SECTION II Literature Review
53. Descriptions of the protective processes
6.1. Macro/exosystemic components of intervention
6.2.4. PSS through structured group psychotherapy with vulnerable children
research programme will inform some aspects of REPSSI's work.
and receive interpersonal input (ibid.). Thus, group therapy can be a powerful mechanism for growth, healing and change. Using a variety of qualitative techniques, Yalom (1985) identified the effective ingredients of group therapy and applied them in his integrative model of interpersonal therapy. He concluded that there were three main factors that were instrumental in increasing the therapeutic impact of groups: (i) interpersonal input; (ii) catharsis; and (iii) self-understanding (Rosenbaum &
Patterson, 1995):
1. Interpersonal input: Social learning, in the form of interacting and observing, is a key mechanism for socialisation especially in the absence of adult attachment figures (or when the attachment relationships are compromised). Groups provide children with:
• feedback about behaviours that are annoying or pleasing to others. As such, it provides guidance on how to adaptively interact with others and can give insight into those cognitions that are self- defeating or self-enhancing (Rose & Edleson, 1987).
• a safe and accepting space to experiment with new skills and behaviours (Berkovitz, 1987a).
Groups can become places where children can reach out to others for support especially if they have previously felt that others would not be able to understand them or if they are ashamed, embarrassed, lack trust or feel guilty as a result of their negative life experiences.
• the experience of feeling less marginalised and to normalise their experiences (LeCroy & Rose, 1986). In turn this enables them to feel a sense of shared reality, group cohesion, a sense of belonging and universality (Yalom, 1985). It can break down the feelings of isolation and alienation frequently experienced by people who have been stigmatised or have suffered significant emotional crises. Feeling accepted is often a first step towards establishing the relationships that are especially important in developing resilience (Mailman, 2002; MadQrin, 2000).
• enable children to learn appropriate interaction with their peers. In this way, they are likely to be reciprocally reinforced, thereby setting in motion cycles of social interchange with the potential for appropriate socialisation and peer acceptance (Geldhard & Geldhard, 2000).
• opportunities for altruism, whereby children become aware of their own and other's feelings, experience compassion and understanding, paving the way towards proactivity (Yalom, 1985).
This can also instill hope in children whose lives have seemed to be bleak and isolated.
2. Catharsis: The opportunity to identify and express emotions is an important curative element of group therapy (ibid.). Participating in group therapy creates opportunities for emotional expression within a safe and contained space (Wenar, 1994; Winnicott, 1965). When one expresses feelings and
thoughts, the intrapsychic need to defend against extremely powerful emotions is unlocked (Winnicott. 1965) and one feels relieved, understood and accepted. The therapeutic support and encouragement enables the child to become self aware rather than reactive to a hostile environment (Geldhard & Geldhard, 2000). Traditional Black African cultures have mourning and funeral rituals that tend to exclude children in the belief that this would 'protect' them from the grief associated with the loss of loved ones. Seldom is a child given an explanation about what has happened when someone has died (Marcus, 2002). Unfortunately, this denies them the opportunity to clarify what has happened, to express their emotions and to be included as part of the inner circle of people considered to be most directly affected by the death. Group therapy affords them the opportunity to express and process their grief within a containing environment in an atmosphere of support and care.
3. Self-understanding: Groups provide opportunities for restructuring cognitions that may have arisen from other person-to-person interactions (Wenar, 1994). Children are inclined to experience feelings of guilt, confusion, fear, internalised badness, inaccurately applied transductive reasoning, etc. These immature cognitions can be corrected within the group and through social learning.
Through group interactions, people make the reassuring discovery that others share similar feelings and experiences to themselves (Wenar, 1994, p. 496). As self-understanding improves, self esteem increases (Wenar, 1994). They have opportunities to try out new forms of social functioning and increase their range of peer interactions.
Working in the context of a group has the advantage of both limiting the special relationship that frequently develops between a client and individual therapist, while simultaneously facilitating the development of caring relationships between the group participants and the community-volunteers who become apprentice-facilitators. Given the demographic profile of the HIV/AIDS pandemic, many children lack consistent and stable care from primary caregivers. Working in peer groups, deceases the possibility of dependency developing between the children and the therapist as well as increasing the possibility that a lasting and supportive relationship will be forged between the children themselves, and between them and the volunteers, especially the apprentice-facilitators. The cost effectiveness of attending simultaneously to several children's psychosocial needs is often given as an advantage of group therapy. In this instance, it is believed that group intervention embodied within a community development model is the treatment of choice. Co-incidentally the magnitude
of the pandemic, as well as the lack of human and financial resources, render individual interventions inappropriate from an economic perspective.
The Structured Group Therapy Programme (SGTP) used in this research programme is an adaptation of the Humuliza Model from Tanzania - a model declared to be best practice (UNAIDS, 2001). From a theoretical perspective, it is based on an integrative, structured model that is topic-focussed. It is designed for specific sub groups of children, at compatible developmental levels, who have similar characteristics and experiences, and thus are assumed to have similar needs (Geldhard & Geldhard, 2001). The Humuliza Model (MMdSrin, 2000) was adapted by the writer (Killian, 2002) in three ways:
• Supervision: The SGTP was recognised as having the critically important potential to evoke powerful emotions in children who had experienced major adversity. Likewise, the therapists and apprentice facilitators were likely to experience much distress when they listened to the life stories and saw the emotions of the children. Yet, the SGTP had great appeal especially for community workers due to the structured nature of the sessions, its availability on the internet (URL: http://www.repssi.org/programs_frame.htm) and its potential to meet an urgent need to help vulnerable children. The programme was thus adapted to emphasise and enhance the understanding of the various processes and to emphasise the critical role that supervision plays in working with deep emotions in a therapeutic manner. Therefore, supervision and debriefing after each session became critical to both help apprentice facilitators (i) to debrief and (ii) to develop a therapeutic understanding of children. The apprentice facilitator aspect of the programme was intended to build the capacity of key community volunteers to address the psychosocial needs of children using a psychotherapeutic model, but also to demonstrate the impact of a PSS approach in working with children. As far as the children were concerned, it was hoped that this would broaden their exposure to caring adults and give them the experience that external support systems are there for them. Hopefully, this would encourage them to look for and use these support systems. By enhancing the sensitivity of community members and key stakeholders to the psychosocial needs of children affected by H1V/A1DS, as well as the needs of the many vulnerable children living within poverty stricken communities. It was also envisaged that community members and the children would become strong advocates for the needs and rights of children within the partnering communities.
• Indigenous games: When Dr. Madorin wrote the programme, he showed great insight into children's needs to simply have fun and play games. Whilst some of the games that are incorporated into the programme are of cross-cultural applicability, he also adapted games to be non-competitive and of the 'new games' genre. The rationale was to anchor learning from working sessions during the group sessions. It was hoped that by using cultural games, children would become proud of and familiar with traditional and appropriate cultural practices, games, songs, myths and legends. This could enable them to develop a strong sense of group identity, with knowledge about the origins and meaning of cultural practices.
The researcher believed that some indigenous games could be adapted for use within the therapy sessions. Therefore, while conducting community entry and community mobilisation processes she collated descriptions of indigenous games. There were three main sources of this information:
grandmothers, young mothers and creche workers, and community workers from Sinani, KwaZulu Natal Programme for Survivors of Violence. Many of these games involve song. The community members usually led the song and games with great enthusiasm and excitement while children played. They were often only able to recall the details of how to play games when there was a group to collate the rules. The apprentice facilitators played a vital role in leading these games during the programmes.
• Some minor alterations were made largely to make the processes more suitable for isiZulu children, to enrich the psychological meaning of certain activities, and to make better use of time allotments.
The Structured Group Therapy Model [SGTP] (Killian, 2002) has 15 pre-defined sessions covering two broad themes: (i) Looking back into the children's past experiences to deal with emotional turmoil, loss, grief, stigma and discrimination with the aim of them gaining some sense of mastery over their past experiences; and (ii) Looking forward to develop greater resilience by enhancing self esteem, enabling more adaptive coping and enabling them to access appropriate support when they need it (See Appendix E). Although risk and resileicne are in some ways integrally related, it was useful in this programme to divide these into distinct stages of the intervention.
Children benefit from having routines in their world, as it is through the use of routines that the world becomes a predictable and safe place (Mailman, 2002). Vulnerable children frequently loose
daily structure as things change and the future becomes unpredictable. Therefore, there was a routine within each session to help establish the therapeutic frame. The daily routine consisted of 7 sections:
(i) the starting ritual; (ii) an introduction to the day's theme; (iii) the first work unit; (iv) break &
refreshments; (v) the second work unit; (vi) indigenous games; and (vii) the closing ritual. At the end of each session, there was a group supervision session with the psychologist and apprentice- facilitators. This provided an opportunity to think about what happened, talk about any issues that had affected them personally, discuss the things that went well and that did not work effectively, raise concerns about individual children and plan for the next session. In effect the supervision sessions can partially be regarded as formative assessments, since it was frequently necessary to use the information from one supervision session to guide the next group therapy session with the children.
In general, the purpose of the SGTP was to introduce a stabilising element into the children's lives to counteract the emotional chaos caused by actual and/or imminent loss of a loved one, or other vulnerability variables, through structuring the daily sessions. It was anticipated that this would decrease the emotional distress that may be exhibited through the manifestation of clinical symptoms such as those associated with internalised and/or externalised disorders (Killian & Brakarsh, 2004) and increase their self esteem. It would also increase the number and quality of social support networks available to vulnerable children.
It was believed that this community-based intervention offers a means of enhancing the quality of microsystemic interactions that vulnerable children experience. It operationalises strategies 1,2 and 3 of strategic framework that was endorsed by the international role players in this field (Hunter &
Williamson, 2002). By sensitising community members to the psychosocial needs of vulnerable children, and using an apprenticeship model to apply the principles through the SGTP, children and communities would be strengthened. Community members would be willing to embark on their own initiatives to meet children's needs with a specific focus on their psychosocial needs. This programme asks community members to give their love and time to address the psychosocial needs of vulnerable children. It was anticipated that by ameliorating risk factors, one would be able to enhance resilience, by focussing on the macrosystemic interactions that were most likely to have a direct impact on the day-to-day functioning of the children.
Chapter 7