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Social Work/Maatskaplike Werk
versión On-line ISSN 2312-7198
versión impresa ISSN 0037-8054
Social work (Stellenbosch. Online) vol.53 no.4 Stellenbosch 2017
http://dx.doi.org/10.15270/52-2-592
ARTICLES
A psycho-social therapeutic group work programme preventing the onset of post-traumatic stress disorder among police officials attached to the specialised units in the South African Police Service
Dr Pieter BoshoffI; Prof Herman StrydomII
IPhD student School of Psycho-social Behavioural Sciences and the Research Unit COMPRES North-West University, Potchefstroom Campus, Potchefstroom, South Africa
IISchool of Psycho-social Behavioural Sciences and the Research Unit COMPRES North-West University, Potchefstroom Campus, Potchefstroom, South Africa
ABSTRACT
This article focuses on the development of a psycho-social therapeutic programme (PTP) for police officials attached to the specialised units in the North West province. The objective is to prevent the onset of post-traumatic stress disorder and the development of trauma-related stress symptoms soon after exposure to a traumatic event. The main focus of this article is on the themes and contents of the designed PTP. The themes of the programme are schematically presented, after which it is discussed in detail according to the subject, aim and content.
INTRODUCTION
Police officials are continuously exposed to job-related trauma and stress such as dealing with unlawful, often dangerous actions of citizens and abusive treatment in the workplace with limited access to psycho-social support. Police officials have more stress-related physical complaints and psychological and social needs than workers in most other professions (Anshel, 2000). The exploration of these needs should form the foundation of an effectively designed psycho-social therapeutic programme (hereafter referred to as a PTP) to act in the best interest of the traumatised police official, to address issues in police work that affect their overall psycho-social wellness, and to empower them with skills to cope more effectively with their circumstances (Litz, Gray & Bryant, 2002; Morash, Haarr & Kwak, 2006). This article describes the aim of the study and provides guidelines for the implementation of the PTP. The planning and compilation of the group work programme are explained and form the major part of this article.
PROBLEM STATEMENT
Police officials are exposed to a unique work environment and face potentially traumatic events which could have an impact on their physical, emotional and social wellbeing (Watson, Jorgensen, Meiring & Hill, 2012). The high risk involved in police work and the ever changing role of the police in society impose new work demands for police officials, making this a highly stressful occupation (Ortega, Brenner & Leather, 2007). As a result police officials are often confused and uncertain regarding the tactical and operational decisions they have to make, while they are expected to apply good judgment under difficult and dangerous circumstances (Deschamps, Pagnon-Badiner, Marchand & Merle, 2003). Their experience of stress arises from the exposure to specific physical or psycho-social demands at work and the perceived imbalance between those demands and the resources available to meet them. According to Morash, et al. (2006), there is evidence that some stress emanates from a lack of support from networks at work and at home. It is, however, necessary for police officials exposed to trauma to receive sufficient and effective support based on their specific needs to prevent the development of trauma-related stress symptoms soon after exposure to a traumatic event.
The South African Police Service (SAPS) places much emphasis on critical incident stress debriefing (CISD) as a model for trauma intervention. CISD is defined as a meeting with a group of people (peer support programme) during or after a traumatic event, for example, an accident or disaster. The debriefing session is conducted to gain an overview of the event, to talk about feelings and reactions, and develop mechanisms to alleviate the emotional impact of an event, prevent traumatic stress and identify those needing mental health services (Carlier, Lamberts & Gersons, 2000; Mitchell, 1983). According to Mthetwa (2012), between 3000 to 4000 police officials received debriefing consultations from Employee Health and Wellness (EHW) during the period 2011-2012. In spite of this statement, the SAPS annual report (2013/2014) still indicates a high occurrence of psychological and behavioural disorders amongst police officials. In recent times international debate, research projects and open criticism of the effectiveness of the current debriefing model have increased. The opinions of Addis and Stephens (2008) as well as Arnetz, Nevedal, Lumley, Backman & Lublin (2009) are that CISD has no, or a negative, effect on primary victims of trauma. These authors are of the opinion that the risk of post-traumatic stress disorder (PTSD) can escalate after debriefing and that some victims might experience secondary trauma because of the repetition of the event. In SAPS CISD is mostly a once-off intervention lacking long-term therapeutic trauma intervention. A programme should thus be developmental in nature which considers the police officials' needs through their active participation in the entire process.
The research question is therefore: What aspects arising from the literature study and the empirical research should be included in a proposed psycho-social therapeutic programme?
AIM
The aim of this article is to develop a PTP considering specific aspects of a literature study and empirical research that will enable police officials to cope better with the impact of trauma.
RESEARCH METHODOLOGY
The researcher used intervention research (D & D model) for the purposes of this study. The D & D is a critical component of intervention research in as much as it is through this model that human service interventions may be designed, developed and evaluated. The D & D is a model that consists of six phases. (De Vos & Strydom, 2011). The outcome of the third and fourth phases of this model, specifically referring to design, early development and pilot testing, is presented in this article. The findings in the problem analysis and information gathering phase lead to the development of the PTP based on various elements of trauma focused, cognitive behavioural therapy (TF-CBT), prolonged exposure (PE) and the eco-systemic approaches as a way of dealing with the problem. The programme was developed as a guideline for early intervention for acute and post-traumatic stress symptoms present after an event until four weeks post-trauma (Becker, Meyer, Price, Graham, Arsena, Armstrong & Ramon, 2009; Moore & Penk, 2011).
These approaches do have some of the functional elements for inclusion in the PTP, for example, psycho-education, prolonged exposure, relaxation, in vivo exposure, cognitive therapy, alterations in systems of care, systems advocacy and problem solving. The eco-systemic approach is a way of seeing the person and the environment in their interconnected and multi-layered reality. The approach supports a transactional fashion of intervention to avoid viewing people in isolation from their life situations (Hepworth, Rooney & Larsen, 2002; Miley, O'Melia & DuBois, 2004). The focus is on the interconnected transactional networks, with specific reference to the community and family as well as environmental, spiritual, social and cultural factors (Orr & Hulse-Killacky, 2006).
De Vos et al. (2011) emphasise the fact that researchers need to design a way to naturally observe events related to the phenomenon, and a method to detect the problem and its scope. The authors are convinced that these two mentioned aspects are important to monitor the effects following intervention. By observing the problem and studying naturally occurring innovations and other prototypes, researchers can identify procedural elements for use in the intervention. The standardised measurement instruments, namely the Critical Incident History Questionnaire (CIHQ) (Weiss, Brunet, Best, Metzler, Liberman, Pole, Fagan & Marmer, 2010), Impact of Event Scale (IDES-R) (Weiss, 2007), Mental Health Continuum Short Form (MHC-SF) (Keyes, 2002; Keyes, 2007) and the Post-Traumatic Cognitions Inventory (PTCI) (Foa, Ehlers, Clark, Tolin & Orsillo, 1999), were utilised before, post- and post-post-intervention in an experimental design.
The researcher presented the PTP to a group of social workers responsible for the specialised units of SAPS in the North West province. The researcher exposed the group of social workers to exactly the same procedures and programme as planned for the main investigation in order to determine the effectiveness of the intervention and to identify which elements of the preliminary programme may need to be revised. The presentation of the programme was also intended as training for the social workers as fieldworkers. This process assisted the researcher to remove any inconsistencies and redundancies to improve the clarity of the formulation of content of the programme to ensure validity, reliability and sensitivity (Strydom, 2011). After completion of this process, the PTP was implemented and used on a trial basis to establish whether it can be put to effect directly after police officials' exposure to traumatic events.
GUIDELINES FOR GROUP WORK WITH POLICE OFFICIALS
Group treatment brings with it the possibility of the restoration of meaning in social participation. It is a dynamic and powerful intervention method for police officials who are dissociated as a result of their exposure to trauma (Beck, 2004). Group work has been chosen as the method for this programme as it is cost effective, provides social support, facilitates the development of interpersonal skills, offers opportunities for acquiring new information, coping skills and self-expectations, and provides peer feedback (Healy, 2012). The mutual identifications and mirroring in the group are powerful therapeutic factors. Traumatised police officials were screened for possible inclusion in the PTP. Police officials excluded were those already diagnosed with PTSD or any other co-morbid disorder, those that are psychotic, homicidal and suicidal.
This kind of group should be homogeneous (Rutan, Stone, & Shay, 2014). For a group to reach its maximum potential, it is important for the facilitator of the group work programme to take into consideration all administrative aspects such as the venue, time, duration of sessions, number of sessions, type and size of the group, and functional resources (Garvin, 2010). Police officials were prepared for the group work programme by determining their level of motivation, discussing the aim of the group work sessions, establishing group norms and introducing methods and procedures to be utilised during the programme for them to be motivated and involved in the process to ensure that they attend the sessions, are responsive and are able to contribute (Foy, Drescher & Watson, 2010; Rutan et al., 2014). The primary focus in group work with traumatised police officials is to create a safe space for the work of the group (Ephross, 2010; Foy et al., 2010).
Foy et al. (2010) and Yalom and Leszcz (2005) point out that it is important to assist the group in developing dynamics (communication, trust, confidentiality, cohesion, social control mechanisms and group culture) that promote the satisfaction of group members' needs while facilitating the accomplishment of group tasks. The trauma group comprised a short-term trauma-focused group with a psycho-social perspective (Keim & Olguin, 2010). The group is therapeutic and psycho-educational in nature (Toseland & Rivas, 2014; Zastrow, 2015). The emphasis was on preventing the onset of post-traumatic stress disorder and the development of trauma-related stress symptoms soon after exposure to a traumatic event (Waldo, Schwartz, Horne, & Coté, 2010). The following phases of the group work process - namely the preparation/pre-group, beginning, middle, end and post-group phases, as proposed by Glassman (2009) and Zastrow (2015) - were included as part of the PTP.
CONTENT OF THE PSYCHO-SOCIAL THERAPEUTIC PROGRAMME FOR POLICE OFFICIALS
The PTP is proactive in nature with an emphasis on the prevention of post-traumatic stress and any other co-morbid disorders, fully recognising the traumatised individual as a whole in his or her environment, or the interconnections present within the situation. The programme is furthermore based on the guidelines of various evidence-based programmes, models and perspectives stemming from a thorough literature study, including different authors such as Baranowsky, Gentry and Schultz (2010), Miley et al. (2004), Saunders (2012), Schnyder, Pedretti and Muller (2012) and Weiss and Santoyo (2012). The programme comprises the objectives, aims and contents of an integrated educational and therapeutic group work programme consisting of 12 sessions.
The content of the programme has been schematically presented after which it is discussed in detail according to the theme, aim and content. A variety of functional aids were used in every session, such as the workbook (which comprehensively explains the activities of every session), name tags, pencils and pens, examination pad, standing board and paper, laptop (PowerPoint presentation) and markers. For specific sessions some additional functional aids were used such as stress balls, slow relaxing music and colouring pencils. The group worker administered the Weekly TST Check-In Scale at the beginning of each session to assess the group members' emotional and behavioural challenges during the previous week and to monitor growth since the previous session. The TST is very helpful in gathering information from the police official every week concerning emotion regulation and social-environmental stability. It is often very helpful to assess specific areas of growth and improvement during the intervention process (Saxe, Ellis & Kaplow, 2007). At the end of each session the group worker collected and stored the completed scales.
Pre-testing
The researcher scheduled a group session with selected police officials two to four weeks after exposure to traumatic events. For the purposes of the research study it was necessary to screen those police officials exposed to traumatic events for possible inclusion in the group. This is important for determining medium- to longer-term distress for those who are at risk of developing a psychological disorder. The PTP is proactive in nature with an emphasis on the prevention of psychological disorders and the inclusion of police officials with PTSD or any other co-morbid disorders that might influence the research outcome. The process was administered by the social worker in SAPS responsible for the Public Order Police Unit in Potchefstroom, who acted as mediator. The following measurement scales were all utilised to screen the participants: the Critical Incident History Questionnaire (CIHQ), which indexes cumulative exposure to traumatic incidents in police by examining incident frequency and rated severity; the Impact of Event Scale - Revised (IES-R), which reflects the DSM-IV criteria for post-traumatic stress disorder; the Mental Health Continuum Short Form (MHC-SF) representing the construct definition for each facet of wellbeing; and the Post-Traumatic Cognitions Inventory (PTCI), which measures trauma-related thoughts and beliefs.
Session 1: Introduction and psycho-education
Rationale
The rationale for session one was to build rapport with the group members, to lay out the course of treatment, to elicit treatment compliance and to educate the group members about trauma, related symptoms, PTSD and trauma recovery.
Content
The group worker welcomed the group members and explained to them that therapy is a safe place to help them feel better about upsetting or confusing traumatic events they have experienced. They were granted the opportunity of drawing, writing, listening, talking and giving their own opinion in therapy. They learned many important things about themselves such as how to relax, how to pinpoint their feelings and how to handle relationships (Hendricks, Cohen, Mannarino & Deblinger, 2006).
The group members were afforded the opportunity to introduce themselves to the rest of the group, while an ice-breaker was used to put everyone at ease and to eliminate a sense of the ranks that form part of the hierarchy of SAPS. The facilitator initially has the responsibility to create an atmosphere of warmth and acceptance that encourages self-exploration and self-expression so that members will gain the maximum from the programme (Toseland et al., 2005). At this stage the group worker gave a layout of the course of treatment. They were given the opportunity to establish the group norms for themselves, the facilitator and the group as a whole. These norms were written down and were visible for the duration of the programme (Kirst-Ashman, 2008).
It is necessary to elicit treatment compliance early in the course of therapy because avoidance behaviour can interfere with successful outcomes. Two forms of compliance one should be most concerned about are attendance and completion of out-of-session practise assignments. It was emphasised that they should tackle issues head-on rather than continue to avoid them (Jin, Sklar, Oh & Li, 2008). The group worker introduced the Weekly TST Check-In Scale proposed by Saxe et al. (2007). As part of psycho-education the group worker discussed the definition of trauma and other related terms. The group worker introduced the process of trauma on the basis of an illustration which explains the process starting at the overwhelming event, and then dealing with the psychological and physiological responses up to the stage during which the individual resorts to self-destructive and destructive action (Ackley & Covington, 2008).
The group worker concentrated on the fight, flight or freeze response, which is normally experienced during or immediately after exposure to a traumatic event (Sanderson, 2006). The group worker introduced and discussed the common signs and symptoms following exposure to traumatic events, for example, attempts to avoid thoughts, poor memory, flashbacks, hyper-vigilance, intrusive thoughts and important other behaviours to raise awareness with an emphasis on normal signs and symptoms in reaction to an abnormal event. Subsequently, group members were provided with an exercise to identify their own symptoms. Group members were encouraged to discuss their scores for this exercise in the group voluntarily. It is important to educate group members with regard to the concept of PTSD. The group worker gave a brief explanation of the diagnostic criteria for PTSD as proposed by the DSM-5 (American Psychiatric Association, 2013). Lastly, the group worker concentrated on treatment recovery on the basis of the linen cupboard metaphor. The clothes in the cupboard are compared with trauma memories, and in the process of unpacking and sorting out the clothes, memories of the traumatic event find their proper place.
Session 2: Relaxation
Rationale
During the group session police officials were taught specific techniques to relax their body and mind in order to feel calm and peaceful, especially during times of distress.
Content
After exposure to traumatic events, police officials often experience symptoms of anxiety, insomnia, hyperventilation, panic attacks and high stress levels (Violanti & George, 2004). Group members were provided with the following guidelines proposed by Williams and Poijula (2013), who emphasise that it is important for group members to practise the relaxation techniques they choose regularly, to try to focus on the particular muscle groups and specific exercises, to combine relaxation with exercise, and to trust the power of the techniques to bring them some peace. It is furthermore important to choose a quiet environment with as few distractions as possible, to adopt a passive attitude to help one rest and relax without forcing one's response preventing one's relaxed response from occurring.
The group worker introduced the first technique, which is grounding, with an emphasis on focusing on the present and the external world. After this the group worker introduced the safe-place exercise, where participants have to think back to a situation in which they felt safe. The group members practised a technique called progressive muscle relaxation. This is a way of relaxing by tensing and relaxing various muscle groups in one's body (Thompson & Franklin, 2010). The next technique is called deep breathing to help one feel relaxed and calm by breathing in slowly and deeply while playing relaxing music in the background (Rosenbloom & Williams, 2010).
The group worker concluded the session by asking about the police officials' reactions to the session and whether they have any additional questions or comments with regard to relaxation. It is important to normalise any emotions and give credit for participation and progress made between sessions.
Session 3: Trauma narrative
Rationale
In this session the group worker afforded the group members the opportunity to tell their story about exposure to the most critical traumatic incidents during their career and also to create a trauma inventory.
Content
The group worker emphasised that before concentrating on the traumas that have impacted on group members, it is important for them to look at who they are. Their sense of self serves as the reference point for who they want to become and what they want to do with their lives. Traumatic experiences can rob them of their sense of self. It is therefore important that they look at what they know about their own core self, their basic identity and whether that self is healthy, partially healthy, or unhealthy (Williams & Poijula, 2013).
Confronting their memories in a safe environment assists them in working through or processing their traumatic history, which also brings closure to traumatic memories. Group members were then been asked to identify the traumas they had experienced, without going into much detail, and the stage or stages in their career at which they had experienced them, using a trauma inventory. The trauma inventory provides the group members with an overview of themselves and what had happened to them during different stages of their career (Schupp, 2015). The session was closed by asking about the police officials' reactions to the session and whether they had any questions about the content. The group worker paid attention to normalising any negative emotions and disturbing thoughts as a result of remembering and talking about past traumatic events.
Session 4: Identifying feelings and thoughts
Rationale
The rationale of the exercise is to assist group members to identify and label their feelings and thoughts in response to their exposure to traumatic events.
Content
A brief description of the meaning of the concepts "feelings" and "thoughts" and their interconnectedness is deemed important to enable the group members to distinguish between and understand the different concepts, specifically with reference to their own personal experience (Pettinelli, 2012:-71). The group worker introduced the ABCs of emotions proposed by McGovern, Mueser, Hamblen and Jankowski (2010a), which explains the process or series of events that leads to something. The A is the situation, or activating situation, the B is the belief or thought about the situation, whilst the C stands for consequence (Meyers, 2006). Group members were guided to recognise their emotions (Ekman & Friesen, 2003:10). Group members had to identify which of the emotional states they personally know, and which they had felt in the past two weeks. They had to circle those they felt and underline those about which they can say that they know how they feel. Most importantly, once the participants completed the exercise, the group worker could determine what this exercise taught group members about themselves.
Group members then had to place different colours next to each of the feelings they had identified. These colours were then used to show where in the body group members experience each feeling (Hendricks et al., 2006). Members did not have to do all the feelings they listed, but they could choose which feelings they wanted to be included. For each feeling they choose, group members had to close their eyes and imagine having that feeling right at the present moment. They had to explain where in the body they experience the feeling. Members had to colour in the places on the picture of a body where they experienced each feeling and then tell the group what it felt like.
Group members were handed out examples of unhelpful thinking habits and then they needed to identify those unhelpful thinking habits that they employ themselves. Once they identified them, they could distance themselves from those thoughts and challenges and see the situation in a different and more helpful manner with realistic thoughts (Andrews, Creamer, Crino, Hunt, Lampe & Page, 2003; Wilkinson, 2015). The group worker explained the interconnectedness between emotions, feelings and thoughts by illustrating the four primary negative emotions, related emotions and the common thoughts that drive them, as explained by Wilkinson (2015). The group worker gave a practical example of the first primary emotions, namely anxiety and fear. Possible negative feelings, namely worry or panic, and the common thought that drives them, namely a feeling that the individual is not safe but in danger, are normally related to these emotions. Following this, group members were afforded the opportunity of continuing the exercise on considering the four primary negative emotions by replacing the related emotions and thoughts with their own.
Session 5: Rating of feelings and affect modulation
Rationale
This session firstly concentrated on rating the intensity of group members' feelings at the time and their unique style of affect regulation, after which possible alterations in the ability of group members to manage feelings, emotions and impulses were discussed.
Content
Group members were encouraged to explain what feelings they experienced at that specific moment and to rate each of those feelings on a scale of 1-10, with 1 meaning no feelings at all and 10 meaning very strong feelings. They then completed the affective style questionnaire, which is a brief instrument to measure individual differences in emotion regulation (Hofmann & Kashdan, 2010). Members were made aware that different situations bring out somewhat different responses, but they were supposed to concentrate on what they usually do. This followed by a hand-out with different facial expressions on them. Group members were encouraged to circle the face indicating how they feel right at that moment, with an explanation of the feeling. Group members were given turns to act out the different feelings, while the other group members try to guess what feeling a member has acted out. Group members were then encouraged to share what had made them feel that way.
Next the emotion expression exercise was introduced with the purpose of helping group members to identify and express their emotions. While describing their experiences of the previous week, they were encouraged to identify the emotion that had accompanied the experience and to call it by name. Group members were encouraged to practise this exercise with a loved one every day (Gibbs, Leggitt & Turner, 2002). The negative emotions diagram designed by Lynch and Mack (2015) was then discussed. The vertical bar (arrow pointing up) represents what group members think will happen if they experience fear or any other negative emotions. Their fear will increase and never end. The horizontal bar represents avoidance, a response that police officials engage in to avoid experiencing uncontrolled fear or negative emotion. This avoidance keeps them from learning what actually happens with emotions, namely that they peak and normally subside like waves in the ocean. Group members were taught how to work with positive imagery with the aim of combating negative feelings about a feared future event, seeing the worst possible things happening. It makes sense that using therapeutic imagery will be most effective to treat distressing imagery (Hall, Hall, Stradling & Young, 2006). Group members were introduced to different forms of imagery, for example, imagery manipulation, imagery editing, changing the content and outcome of distressing and intrusive imagery, and compassionate and nurturing imagery. Group members were encouraged to complete an exercise called the DVD technique. This is a very important technique to deal with flashbacks whereby the individual puts the memories that repeat in a shortened form on a "DVD" in their mind. Group members could play their memories in small sections or even fast-forward or scan backwards. Through these actions, they were given a choice with regard to remembering, and control over the memory (Williams & Poijula, 2013). The technique also involves promoting self-compassion and imagery rehearsal during which group members can mentally rehearse a feared imagined future event.
Group members were provided with a hand-out containing information on how to deal with negative emotions, which guided group members through the process of identifying emotions and the resulting feelings, and how to think and do differently. The STOPP the feeling worksheet is a goal-orientated, short-term intervention in which the group worker and the group members worked collaboratively to address their problematic thinking and behaviour in order to assist members to feel, think and do differently (Williams & Poijula, 2013). Group members were encouraged to think of a situation in which they had an overwhelming negative emotion, to describe it and to name the initial emotion that had arisen from the situation. Members then reflected on and applied the six steps in the STOPP the feeling worksheet to guide them with regard to controlling the emotion. It is important to normalise any emotional discomfort and the group worker gave credit for participation and progress made since the previous session.
Session 6: Altered thinking
Rationale
The session concentrated on group members' patterns of problematic thinking and particularly strong tendencies towards any counterproductive patterns of reactions to the trauma.
Content
This session built on the ABCs of emotions proposed by McGovern et al. (2010b) by adding the cognitive behavioural therapy strategy of disputing the belief. Evaluating the evidence for and against the belief, and considering the potential use of a common style of thinking, can help loosen the conviction with which troubling beliefs are held and consequently lead to negative emotions and behaviours. Group members were introduced to the ABCDE of emotions proposed by McGovern et al. (2010a) by adding D and E to the alphabet. They were given a hand-out that shows and explains the D and E. The D stands for Disputing the Belief and the E for Entirely new thought or behaviour. Group members were afforded the opportunity of applying the ABCDE to practical examples during the session. This helped group members to end up with a new thinking pattern.
The group worker discussed common styles of thinking, especially styles pertaining to thinking negatively about themselves and situations over a period of time. This hand-out assisted members in thinking more flexibly and in making use of positive affirmations by using positive statements to help them to change their style of thinking and develop a new attitude towards themselves and their situation. Next, members were given the opportunity of practising the skill of immediately turning around negative thoughts by using positive affirmations (Andrews et al., 2003) from their own lives such as finding an entirely new thought and behaviour pattern (Allen, 2005).
Session 7: Challenging destructive and self-destructive behaviour
Rationale
This session concentrated on raising awareness of destructive and self-destructive responses and behaviours, for example, anger, aggression, substance abuse and suicide ideation and actual suicide. Group members were also assisted in identifying these types of behaviours.
Content
The aggression cycle comprising the different stages of anger was introduced to the group. Any episode of anger display starts as a result of a trigger event and builds up through three stages, namely a trigger, a violent expression and then the post-expression stage during which the person starts realising the negative consequences that were the direct result of the verbal or physical aggression (Videbeck, 2014). The understanding of these stages is important as part of managing problem anger. Group members were introduced to different skills for managing anger, specifically referring to passive, aggressive and assertive behaviours. Members were given the opportunity to share the personal skills they apply for managing anger, with a possible explanation of the consequences (Thomas, 2010).
Group members were made aware of the link between traumatic events and alcohol/drug abuse and the reasons why some police officials resort to these substances. Unfortunately this comes at a very high price as it will reduce the anxiety in the short term, but it will come back twofold as the side effects set in (Lynch & Mack, 2015). Group members were once again introduced to the STOPP substance abuse worksheet. This worksheet is a goal-oriented, short-term intervention in which the group worker and the group members worked collaboratively to address their problematic thinking and behaviour in order to overcome their cravings. Group members were introduced to the link between post-traumatic stress, suicidal thoughts and actual suicide (Escolas, Bartone, Rewers, Rothberg & Carter, 2010). During this session group members were encouraged to discuss the risk factors for suicide.
Group members were requested to complete the Suicide Behaviours Questionnaire - Revised (SBQ-R) developed by Osman, Bagge, Gutierrez, Konick, Kopper and Barrios (2001), with the aim of assessing the frequency of suicidal ideation over the previous twelve months, the threat of suicide attempt and the self-reported likelihood of suicidal behaviour in future. The group members were then introduced to a safety plan which would guide them to balance the pain and the coping resources step by step until they feel safe. Group members were encouraged to practise the plan during the session, but were also advised to keep the plan where they can easily find it during a crisis situation.
Session 8: Problem solving
Rationale
Group members were educated during the session with regard to possible strategies for effective problem solving. The group worker concentrated on the identification of problems in the session to assist group members to consider multiple perspectives and outcomes before making a decision.
Content
The group worker explained that problem solving generally involves a process through which an individual attempts to identify effective means of coping with the problems of everyday living. This often involves a set of steps for analysing a problem, identifying options for coping, evaluating the options, deciding upon a plan and developing strategies for implementing the plan (Cully & Teten, 2008). Problem-solving strategies can be used with a wide range of problems, including anxiety, stress management, coping with illness, addiction, family/relationship problems and financial difficulties. Problem-solving techniques teach skills that aid the individual in gaining increased control over life issues that previously felt overwhelming or unmanageable. In this way, problem solving can help with practical problem resolution and emotion-focused coping (Greenwald, 2013). The group worker is not responsible for finding answers to these questions, but should rather aid the group members to find their own answers.
Group members were enabled and encouraged to apply these strategies after therapy ends and were taught to carefully examine a problem, compile a list of solutions and make decisions concerning which strategies are appropriate for addressing a variety of problems. Intervention strategies should be tailored according to a specific individual or group. A thorough assessment of the problem should be made before proceeding with problem-solving therapy; group members should be encouraged to try as many solutions as possible and a decision should be made as to whether the group members require more problem-solving work to experience growth through the therapeutic process.
To facilitate learning, the group worker explained the SOLVED problem-solving technique, introduced by Cully and Teten (2008), by providing examples of the SOLVED programme at work. This technique involves 5 steps in solving a problem: the identification of a specific problem, possible solutions, verification of the best solution, enacting the solution and deciding whether the solution is successful. Group members were encouraged to identify a specific problem in their personal lives which they would like to solve. They were guided to list possible solutions, after which group members kept an open mind to evaluate the pros and cons of each solution.
Session 9: Managing trigger events
Rationale
It is important for group members to learn to recognise their avoidance and safety behaviours as a way of escaping trigger events that elicit feelings of anxiety, fear, anger or other types of distress.
Content
The group worker defined a trigger as an event, object or cue that elicits feelings of anxiety, fear, anger or other types of distress. Triggers are often harmless, but have become associated with the original trauma. For most people with post-traumatic stress, triggers are not inherently dangerous, but they remind them of their traumatic experiences (Krippner, Pitchford & Davies, 2012). The brain recognises the similarity and - not realising that the danger is over - produces a surge of anxiety that activates the fight or flight response. Certain sights, sounds, smells, physical sensations, places, activities and situations can be triggers for people with post-traumatic stress and can produce a surge of anxiety and a strong urge to escape or avoid the situation. Group members were then encouraged to identify what triggered feelings of fear, threat, anger or general discomfort in them during the preceding week.
The group worker explained avoidance and safety behaviours. Avoiding things that make one feel anxious or uncomfortable is only natural. Common avoidance behaviours for police officials include staying away from crowded public spaces, not answering the phone or staying in their room. Avoidance reduces one's ability to effectively manage real-life challenges and responsibilities. The brain continues to label them as associated with trauma and they continue to have the power to produce fear. In fact, the fear can grow over time. Avoidance of people and activities leads to isolation, which can contribute to depression and relationship problems (Persons, 2008). Group members should realise that learning to overcome the urge to escape/avoid and to face your fears directly without relying on safety behaviours is what helps to relieve post-traumatic stress. When presenting the material, it is important to encourage the police official's personal motivation to make a behavioural change. The group worker explicitly discussed the cost of some police officers' past and current avoidance behaviours.
The group worker also discussed the fact that it is common to develop safety behaviours, which are rituals and habits intended to reduce distress. Common examples of safety behaviours for police officials included constant visual scanning for threats, carrying a weapon or controlling the perimeter of your home. Avoidance and safety behaviours may make one feel better, but they do not actually make one any safer. Unfortunately, when dealing with triggers, avoidant and safety behaviours do not work to one's advantage in the long run. Avoidance and a sense of safety may reduce emotional distress for a little while, but in the long run they increase the symptoms associated with post-traumatic stress (Bryant, 2006). Participants were requested to complete the avoidance and safety behaviour worksheet and share examples of their personal avoidance and safety behaviours during the session if they felt comfortable about doing so. This worksheet assisted group members to learn to recognise their avoidance and safety behaviours as an important aspect of this programme. To assist members, they were provided with a checklist with common triggers, avoidance and safety behaviours with which they could identify.
The STOPP the trigger worksheet took group members through the process of identifying the trigger to deliberately expose themselves to the memories and real-life situations they fear. Group members were encouraged to repeat the same exposure exercise many times for it to work. Lastly the group worker summarised and checked for police officials' reaction to the session.
Session 10: Changes in systems of care
Rationale
Group members were encouraged to discuss the impact of trauma on interpersonal relationships. Enduring and surviving traumatic experiences can lead to problems with attachment, intimacy and interpersonal relationships that did not exist before the trauma.
Content
Group members were sensitised to the way that PTSD can affect important others, for example, the family, friends and colleagues. The symptoms of acute post-traumatic stress, PTSD and other trauma reactions change the way a trauma survivor feels and can affect everyone else in the support system. Group members were encouraged to reflect on these and other reactions based on their own relationships and to share with the group if they felt comfortable about doing so.
Bearing in mind the above description, it is important for police officials to build trust and to establish some level of intimacy in relationships. Some of the group members might have been betrayed by people with whom they were very close in the past. Betrayal in the past may lead group members to have difficulties with trust in the present (Williams & Poijula, 2013). Group members were given the opportunity to examine their own beliefs about trust, to set boundaries, communicate effectively and know when and how to rely on themselves and on others. Group members carried out a journal exercise on their beliefs about trust to identify and challenge their own beliefs about trust.
Intimacy is the capacity to feel connected to oneself and to others. Enduring trauma may lead to a disconnection between oneself and others (Boon, Steele & Van der Hart, 2011). The aim of this part of the session was to teach group members to build healthy attachments that are reciprocal and based on a new belief system so that they do not feel vulnerable. These beliefs include beliefs of empowerment and self-acceptance. The group performed an exercise around "my beliefs about intimacy" that could help group members to identify a belief or beliefs about intimacy they wanted to examine or challenge.
The group worker explained a boundary as the way one lets oneself know where one has ended and where someone else has begun. If group members are able to set appropriate boundaries, they have a better chance of maintaining good relationships with others. Group members were requested to complete the exercise on "my emotional boundaries." Gehart (2014) emphasises that one's emotional boundaries include one's need for internal safety. And if one lacks good emotional boundaries, one may lose one's sense of personal identity.
Papazoglou (2013) states that a sense of humour and finding positives is important when the world seems to be closing in and one's stress level rises. As with any other skill, developing a sense of humour calls for some attention and practice. In an attempt to help group members develop a sense of humour, the group worker provided suggestions and other ways of increasing positive experiences. The group worker helped the group members to explore what makes them laugh, as well as how to identify those people who make them laugh, and introduced ways to enjoy life.
Cox and Demmitt (2014) explain that being able to maintain a good relationship means that oneself and the other person respect one another and accept each other as they are. Group members were introduced to effective communication techniques and encouraged to practise them, which involves active listening, asking questions, describing feelings and behaviour, and using "I" messages (Saphiere, Mikk & DeVries, 2005). Waldron (2014) found that shared socialising and close proximity are features of workplace friendship, whereas closer relationships were constituted by activities such as talking through important life events, unrelated to work, as well as sharing major work challenges, all of which are critical aspects in the development and maintenance of good relationships.
Session 11: Systems advocacy
Rationale
Advocacy is one of the most important tools in psycho-social therapy for addressing instability in the social environment. Systems advocacy is primarily used in the surviving and stabilising phases of treatment to remedy key problems in the social environment.
Content
Often police officials and their families do not advocate for themselves because they do not know what their rights are, they do not know how to advocate for what they need, or they have not identified a particular problem as important enough to advocate for changing it. This can be addressed by providing the police official and his/her family with information and education about advocacy. Group members were introduced to the meaning of systems advocacy. Advocacy generally means to plead for your cause or another's, and to gain access to services needed to enhance self-empowerment (Saxe et al., 2007). Group members were introduced to the ten domains that affect families. A specific case study was introduced to illustrate the various domains that have an influence on the self and the family.
The group worker introduced the four-step advocacy assessment plan as proposed by Saxe et al. (2007). This assessment plan guides group members in how to navigate the respective social-environmental conditions contributing to their personal emotional states, to determine whether services and/or benefits to which the police officials are entitled are in place, and to identify possible barriers that diminish the family's likelihood of accessing them. The aim is to effect improvement in overall psychosocial wellbeing. Next, group members were introduced to the systems treatment plan, which they need to develop to maximise their family's likelihood of accessing the necessary services and benefits. The systems treatment plan specifies the priority problem to be addressed, the advocacy solution to address it, and what is expected of the police official and the therapist (Saxe et al., 2007).
Session 12: Relapse prevention
Rationale
Group members were prepared for terminating treatment and ending the regular group meetings. Group members were also afforded the opportunity to reflect on progress, benefits and disappointments, to acknowledge what has changed and what has not. Lastly, they were taught techniques for preventing relapse in future.
Content
The termination of the psycho-social therapeutic programme should be handled with care. Group members should realise that the programme is time limited and that every member should become their own personal therapist and that it is important that post-traumatic stress should not be neglected in future and treatment be sought whenever they feel the need (McGovern et al., 2010b). reaching this stage in the programme indicates that the group members stuck with the programme. They showed courage and determination, something that should be acknowledged and celebrated (McGovern et al., 2010b).
Group members might be concerned that they would not be able to manage future psycho-social problems or stressors without the aid of therapy. The group worker therefore reviewed what was learned in the process to assist group members with what to do in case of a setback and how to maintain progress. The group worker pointed out that it is normal for those involved in psycho-social therapy to experience a relapse, but that it is important to know how one recovers from a relapse. It is not unusual to re-experience post-traumatic stress symptoms even after recovery, especially on occasions such as an anniversary of the trauma.
The group worker introduced the relapse, recovery and resiliency worksheet by firstly identifying possible old ways of handling problems. The group worker emphasised the road to recovery as group members decide to use new skills instead of continuing the old pattern. The focus should be on group members' resilience by teaching them not to give up and to emphasise that they are able to overcome what they think they cannot. Members were granted the opportunity to discuss their experiences during the session. They were introduced to the relapse prevention plan for when they notice the above signs. This plan could include writing and implementing new hierarchies, re-reading the resources and forms they had used in treatment and the utilisation of resources to keep stress under control.
The group worker summarised the sessions and allowed group members to reflect on progress towards the goals they indicated at the outset of the programme as well as on their disappointments and on what still needs to be done. The participants were encouraged to congratulate and motivate each other for completing the programme. Where group members did not make progress, or only limited progress, this should also be discussed and acknowledged (McGovern et al., 2010b). During the transition phase police officials might be referred or introduced to recovery support groups for on-going support both for mental health and social issues.
The researcher scheduled an appointment for one month after termination of the programme for a follow-up assessment. Group members again completed the CIHQ, IES-R, MHC-SF, PTCI and the post-test of the self-developed schedule in order to determine the impact of the programme on police officials' psycho-social wellness. The group worker closed the PTP by affording group members the opportunity to say goodbye to each other and to communicate openly about what this means to them.
Post-treatment assessment
The CIHQ, IES-R, MHC-SF, PTCI and the post-post self-developed questionnaire were again completed by the group members three weeks after termination of the programme. The process was administered in a group by an independent group worker. The aim was to determine whether there was an improvement in the participants' overall psycho-social wellbeing after participation in the PTP, even three weeks after termination of the programme.
DISCUSSION
The objective of this article was to develop a PTP that is sensitive and responsive to the needs of police officials after exposure to traumatic events. The programme aims to empower police officials attached to specialised units with the necessary knowledge and skills to cope better with the signs and symptoms after exposure to trauma. Its features are that it is proactive in nature with an emphasis on the prevention of post-traumatic stress or any other co-morbid disorder, promotes resilience, recovery and systems of care, is attractive, accessible and responsive, and provides safe services.
The specific needs of police officials attached to the specialised units of SAPS in the North West province, including their emotional and social needs as identified through a needs assessment, formed the foundation when the PTP was planned and compiled. Various evidence-based models, perspectives and existing guidelines regarding group work with traumatised police officials were taken into consideration during the planning process. The screening criteria for inclusion in the programme were discussed as well as how the programme will be presented in the group.
The programme comprises the objectives, aims and contents of an integrated educational and therapeutic group work programme consisting of 12 sessions. The contents of the group work programme have been presented schematically, after which it has been discussed in detail with reference to the themes, namely psycho-education, relaxation, trauma narrative, identifying emotions, feelings and thoughts, rating of feelings and affect modulation, altered thinking, challenging destructive and self-destructive behaviour, problem solving, managing trigger events, changes in systems of care, systems advocacy and relapse prevention. The article explains the intervention techniques that assist the social worker and the group members to achieve the goal. It also explains a variety of resources and activities, as clinically indicated, for example, role plays, relaxation exercises, worksheets, surveys, therapeutic games and music, which provide the framework for each component of the PTP. These activities were developed for implementing the PRACTICE component of the PTP.
A PTP is recommended for police officials exposed to traumatic events as it builds a set of skills that enable an individual to relax, to remember, to verbalise traumatic events, to be capable of identifying how situations, thoughts and behaviours influence emotions and to improve feelings by changing dysfunctional thoughts and behaviours, to challenge destructive and self-destructive behaviour, to manage trigger events, solve problems, change systems of care, to use systems advocacy for addressing instability in the social environment, and to know how to prevent a relapse. The acquisition of new skills not only has a positive impact on the individual, but also on the interconnected systems of care. The process of skills acquisition is collaborative. Skill acquisition and practical activities are what set this kind of therapy apart from "talk therapy." With their psycho-social needs addressed, these police officials should be more empowered to cope with acute post-traumatic stress reactions and their impact on their systems of care, preventing the possibility of developing long-term distress, for example, post-traumatic stress or any other co-morbid disorders.
RECOMMENDATIONS
The PTP addresses the psycho-social needs of police officials. They are empowered to cope with acute post-traumatic stress reactions and their impact on their systems of care, thus preventing the possibility of developing long-term distress, for example, post-traumatic stress or any other co-morbid disorders. Based on the discussion of the results from this study and on the conclusion drawn, the following recommendations can be made:
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The intended use of the PTP by mental health professionals within the SAPS (Employee Health and Wellness) is subjected to training in the PTP;
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The PTP includes activities that require certain techniques. It is therefore important that these techniques be practised in session and labelled as homework;
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The group worker should be creative and concentrate on the police officials' strengths and interests during the group sessions;
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Some of the activities included in the PTP may not be appropriate for all police officials, and hence flexibility needs to be balanced with fidelity to the treatment model;
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With their psycho-social needs being addressed or met, police officials should be more empowered to be able to cope with the reality of trauma caused by their unique working environment; and
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A PTP is therefore recommended for police officials attached to specialised units who are involved in and affected by trauma as a result of their unique working conditions.
CONCLUSION
Police officials exposed to high-risk situations can gain important skills to cope with trauma through group work programmes. The PTP has been designed in correlation with the needs of police officials at risk of developing psycho-social problems. It can be utilised for police officials exposed to unique work demands to fight the battle against long-term distress. The PTP can be seen as a structured, constructive and 'non-threatening' way of providing support to vulnerable police officials who find themselves in an environment in which stress-related problems are usually stigmatised. New technology has been developed and implemented in empowering police officials to deal with the signs and symptoms following exposure to traumatic events to better deal with trauma and prevent post-traumatic stress or any other co-morbid disorders. In this article the objective of the study was outlined and related terminology discussed. Guidelines for group work with traumatised police officials have been provided and the screening of members for inclusion in a group was discussed. The main focus of this article has been on the themes and content of the designed PTP. The contents of the group work programme was presented and discussed schematically with respect to the specific subject, aim and content.
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