Debra Kaminer

Healing Processes in Trauma Narratives: A Review

Re-tellings of the trauma story are a standard component of most current therapeutic interventions with trauma survivors. However, the exact therapeutic processes whereby trauma narratives may facilitate change are not always clearly explicated in the literature. In order to identify these processes, a review was conducted of the published literature on those psychotherapeutic interventions for trauma that centralise the role of the trauma narrative in the recovery process. The review indicates that six therapeutic processes have consistently been proposed through which producing a trauma narrative as part of the therapy process may facilitate recovery from post-trauma pathology: emotional catharsis; the creation of linguistic representation; the habituation of anxiety; empathic witnessing of injustice; developing an explanatory account; and the identification of purpose and value in adversity. The role of the therapist during the trauma re-telling may differ in important ways, depending on the specific therapeutic process that the therapist and client are concerned with at a particular point in therapy. The implications for trauma counsellors, and for future research, are discussed.

Forgiveness: Toward an Integration of Theoretical Models

Studies on forgiveness have only recently emerged in the psychological literature. Despite evidence that forgiveness is associated with positive therapeutic outcomes, the concept has received little theoretical consideration in mainstream psychology. Existing definitions and models of forgiveness differ widely, and little attempt has been made to integrate these diverse approaches. Based on a review of the Medline and Psychlit databases, the present article evaluates current conceptualizations of forgiveness in the psychological literature. The values and limitations of each approach are discussed with reference to two case studies: a close interpersonal relationship and a human rights violation presented to the Truth and Reconciliation Commission in South Africa. A new theoretical model, integrating the most valuable aspects of existing approaches, is proposed.

Assessing post-traumatic stress disorder in South African adolescents : using the child and adolescent trauma survey (CATS) as a screening tool

BackgroundSeveral studies have demonstrated that South African children and adolescents are exposed to high levels of violent trauma with a significant proportion developing PTSD, however, limited resources make it difficult to accurately identify traumatized children.MethodsA clinical interview (K-SADS-PL, selected modules) and self-report scale (CATS) were compared to determine if these different methods of assessment elicit similar information with regards to trauma exposure and post-traumatic stress disorder (PTSD) in adolescents. Youth (n = 58) from 2 schools in Cape Town, South Africa participated.Results91% of youth reported having been exposed to a traumatic event on self-report (CATS) and 38% reported symptoms severe enough to be classified as PTSD. On interview (K-SADS-PL), 86% reported exposure to a traumatic event and 19% were found to have PTSD. While there were significant differences in the rates of trauma exposure and PTSD on the K-SADS and CATS, a cut-off value of 15 on the CATS maximized both the number of true positives and true negatives with PTSD. The CATS also differentiated well between adolescents meeting DSM-IV PTSD symptom criteria from adolescents not meeting criteria.ConclusionsOur results indicate that trauma exposure and PTSD are prevalent in South African youth and if appropriate cut-offs are used, self-report scales may be useful screening tools for PTSD.

Gender patterns in the contribution of different types of violence to posttraumatic stress symptoms among South African urban youth

OBJECTIVE Identifying the comparative contributions of different forms of violence exposure to trauma sequelae can help to prioritize interventions for polyvictimized youth living in contexts of limited mental health resources. This study aimed to establish gender patterns in the independent and comparative contributions of five types of violence exposure to the severity of posttraumatic stress symptoms among Xhosa-speaking South African adolescents. METHOD Xhosa-speaking adolescents (n=230) attending a high school in a low-income urban community in South Africa completed measures of violence exposure and posttraumatic stress symptoms. RESULTS While witnessing of community violence was by far the most common form of violence exposure, for the sample as a whole only sexual victimization and being a direct victim of community violence, together with gender, contributed independently to the severity of posttraumatic stress symptoms. When the contribution of different forms of violence was examined separately for each gender, only increased exposure to community and sexual victimization were associated with symptom severity among girls, while increased exposure to direct victimization in both the community and domestic settings were associated with greater symptom severity in boys. CONCLUSIONS The findings provide some preliminary motivation for focusing trauma intervention initiatives in this community on girls who have experienced sexual abuse compounded by victimization in the community, and boys who have been direct victims of either domestic or community violence. Further research is required to establish whether the risk factors for posttraumatic stress symptoms identified among adolescents in this study are consistent across different communities in South Africa, as well as across other resource-constrained contexts.

Disrupted rapid eye movement sleep predicts poor declarative memory performance in post-traumatic stress disorder.

Successful memory consolidation during sleep depends on healthy slow‐wave and rapid eye movement sleep, and on successful transition across sleep stages. In post‐traumatic stress disorder, sleep is disrupted and memory is impaired, but relations between these two variables in the psychiatric condition remain unexplored. We examined whether disrupted sleep, and consequent disrupted memory consolidation, is a mechanism underlying declarative memory deficits in post‐traumatic stress disorder. We recruited three matched groups of participants: post‐traumatic stress disorder (n = 16); trauma‐exposed non‐post‐traumatic stress disorder (n = 15); and healthy control (n = 14). They completed memory tasks before and after 8 h of sleep. We measured sleep variables using sleep‐adapted electroencephalography. Post‐traumatic stress disorder‐diagnosed participants experienced significantly less sleep efficiency and rapid eye movement sleep percentage, and experienced more awakenings and wake percentage in the second half of the night than did participants in the other two groups. After sleep, post‐traumatic stress disorder‐diagnosed participants retained significantly less information on a declarative memory task than controls. Rapid eye movement percentage, wake percentage and sleep efficiency correlated with retention of information over the night. Furthermore, lower rapid eye movement percentage predicted poorer retention in post‐traumatic stress disorder‐diagnosed individuals. Our results suggest that declarative memory consolidation is disrupted during sleep in post‐traumatic stress disorder. These data are consistent with theories suggesting that sleep benefits memory consolidation via predictable neurobiological mechanisms, and that rapid eye movement disruption is more than a symptom of post‐traumatic stress disorder.

Traumatic stress: established knowledge, current debates and new horizons

Traumatic stress studies is a well-established, vibrant and ever-growing cross-disciplinary area of research and practice to which psychologists have made a substantial contribution. This article presents an overview of the field, acknowledging the close relationship between the study of post-traumatic stress disorder more specifically and the field of traumatic stress studies in general. The authors focus on four key dimensions: historical and conceptual issues, diagnostic features and debates, aetiological research findings in relation to vulnerability to disorder and treatment approaches to post-traumatic stress disorder and related conditions. It is observed that there is both extension and deepening of knowledge based upon scientific advances such as neuroimaging and gene mapping technology, employment of meta-analyses, increased attention to randomized control studies and emphasis on more comparative research. Alongside such developments is the posing of important philosophical and psychosocial questions and increasing recognition of the need to contextualize both where and how established knowledge has been generated and how this may need to be expanded.

Photovoice as Community Engaged Research: The Interplay between Knowledge Creation and Agency in a South African Study on Safety Promotion

This article aims to describe Photovoice as a method and process of enacting community engaged research. The multi-dimensional nature of Photovoice is illustrated though a case application, focused on safety promotion in two South African low-income communities. Twenty youth, evenly distributed by gender and ranging in age from 13 to 15 years, were conveniently engaged as participants in the case application. In positioning ourselves as critical commentators, we employ the case application to illustrate the Photovoice process of engaging participants in observations and dialogue about their communities; creating a safe environment for critical reflection on current community realities; shifting participants towards action; and facilitating community change. Our critical reflections and descriptions of the processes and steps inherent to Photovoice highlight the value of a youth- and community-centred approach to research.

Perpetuating the cycle of violence in South African low-income communities : attraction to violence in young men exposed to continuous threat

Background Life in the low-income urban communities of South Africa is imprinted by a cycle of violence in which young males predominantly are in the roles of both victim and perpetrator. There is some evidence that adolescents who show an attraction to cruelty can display high levels of psychosocial functioning despite the presence of posttraumatic stress symptoms. However, the role of appetitive aggression in the context of ongoing threats and daily hassles is not yet fully understood. Objective In this study, we examine the role of attraction to violence in areas of continuous traumatic stress exposure and its effect on posttraumatic stress disorder (PTSD) severity and violence perpetration. Method A sample of 290 young males from two low-income Cape Town communities was surveyed. We assessed appetitive aggression with the Appetitive Aggression Scale (AAS), PTSD symptoms with the PTSD Symptom Scale-Interview, the number of witnessed and self-experienced traumatic event types with an adaptation of the Child Exposure to Community Violence questionnaire, and the number of perpetrated violence event types with an adapted offence checklist from the AAS. Results Appetitive aggression scores were predicted by witnessed as well as self-experienced traumatic events. Higher appetitive aggression scores resulted in higher levels of PTSD severity and perpetrated violence. Conclusions Young males living in the low-income areas of South Africa may develop an attraction to cruelty in response to exposure to violence. Their willingness to fight in turn can increase the likelihood of continued violent behaviour. In contrast to previous research from postconflict areas, appetitive aggression and engagement in violence do not prevent the development of PTSD, but are instead associated with higher levels of posttraumatic stress. PTSD symptoms such as avoidance and hyperarousal, as well as an attraction to cruelty and thus the willingness to fight, might support survival in areas of ongoing conflict, but at the same time they could fuel the cycle of violence.

The contribution of different forms of violence exposure to internalizing and externalizing symptoms among young South African adolescents

While many youth are exposed to multiple forms of co-occurring violence, the comparative impact of different forms of violence on the mental health of children and adolescents has not been clearly established. Studies from low and middle income countries in particular are lacking. The present study examined the contribution of different forms of violence to internalizing and externalizing symptoms among young adolescents in South Africa. A community-based sample of 616 high school learners completed self-report scales assessing exposure to six different forms of violence and the severity of depression, aggression and conduct disorder symptoms. In bivariate analyses, all six forms of violence were significantly associated with internalizing and externalizing difficulties. When the contribution of all forms of violence to mental health outcomes was examined simultaneously, domestic victimization emerged as the strongest predictor of both internalizing and externalizing difficulties. Cumulative exposure to other forms of violence contributed further to the prediction of aggression and conduct disorder, but not depression. Recommendations for future research, and the implications of the findings for prioritizing the development of violence prevention and intervention initiatives in the South African context, are considered.

The psychiatric sequelae of human rights violations: A challenge for primary health care

High rates of psychiatric morbidity have been documented in survivors of gross human rights abuses. Nevertheless, there has been relatively little focus on such patients in the context of primary care medicine. A sample of 134 survivors of gross human rights violations was assessed using a structured interview to determine exposure to violations and psychiatric status. In addition, psychiatric treatment history was probed with an open-ended interview. The study found that of the 95 of 134 (72%) participants who were assessed and found to have a current psychiatric diagnosis, only three were receiving treatment for such a disorder. Many subjects had presented to primary care clinics with somatic symptoms and had been prescribed benzodiazepines. Reasons for not reporting trauma or not seeking treatment included issues revolving around fear and mistrust, privacy and confidentiality, re-experiencing the trauma, and lack of awareness. Misdiagnosis and ineffective treatment of survivors of human rights abuses are likely to pose a significant drain on primary care resources. Accurate diagnosis and appropriate treatment are important challenges in primary care settings.