they are going crazy, as well as to reduce the chances of a client suffering secondary traumatisation because of the fear of their reactions/symptoms.

3. Addressing survivor guilt or self-blame

In this phase, feelings of self blame or survivor guilt need to be explored. In many cases survivor guilt may not be present but in practically every case, there are feelings of self-blame. Self-blame may represent a wish to retrospectively "undo" the trauma and restore a sense of control. Self-blame may also relate to the belief that the person could have done more to prevent what happened. Survivor guilt may emerge when someone has died in a traumatic incident. Where clients present with guilt feelings or self-blame in the counselling situation, it is imperative that the counsellor take the client through the events very carefully, while at the same time exploring alternative scenarios and how useful these would have been. During this process, clients usually discover that their guilt is irrational and that under the circumstances they did the best that they could. In cases where a client's actions did cause the situation, the counsellor needs to help the client separate outcome from intent/motive. Addressing survivor guilt or self-blame serves various functions: it reassures the client that he/she did the best he/she could under the circumstances; it helps restore self-esteem through affirming any thoughts, behaviours or strategies that were effective in the situation; it reinforces the fact that the client's actions facilitated his/her survival; it addresses concerns clients may have about how their actions affected others; it explores irrational beliefs that may have developed.

4. Encouraging mastery

In this phase of the model the counsellor assists the client to carry on with the tasks of daily living and to restore the client to previous levels of coping. One of the most important aspects of coping is adequate support, therefore the counsellor encourages building and mobilising existing support. Where necessary, clients are provided with various techniques to assist with coping. These include relaxation and stress/anxiety management skills, cognitive techniques such as thought stopping, distraction and time structuring, as well as systematic desensitisation. In restoring the coping capacity of the client, anxiety is greatly reduced.

5. Facilitating creation of meaning

The final stage of the model is optional and only pursued if the client raises meaning issues. In assisting a client with establishing meaning out of a particular event, it requires the counsellor to engage with the client's belief system, be this on a cultural, political, spiritual or existential level. Work in this area is designed to be respectful of the client's existing beliefs and experience, while at the same time assisting the client in deriving some meaning from the event in a way which engenders hope and some future perspective. In essence, this phase of the intervention model can be understood as enhancing the client's ability to understand him/herself as a survivor rather than a victim.

The reader is referred to Eagle (1998) for a detailed theoretical exposition of the integrative nature of the model and its components.

Hundreds of clients have been counselled at the Trauma Clinic using the Wits Trauma model. Subjective reports from counsellors and clients demonstrate the model's efficacy in alleviating symptomatology in most clients treated using this counselling model. However, the model has not been subjected to evaluative experimental research. In this study, the researchers begin to look at some of the strengths and limitations of the model.

Methodology

The aim of this study was to examine counsellors' experiences of the model based on their daily use of it. This research was of a qualitative nature and was exploratory rather than experimental.

Subjects

Twelve trauma counsellors participated in this study, nine clinical psychologists, a psychiatric nurse specialist and two volunteer counsellors. All participants were female. Counsellors engage with trauma work on a daily basis and their levels of experience in using the model range from a minimum of one to ten years.

Data collection

Semi-structured interviews were conducted with each participant regarding their use of the model in working with adult trauma survivors who presented at the clinic. Participants were asked questions pertaining to their perceptions of the usefulness of the model, its cross cultural applicability, its strengths, shortcomings and recommendations for improvement or modification. On average, each interview lasted for approximately forty five minutes and one of the authors acted as a scribe while the other conducted the interview.

Data analysis

The interview material was reviewed and common themes were identified pertaining to the model's strengths, limitations and recommendations.

Results

Strengths

In general, all the counsellors interviewed had positive experiences using the model in cases of uncomplicated trauma and with functional clients who have been temporarily disorganised as a result of their traumatic experience. Even in cases of historical, complex or multiple traumas, counsellors found the model applicable when used within a longer term psychotherapeutic approach. Counsellors expressed confidence in the model based on their experiences with it. As summed up by one counsellor, "the success of the model lies in the fact that I have seen it work, I believe it works, and so I feel equipped and confident when going into a session". Counsellors have seen a reduction in post traumatic stress symptoms and improved coping in clients who have been treated using this approach.

The model is experienced as useful with diverse types of trauma and with clients from different cultural and socioeconomic backgrounds. The model has also been found to be effective with men and women of different age groups. Clients do not have to be psychologically minded or sophisticated to benefit from this approach. Although clients from different backgrounds and types of trauma go through the same structured approach, counsellors reported that clients respond to particular parts of the model according to their particular needs. For example, for clients who come from a culture where talking is not encouraged, the telling of the story is the most important part of the counselling. In those clients who have high levels of guilt, the restoration of self esteem and self respect is given more emphasis. Due to the interchangeability of the counselling stages, the client can start at the point which is most comfortable for him/her. The model's ability to meet the unique individual needs of clients is thus considered a strength.

One important factor identified as contributing to the success of the model lies in its clear structure which is comprehensive enough to address most of the needs and concerns of trauma survivors. Counsellors experience the model as one which is focused and practical in its approach. This is particularly helpful in reducing anxiety in novice counsellors. The structured nature of the model enables both qualified mental health professionals, as well as volunteer counsellors and students to apply it. Another strength of the model lies in the fact that counsellors from different theoretical orientations have all found that it can be integrated into their therapeutic styles. The flexibility of the model means that other techniques such as Eye Movement Desensitisation and Reprocessing can successfully be incorporated.

The importance of a good therapeutic relationship was highlighted by all the counsellors. Counsellors also emphasised that the model is only a framework, the implementation of which is dependant upon a solid foundation in counselling skills.

Limitations

A number of limitations in the use of the model were identified by counsellors.

The model is based on the assumption that clients have sufficient ego strength. Problems have been encountered when working with clients who are still reliving events, are highly anxious and who display regressive features. This approach is not applicable to psychotic clients and complicated in those with personality disorders and psychiatric conditions. In addition, the model assumes a level of verbal ability and thus needs to be adapted for use in clients with limited verbal skills.

Research suggests that counselling trauma survivors evokes strong transference and countertransference reactions (Cerney, 1995; Herman, 1992; McCann & Pearlman, 1990; Straker & Moosa, 1994; Wilson & Lindy, 1994). The nature of trauma is such that intense emotions are aroused soon after the counselling process has been initiated. Clients often develop positive (or negative) introjects and dependency on the counsellor. The short term nature of the model precludes the possibility of adequately addressing these aspects of the therapeutic process, which can impact on both the counsellor and the client.

A major shortcoming of the model's application has been identified in relation to counselling the elderly. All counsellors experienced difficulties when working with this age group. Problems encountered in the elderly included rigid thought patterns and coping skills, clinical depression, cognitive and memory impairment, physical injuries, inadequate support networks and practical difficulties. A prominent feature of trauma in this age group, is the experience of profound despair and hopelessness which counsellors have found resistant to treatment. These problems are not viewed as a fault of the model but rather due to the ageing process. In view of the increasing number of referrals of the elderly to the clinic, counsellors identified the need to adapt the model to adequately address the needs of this client group.

Some counsellors suggested that work with certain adolescents also requires adapting the model to facilitate completion of developmental tasks associated with this stage, with particular reference to identity formation and sexuality.

Participants expressed concern regarding the model's effectiveness in cases of traumatic bereavement. Due to the fact that traumatic bereavement is one of the most common reasons for referral, the failure to integrate principals of bereavement counselling into the trauma model, is viewed as a serious gap.

The model is not perceived to adequately address the resolution of anger in traumatised clients. In many cases, counsellors were of the opinion that clients had resorted to maladaptive ways of dealing with their anger.

The Wits Model has been found to be applicable across cultures. However, participants experienced the model to be less effective in some older black men where traditional belief systems are still very strong. Traditional beliefs about causality make working with blame and guilt, as well as facilitating the creation of meaning, problematic. This can result in a disjunction between the counsellor and the client's belief systems. Counsellors may feel a tension in discerning how directive one can be without imposing their own cultural values and belief systems onto the client. This is particularly difficult when counsellors believe that certain traditional practices are counterproductive to the healing process, for example in cases where clients are clearly being financially exploited. Working through some of these issues is often more complicated for black counsellors where clients incorrectly assume that they share a common assumptive world and belief system with the counsellor. Of significance is the fact that many of the above clients who presented at the clinic had already consulted traditional healers and only initiated counselling when traditional methods had failed to alleviate their symptomatology. This also appears to be more common in cases involving traumatic bereavement.

The model has been found to be somewhat deficient when dealing with clients who present with physical injuries and somatic complaints. This model of treatment neglects the soma and does not sufficiently integrate techniques which address the somatic level and physical experience of trauma, apart from strategies aimed at reducing anxiety.

The greatest weakness identified, relates to the fifth component of the model, the facilitation of meaning. In certain clients, meaning can only be derived from a thorough review of their life history. The short term nature of the model impedes such an understanding. Counsellors are often faced with the dilemma of whether to be directive in introducing this phase without the client initiating it. In the current context of increasing incidents of criminal victimisation which are often of an extremely violent and random nature, clients are finding it more and more difficult to make sense of their experiences. This is in sharp contrast to the apartheid era during which time clients were more able to understand their experiences in terms of the political struggle and conflict.

Most counsellors were concerned about the fact that clients often construct meaning in negative ways which potentially contributes to increased levels of racial prejudice, intolerance, anger, hostility, fearfulness and violence. These attitudes are frequently reinforced by the manner in which the media reports violence.

A final limitation of the model is its focus on the individual. Although support systems are explored within the mastery phase, counsellors felt that this needs to be more systemic in its approach and should ideally always be offered in conjunction with joint family counselling, particularly when dealing with rape survivors.

Discussion and Recommendations

The Wits Trauma Counselling Model is a short term, structured psychotherapy intervention which counsellors have found useful in dealing with clients from varied socioeconomic backgrounds, cultures and age groups across a range of (uncomplicated) traumas. The model's integrative approach is identified as a major strength as it addresses both the internal and external world of the trauma survivor. Even in cases of complex and multiple trauma, aspects of the model have been found useful when integrated with other treatment strategies. In addition, the model is not limited by counsellors' theoretical training and is successfully used by both volunteer and professional counsellors. These strengths make this model particularly relevant for use in the South African context, where high levels of violence and trauma necessitate using a short term, flexible approach which is applicable cross culturally and which is not the exclusive domain of professionals.

Some reservations regarding the model's applicability were expressed. The model makes implicit assumptions about clients' ego strength and verbal abilities. Counsellors report that clients who display high levels of dissociation, anxiety and regression require a different clinical approach. Clients with psychiatric and personality disorders present with difficulties which are beyond the scope of the model. In these cases, counsellors with a professional training are able to draw on their clinical skills. However, volunteer counsellors are not trained to deal with these cases. More rigorous intake procedures need to be implemented in order to prevent inappropriate case allocation to volunteer counsellors. Although this approach will be more time consuming, clients' needs will be appropriately met and volunteer counsellors will not be burdened with having to counsel clients that they are ill equipped to manage.

The model relies heavily on verbal communication and in cases where clients are not verbally expressive, counsellors need to apply the model using alternative mediums such as music, art, drama and body therapies. It would be useful for some of these techniques to be included in the model to complement cognitive-behavioural and psychodynamic principles in order to make it a truly integrative approach. This type of approach is also recommended when working with clients who have physical injuries and somatic complaints, in order to address the bodily level of their traumatisation.

The model's limitation in dealing with issues of countertransference and transference is not easy to resolve. Cost factors and time limitations dictate that counsellors do not have the opportunity to work on a deeper intrapsychic level. Although counsellors had identified this as a shortcoming in the model, it has not presented as a difficulty which impacts on the perceived success of the counselling. It is, however, recognised that counsellors need to deal with their transference and countertransference reactions in supervision and therapy, in order to minimise the risk of vicarious traumatisation (Figley, 1995; McCann & Pearlman, 1990; Wilson & Lindy, 1994).

The authors propose that Erikson's theory of psychosocial development is a useful framework for conceptualising some of the problems identified in working with the elderly. Erikson conceptualises the developmental process as a series of life stages through which an individual passes. Each of the stages has certain developmental tasks which require resolution. The developmental task of the later years is reviewing one's life and accepting its meaning. The psychosocial crisis of this, the final stage of development, is integrity versus despair. Issues of life and death are of major importance and hope and despair remain central themes.

This theory seems particularly relevant to understanding the elderly's response to trauma, as trauma appears to rupture the normal process of development and exacerbates the psychosocial crisis of this stage. Trauma, which shatters basic assumptions about the self, the world and others, often leads to a breakdown in trust. In terms of Erikson's theory, trust is defined as "the assured reliance on another's integrity" (Knowles, 1986, p. 191). At this stage, the shattering of trust results in despair, rather than in a sense of integrity. A lack or loss of integrity is characterised by a fear of death; despair expresses the feeling that life is short and that there is insufficient time to try alternate roads to integrity (Knowles, 1986).

The situation of traumatised elderly clients is often made worse by the fact that they may be socially isolated and suffering from physical frailties. These difficulties, coupled with the psychological impact of the trauma and resultant despair, may have a detrimental effect on the recovery process. At a time when individuals are psychologically preparing themselves for their own death, there is little incentive or desire to reinvest in building trust, establishing new relationships and new coping mechanisms.

When counselling clients in this age group, counsellors need to integrate a developmental perspective into the way in which they help clients understand their experiences. It may be helpful for clients to understand their experiences not only in terms of trauma but also in relation to developmental tasks that they would be negotiating anyway.

Similarly, counsellors may benefit from integrating a developmental approach to their work with adolescents. Erikson's theory of psychosocial development refers to adolescence as a stage of transition from childhood to adulthood. The psychosocial crisis of this stage is the formation of identity versus role confusion. Counsellors raised the fact that traumatised adolescents frequently present with identity issues.

Almost all counsellors recommended additional training in bereavement counselling as an essential addition to the basic trauma counselling model. It was also suggested that the model include a specific step which focuses on working through anger. In many clients, incorporating anger into the other steps, does not facilitate adequate resolution. This failure can result in maladaptive coping such as displacement of anger, acting out and in some cases, revenge attacks (Hajiyiannis, Alderton, & Robertson, 1998). Given the already high levels of aggression and violence in our society and the culture of violence – where violence has become a socially sanctioned mechanism for resolving conflict and for attaining change – (Simpson, 1991), it is important that anger is dealt with in order to intercept cycles of violence. Counsellors need training in specific anger management skills which can be utilised in the mastery phase.

Counsellors highlighted the need to be sensitive to cultural belief systems and traditional healing rituals. The need to accommodate these practices has been emphasised. However, this can present a challenge when the counsellor perceives certain practices to be destructive to the client's healing. The non-judgemental approach used in counselling can leave counsellors feeling helpless when dealing with these difficulties. Our findings present a challenge to researchers and clinicians to find more effective ways of integrating Western models of intervention with traditional African healing practices. Counsellors also need to be proactive in documenting cases where traditional healing has facilitated recovery, and cases where these practices have been destructive. Such a case law can be used to make policy recommendations regarding tighter laws governing traditional healing practices. This may make a valuable contribution to facilitating the integration of African and Western practices.

The sociopolitical context within which victimisation occurs affects the meaning which the event has for the individual, as well as the process of working through the trauma. In the past, victimisation was often understood in terms of the political context and struggle. With the increasing levels of random criminal violence in which anyone is a potential victim, clients are finding it extremely difficult to derive meaning out of their experiences. Many South Africans had positive expectations of a fair and just society following the transition to democracy. Trauma frequently shatters these hopes and clients grapple with making sense of the traumatic event. It has been suggested that clients need to establish meaning on both a cognitive and emotional level (Roth & Lebowitz, 1988). In the current context, many victims are struggling to find an adequate explanation for their trauma. In the absence of this, they may resort to increased self blame or interpret their experiences in terms of racial prejudice, anger towards the state, negativity and pessimism.

Trauma workers involved in the field of rape counselling, counselling of incest survivors and Vietnam veterans have advocated the importance of contextualising this work in the sociopolitical context (Herman, 1992). Given our political history, the authors recommend that it may be beneficial to incorporate a psycho-educational approach into the model which can facilitate an understanding of the context within which violence occurs. This would need to be done in a respectful and sensitive manner so as not to be overly directive or to impose meaning onto the client. Such an understanding however, may assist the client in deriving meaning structures which move beyond the personal to a broader understanding of the societal context. This may reduce personalisation and self blame in clients, as well as facilitate a cognitive understanding of the processes of transition.

It has been argued that self blame is culturally inculcated in victims, and treatment must therefore include a critical deconstruction and unlearning of these attitudes (Lebowitz & Roth, 1994). Considering the fact that a culture of violence exists in our society, there is a need to incorporate a component which directly challenges myths and attitudes about violence, into the treatment model. Engaging in a debate around the sociopolitical context may assist the counsellor in normalising racist feelings in clients for whom these feelings are ego dystonic.

Conclusion

Counsellors' appraisals of the Wits Trauma Counselling Model have been presented. Overall, there is support for the continued use of the model as an effective psychological intervention for most clients who present with uncomplicated trauma. Recommendations for the improvement of the model are made, with particular reference to working with the elderly, anger management, and the inclusion of a sociopolitical analysis in order to facilitate meaning.

References

Brom, D., Kleber, R. J., & Defares, P.B. (1989). Brief psychotherapy for post traumatic stress disorders. Journal of Consulting and Clinical Psychology. 57(5), 607-612.

Cerney, M.S. (1995). Treating the "heroic treaters". In C.R. Figley (Ed.), Compassion Fatigue: Coping with secondary traumatic stress in those who treat the traumatised (pp. 131-149). New York: Brunner/Mazel.

Eagle, G.T. (1998). An integrative model for brief term intervention in the treatment of psychological trauma. International Journal of Psychotherapy. 3(2), 135-146.

Figley, C.R. (1995). Compassion fatigue as secondary traumatic stress disorder: An overview. In C.R. Figley (Ed.), Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatised (pp. 1-20). New York: Brunner/Mazel.

Hajiyiannis, H., Alderton, C., & Robertson, M. (1998). Through the doors of the CSVR Trauma Clinic: A view of crime. Paper presented at International Conference for Crime Prevention: Strategies to Build Community Safety, Johannesburg, South Africa. 26-30 October 1998.

Herman, J.L. (1992). Trauma and recovery. New York: Basic Books.

Janoff-Bulman, R. (1992). Shattered assumptions: Towards a new psychology of trauma. New York: The Free Press.

Janoff-Bulman, R., & Frieze, I.H. (1983). A theoretical perspective for understanding reactions to victimisation. Journal of Social Issues. 39(2), 1-17.

Knowles, R.T. (1986). Human development and human possibility: Erikson in the light of Heidegger. University Press of America: Lanham.

Lebowitz, L., & Roth, S. (1994). "I felt like a slut": The cultural context and women's responses to being raped. Journal of Traumatic Stress. 7(3), 363-390.

McCann, L., & Pearlman, L.A. (1990). Vicarious traumatisation: A framework for understanding the psychological effects of working with victims. Journal of Traumatic Stress. 3(1), 131-149.

Prout, M.F., & Schwarz, R.A. (1991). Post traumatic stress disorder, a brief integrated approach. International Journal of Short-Term Psychotherapy. 6, 113-124.

Roth, S., & Lebowitz, L. (1988). The experience of sexual trauma. Journal of Traumatic Stress. 1(1), 79-107.

Sherman, J.L. (1998). Effects of psychotherapeutic treatments for PTSD: A meta-analysis of controlled clinical trials. Journal of Traumatic Stress. 11(3), 413-435.

Simpson, G. (1991). Violence and social change: Some effects on the workplace and some possible solutions. Paper presented to The National EAP Committee of the Institute for Personnel Management Conference: The role of the EAP in managing trauma, Johannesburg, South Africa. August 1991.

Straker, G., & The Sanctuaries Team (1987). The single therapeutic interview. Psychology in society. 8, 48-78.

Straker, G., & Moosa, F. (1994). Interacting with trauma survivors in contexts of continuing trauma. Journal of Traumatic Stress. 7(3), 457-465.

Wilson, J.P., & Lindy, J.D. (Eds.). (1994). Countertransference in the treatment of PTSD. New York: Guilford Press.

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