The Experience of Therapy by Therapists and Survivors after Exposure to Armed Robbery

Abstrak Abstract In hierdie artikel word die resultate bespreek van navorsing wat gedoen is om vas te stel wat die belewenis van terapie is deur onderskeidelik die oorlewende van gewapende roof en die terapeut van die oorlewende van gewapende roof, waar terapie voortydig deur die oorlewende van gewapende roof gestaak word, 'n Hoë persentasie van terapie vir die oorlewende van gewapende roof word voortydig deur die oorlewende van gewapende roof gestaak en lei daartoe dat die indiwidu wat aan hierdie tipe van geweld blootgestel was, nie al die moontlike geleenthede tot herstel kan benut nie. Die navorsingsvrae wat hieruit ontstaan het is: " Hoe beleef oorlewendes van gewapende roof terapie nadat hulle blootgestel was aan 'n gewapende roof? " en " Hoe beleef terapeute terapie met die oorlewende van gewapende roof? " 'n Kwalitatiewe, verkennende, beskrywende en kontekstuele navorsingsontwerp is gebruik. Fenomenologiese, semi-gestruktureerde onderhoude is met oorlewendes van gewapende roof en terapeute gevoer ten einde hulle belewenisse te verken en beskryf. Daar is bevind dat terapie tot belewenisse van woede, vrees, hartseer en vrede lei. Die behoeftes van oorlewendes van gewapende roof wat gedurende terapie geïdentifïseer is, is behoeftes aan omgee, beskikbaarheid, empatie, luister, fokus op die gewapende roof, hulp met hantering van probleme, 'n vertrouensverhouding met die terapeut, sensitiwiteit deur die terapeut en omgee deur belangrike ander vir die oorlewende van gewapende roof. Hierdie behoeftes is deur beide die groepe geïdentifiseer. Wanneer daar nie in dié behoeftes voorsien word nie, word terapie voortydig gestaak en as onsuksesvol beleef. Drie beginsels vir terapie is ook geïdentifïseer, naamlik terapie moet so gou moontlik 'n aanvang neem, die verloop en tegniek moet verduidelik word en simptome wat verwag word moet verduidelik word. In this article the results of research undertaken to ex­ plore the experience of therapy by respectively the sur­ vivor of armed robbery and the therapist of the survi­ vor of armed robbery in the case where therapy is pre­ maturely terminated by the survivor of armed robbery are discussed. A high percentage of therapy for the survivor of armed robbery is being terminated prema­ turely by the survivor. This might be the reason for failing to use all possible opportunities to recover within reasonable time. The research questions that arouse are: " How do survivors of armed robbery experience therapy after being exposed to armed robbery? " and " How do therapists experience therapy for the survi­ vor of …

In this article the results of research undertaken to ex plore the experience of therapy by respectively the sur vivor of armed robbery and the therapist of the survi vor of armed robbery in the case where therapy is pre maturely terminated by the survivor of armed robbery are discussed.A high percentage of therapy for the survivor of armed robbery is being terminated prema turely by the survivor.This might be the reason for failing to use all possible opportunities to recover within reasonable time.The research questions that arouse are: "How do survivors of armed robbery experience therapy after being exposed to armed robbery?" and "How do therapists experience therapy for the survi vor of armed robbery?"A qualitative, exploratory, de scriptive and contextual research design was utilised.Phenomenological, semi-structured interviews were conducted with survivors of armed robbery and thera pists of survivors of armed robbery to explore and de scribe their experiences.It was found that therapy leads to the experience of anger, fear, sadness and peace.The following needs of the survivor of armed robbery in the course of therapy were identified: a need to be cared for, availability, empathy, listening, focus on the armed robbery, help with the handling of problems, a trustworthy relationship with the therapist, sensitivity by the therapist and caring by important others in the life or the survivor of armed robbery.These needs were identified by both groups of participants.When these needs are not met within therapy, therapy is ter minated prematurely and experienced as unsuccessful.Three principles of therapy were identified, namely that therapy should start as soon as possible, the trend and technique should be explained and signs and symp toms should be explained.

Background and orientation
In the past five years armed robbery escalated dramatically according to the numbers published thereof.From January to June 1997 a total number of 3 896 armed robberies were referred to court (Bothma, 1997:3).Within two days in Sep tember 1999 five cash-in-transit robberies took place in and around Johannesburg (Steenkamp, 1999:2).From January 1997 between 244 and 351 cases of armed robbery of vehi cles are reported per month (Van Zyl, 1999b: 14).It is no wonder that South Africa's budget for safety and security for 1997 represent a 15% increase compared to the figures of 1996 (Thiel, 1997:2).
The tendency of mental health problems due to exposure to life-threatening situations increases in the same ratio to the increase of these situations (Rautenbach, 1997:10).In a study where one thousand and seven respondents were used, it was found that a 39,1% chance exist that a person exposed to a traumatic situation would become mentally ill because of it (Davis & Breslau, 1994:290).
Healthcare by means of therapy is usually recommended, as it can save expensive expenditures for medication and admission when a mental health problem is left to become worse (Davis & Breslau, 1994:290).
Premature termination of therapy was observed by 77% of clients exposed to group therapy and 32% of clients ex posed to individual therapy (Allen & Bloom, 1994:433).

Problem statem ent and research objectives
The researcher and fellow therapists found that survivors of armed robbery do not complete therapy.This might be the reason for failing to use all possible opportunities to recover within a reasonable time and may even lead to a need for more aggressive, expensive types of therapy like medication and admission.
The following questions arouse: ''How do survivors of armed robbery experience therapy after being exposed to armed robbery?" and "How do therapists experience therapy for the survivor of armed robbery?" The objectives of this research were to explore and de scribe the experience of survivors of armed robbery and their therapists of therapy after the armed robbery to un derstand why therapy is terminated prematurely.

Research design and method
A qualitative, exploratory, descriptive and contextual re search design was utilised (Schurink, 1998:240,280;De Vos & Fouché, 1998:80).In the first step of the research phenomenological, semi-structured interviews were con ducted with survivors of armed robbery who terminated therapy prematurely as well as with therapists of survivors of armed robbery where the survivors terminated therapy prematurely.Interviews were transcribed verbatim.Field notes were taken down in the course of the interviews and thereafter.Two coders then analysed the raw data and followed it up with consensus interviews as directed by Tesch (in Creswell, 1994:152).
The population for this research consisted of survivors of armed robbery as well as the therapists of the survivors of armed robbery.Purposive sampling was done based on the criteria of: Participants were invited to take part in this research project voluntarily.They were assured that they could withdraw at any time without penalty.All information regarding the re search were provided to possible participants so that they could give their informed consent.Measures to ensure anonymity and confidentiality were described.No names were used in the interviews.The audio taped recordings of the interviews were kept under lock and key and were de stroyed after the verbatim transcription of the interviews.
The telephone number of a counsellor was provided for participants needing support after the research interview.
The researcher also undertook to provide feedback on the research results to those participants requesting it.

Measures for ensuring trustworthiness
Throughout the research Guba's model for trustworthiness as described in Lincoln & Guba (1985:289-331) was used.
Truth-value was ensured by utilising the strategy of cred ibility and applicability by applying the strategy of trans ferability.Consistency was ensured through the use of the strategy of dependability.Neutrality was obtained by ap plying the strategy of confirmability.
Table 1 is a summary of the strategies used to obtain trust worthiness.

Data-collection
Phenomenological interviews were conducted with partici pants by the researcher.The research question posed to survivors of armed robberies was: "Tell me about your ex perience of therapy after being exposed to an armed rob bery".The question to therapists of survivors of armed robbery was: ''Tell me about your experience of therapy with survivors of armed robbery".If it did not come natu rally, participants were asked about the experience they had with premature termination of therapy by the survivor of armed robbery.
The participants were lead to tell their experience in a narra tive style with the least possible disruption and the use of non-verbal techniques like nodding, minimal verbal re sponses, paraphrasing, open-ended questions, reflection of feelings and a summary at the end of the interview (Hollway & Jefferson, 2000:31;Okun, 1987:76-77).
During the course of the interviews and thereafter, field notes were written by the researcher (Woods & Catanzaro, 1988: 283).The interviews were verbatim transcribed to enable coders to analyse the data.

Data analysis
The data were analysed by two coders separately from each other, the independent coder being a psychiatric specialist with experience of coding of qualitative research, and the researcher self.
A protocol for coding was described and supplied to the independent coder.The protocol was also adhered to by the researcher.Steps that had to be followed were: Gather information for all categories and do a pre analysis.
Consensus discussions between the independent coder and the researcher, with follow-up discussions between the researcher and promoters were held.
A literature control was conducted to verify the results of the research.Results are described in three main catego ries, namely feelings experienced, needs of the survivor of armed robbery within therapy and principles of therapy.
With each theme a translated quote will be given and it will be supported by some literature quotes.

Results, discussion and literature control
Phenomenological interviews were conducted by the esearcher with two groups of participants, the survivors of armed robbery and therapists of survivors of armed rob bery.One pre-study interview was conducted with a survi vor of an armed robbery.Eight further interviews were conducted with survivors of armed robberies, of which four were females and four were males.The armed robberies which these individuals experi enced include bank-supermarket-and other shop robber ies.The participants included security staff, sales persons, as well as managers of the involved businesses.The ages of the participants varied from eighteen years to fifty five years.Three of the interviews were conducted in English and the rest were conducted in Afrikaans.
Five interviews were conducted with therapists of survi vors of armed robberies.Three of these therapists were females and two were males.The therapists originated from different disciplines including psychology, social work and theology.The ages of the therapists varied from thirty years to sixty years.All the interviews were conducted in Afrikaans as that was the language of preference (Marais, 2001:38-39).
On the research questions posed to participants, both sur vivors of armed robbery and therapists of survivors of armed robbery, reacted firstly by describing the feelings experienced in therapy.The four major feelings that were experienced were feelings of anger, fear, sadness and peace (Marais, 2001:40-75).

Experience of anger
A survivor of armed robbery worded his feelings as fol lows: "But I don't know, 1 have the feeling I cannot trust them.I do not know they... may be because it happened.Because I have... look I... in my work I must be friendly to anybody... even if they are who... when they enter 1 greet them... now if I know them then 1 ask how they are and so on... but at that moment everything was destroyed... why was I friendly to them and they treated me like this..." Unsatisfaction with the therapist is also a reflection of an ger experienced in therapy, and was verbalised as follows: "It was actually a waste of time, I felt it did not help me at all".
Therapists also experienced anger towards the robbers while the survivor is debriefed.A therapist said: " .. Therapists also reflected irritation when they had to listen to the same detail over and over for the sake of therapy.A therapist said: .. I sat here at a stage and this person went on about the chain around her neck... and I nearly felt this is irrelevant... Yes it is too much detail... this was not lifethreatening..." In the literature Kenardy, Webster, Lewin, Carr, Hazell and Carter (1996:42) reveal that 20% of people reckon after de briefing that it did not help them at all and see it as a waste of time.

Experience of fear
Participants in both groups experienced fear in therapy.
Survivors would experience fear when talking about what happened as follows: "... that is now when it comes back sometimes... when I become nervous or fear or so then my whole body starts to shiver".
Fear is also experienced by the survivor of armed robbery about the process and uncertainties about therapy.A sur vivor says: "... so I said to him I am scared..." and .. may be I can find something about myself that I did not want to know..." Therapists experience feelings of fear and uncertainty within therapy.A therapist verbalised: " I doubted because it was too quick for me... and you get to a stage where you feel, but now he is okay... this person's character and personal ity was... if I kept on hammering he would have left me totally".
Therapists also experience fear about the escalation of armed robbery and the threats it holds for them: "... you know from time to time I would wonder when will it happen to me..." Casement (1985: 146) reflects in his notes on internal super vision: "I could feel myself becoming increasingly anxious. 1 realised that 1 was on the receiving end of a powerful projective identification; yet I was not sure what exactly was being put into me...I felt afraid".Peplau (1988:139) states that a therapist will find it hard to establish rapport when her own anxiety levels are too high.This will de crease her ability to concentrate and observe.

Feelings of sadness
Survivors of armed robbery experience sadness about the losses through the robbery as reflected by this 18 year old boy: "As I would ask why was my friend shot dead... one have to accept it and the Lord determined that".
Sadness is also experienced as powerlessness and disap pointment when he feels that others do not understand him.A survivor of armed robbery worded it as: "My medi cal aid could not pay it anymore because uhh...I was prom ised the Bank would pay... so 1 had to terminate or sit with debt of two-, three thousand Rand.. and "... but it didn't really felt as if she understood me so well you know it really felt as if she wasn't really interested... she... it is just her job".
Therapists experience sadness when they feel powerless about their inability to alleviate the pain of the survivor of armed robbery as said by a therapist:" .Therapists experience hopelessness about the future of the country when they are too much exposed to therapy of survivors of armed robberies.A therapist said:"We are sitting in a country where people are traumatised... it is a country of shattered assumptions... these broken expecta tions that are only confirmed and confirmed which leads to a feeling that it is going bad and worse and then I can just expect that it will get even worse".Dyregrov, Kristoffersen and Gjestad (1996:552) report that therapists experience feelings of uncertainty and a feeling that life can not be predicted.These writers also note that in the case of helpers at big bus accidents, the helpers become overanxious about the safety of their relatives when they are about to use bus services.
The behaviour of survivors of armed robbery can also hurt therapists, as is the case with the following statement: ".. .donot come with that religious scrap to me, go away!He thus chased me away..."  Frankl (1979: 18-24) describes that peace is found when sense can be discovered from senseless critical situations, and names it "survival value".

Experience of peace
The needs of survivors within therapy will now be dis cussed.

Needs of the survivor of armed robbery within therapy
The needs of the survivor of armed robbery that were iden tified by therapists and survivors themselves are needs for caring, availability, empathy, listening, focus on the armed robbery itself, help to handle problems, a trustworthy rela tionship with the therapist, sensitivity by the therapist and caring from important others in the life of the survivor of armed robbery.These needs will now be discussed to gether with verbatim quotes and appropriate literature.

The need to be cared for by the therapist
Survivors of armed robbery have a need to be cared for in therapy.If this need is not met, premature termination of therapy by the survivor of armed robbery often follows.A survivor that did not experience being cared for said: .. it did not help much.I do feel a little bit better but that is 0.5 to 1.00 better" (Fieldnote: terminated after two sessions with different therapists).
Where caring is being experienced, therapy is seen as suc cessful, as seen through the eyes of this survivor: "1 think it was good that I went to talk to someone, somebody to who you can tell what happened and how you feels and what you must do about it and who must do what..." Therapists also feel that caring must be given in therapy as reflected in the words of a therapist: " .. .andthen you have a atmosphere of caring for each other and that is good for them".Mitchell (1986b:24) explains caring within therapy as fol lows: " Talk to the victims.They need lots of reassurance and guidance....When appropriate, a gentle touch of the person's hand or shoulder may be extremely helpful".

Need for availability by the therapist
Therapists for survivors of armed robberies should be avail able to their clients as reflected by a survivor: "Ja... she did she said that I should actually phone her... or she would phone me every two weeks..." (Fieldnote: Premature termi nation after one session only.No telephonic contact was made).
Therapists feel that extraordinary measures can be taken to accommodate survivors of armed robberies as said by a therapist: "...if a client do not pitch for a appointment, I phone them myself...I make a offer to have another ap pointment..." and "I think it can be problematic to only stick to appointments, because if there are problems you cannot see him immediately in case of a crisis".
According to Rubin (1990: 257) a team of therapists who are "genuinely committed to responding within seventy two hours of an incident" is the most successful.
Need for empathy by the therapist A participant in a study of Robinson and Mitchell (1993:377) described the worth of empathy as follows: "Knowing that I was not alone and that we shared common feelings".
Empathy is seen as one of the conditions for effective help by therapists (Manton & Talbot, 1990:511-512).

Need for listening by the therapist
Survivors of armed robbery do have a special need to be listened to.A survivor reflected on the success of skilled listening by a therapist as follows: ''And as I started to talk each time that I went there something came out... it was as if something was lifted from me" Therapists acknowledge the worth of listening to the sur vivor of armed robberies with the following words: "... and many a time I just sat there and he talked... and he had the need to tell..." (1994: 400) words it as follows: "... the act of listening both in depth and with empathy may be the criti cal element in healing and this is likely to be the case par ticularly with traumatised people".

Need for focus on the armed robbery
Survivors of armed robbery feel that they went for therapy because of the robbery, therefore they need to focus on it instead of focusing on other aspects of their lives.A sur vivor that terminated therapy said: "Let me tell you he spoke on a lot of private things with m e... this bothered me in a way, a bit" Therapists that were participating in this study felt that the focus of therapy should be on the robbery and not on other underlying factors.A therapist's words were:" ... re living the incident...yes I focussed on that... the trauma.What do you smell what do you feel?" Lundin (1994: 387) states it that crisis interventions must be early, short and problem focussed.
Need to be helped with the handling of problems Survivors of armed robbery have problems to handle daily problems without help.They do have a need to get sup port and advice from the therapist, as reflected here: " They advised me to cry when I feel sad.. .If you feel like crying, then you should go somewhere and cry..." Therapists also feel that some advice can be given to survi vors of armed robbery to help them to cope with daily prob lems.A therapist said: "A lot of people can despite all... and they function quite normal... and then they know that when I get a nightmare, I can handle that like this..." Duckworth (1990: 13) views practical advice on how to manage problematic situations at home and at work as psy chological first aid and sees it as an essential point of de parture for therapy.

Need for a trustworthy relationship with the therapist
Survivors emphasised the importance of trust in the rela tionship between the therapist and survivor of armed rob bery."At more or less the third time I was more at peace... it was as if I could talk immediately..." Where trust did not exist, termination was more certain to happen for example in the case of the following experience by the survivor: " Well the guy that I actually saw didn't impress me at all.. .''(Fieldnote:termination of therapy after second session).
Therapists felt very strong about establishing a trustwor thy relationship as worded by the following therapist: " ... that initial real contact... and that the person can link with you..." Ochberg (in Allen & Bloom, 1994:427) states: " The thera peutic relationship must be collaborative, leading to em Curationis powerment of one who has diminished in dignity and secu rity..."

Need for sensitivity by the therapist
Therapists need to be sensitive to the needs of their cli ents, as reflected in the following statement: " ... and I gave him a negative answer to show that I didn't want to discuss that... Then he understood I didn't want to talk about it".
Participating therapists in this study realised that they need to be sensitive to the survivor of armed robbery.A thera pist said: " ... I naturally started with relaxation therapy, because he was so nervous".
Well-known therapist, Carkhuff (1969:23) states it as fol lows: ''While structurally directful, the helping program is constantly shaped by the feedback from the helpee con cerning what is effective for him".
Need for care by the important others in the life of the survivor of armed robbery Although the need to be cared for by important others cannot be fulfilled within therapy therapists should try to help them to do so.Such an important other can be the employer who would not necessarily know what to do.The need for a better understanding and care is seen in the following words from a survivor: " ... with whom we are now, they said you can only take off such or such a time..." (Field note:Therapy terminated because off times did not suit therapist).Rubin (1990: 257) reports that in the case where employees are allowed to have therapy in on-duty time, attendance are good and people seem to benefit by therapy.
Three principles for therapy will now be discussed.

Principles for therapy
Therapy should commence as soon as possible In interviews done for this study, both therapists and sur vivors of armed robberies reckoned that therapy should commence as soon as possible after exposure to the trauma of armed robbery.Therapy that commenced early thereaf ter was seen as more successful.
A survivor of armed robbery reflected as follows: " I went to the psychologist the next day after the robbery...I never had any nightmares or any you know any flashbacks it meant to me that therapy does work..A therapist's meaning on the commencement of therapy was:" It is very intensive therapy... so uhh... so as usual I do not work for very long with people, but if I can com mence shortly after... while the thing is still warm...I could get away with eight sessions...uhhh if it was after some time and it became post-traumatic stress, then I would say I am working on a average of fifteen to eighteen sessions.
In the literature the same information was found.Emo tional support and physical presence are seen as very im portant from the time directly after the trauma until the worst shock is over.It is said that a typical debriefing should take place within two to three days after the trauma.Individuals that were debriefed shortly after exposure are less prone to develop post-traumatic stress disorder.It is also said that interventions within 24 to 48 hours after the trauma reduce the long-term effects of the trauma (Bisson & Deahl, 1994:717, 718;Beyers & Joubert in Louw, 1989:152;Mitchell, 1983:36,37).
The trend and technique of therapy should be discussed The signs and symptoms expected must be explained.
Survivors of armed robbery have a need to know what symp toms to expect.This is the knowledge that a therapist should share and use to assure the survivor of her/his normality.When they know that all survivors would experience these symptoms, they feel at ease and do not become obsessive with their symptoms.
A survivor worded it as follows: " You talked about it and you know exactly what to expect... the symptoms you can expect...With the therapy you understand that this can happen and it is normal... you know how to handle it".A therapist reflected: " ... we tell them you can expect to get nightmares... so that you basically work preventative and so that they have something to measure themselves if they are normal".Mitchell (1986b:25) summarises it as follows: "The group leader provides reassurance that what the members of the group are experiencing is a set of normal reactions to a bad incident and that they are not going crazy".

Caring for the therapist
In this study it was clear that therapists themselves also need to be cared for.Therapists that only work with these highly traumatised survivors were traumatised themselves.
A therapist's reflection was: a person is naturally in such a situation as therapist also aware of how exposed we are and I think one must be careful not to become paranoid about all the things that you are exposed to..."

Conclusion
Therapists and survivors of armed robbery experience feel ings of anger, fear, sadness and peace within therapy.The needs of survivors that should be met within therapy are needs to be cared for, availability of the therapist, empathy and listening by the therapist, focus on the armed robbery, help with the handling of problems, a trustworthy relation ship between therapist and survivor, sensitivity from the side of the therapist and help to receive caring by the im portant others in the life of the survivor.The three princi ples of therapy identified by both groups were: therapy should commence as soon as possible after the trauma, the trend and technique of therapy should be discussed with the survivor of armed robbery and the expected signs and symptoms following this trauma have to be discussed with the traumatised.
Finally it was found that therapists dealing with this type of therapy also are in need of caring.

Lim itations
Limitations were limited by using an independent coder and consultations with study leaders.The usefulness of this information is of limited worth if it is not taken further into specific guidelines for therapy.

Recommendations
Regarding promotion of better therapy for survivors of armed robbery, recommendations for nursing practice, nurs ing education and nursing research will now be discussed.

Nursing practice
Specific guidelines for therapy for the survivor of armed robbery should be developed through further research to make the information gained through this study useful to nursing practice.
. my own reaction to what happened to him... in the sense that I became angry and upset about that what happened to him with the trauma and the unfairness and what happened to him... what was done to him and there is nothing you can do about it..."

Table 1 :
Strategies to ensure trustworthiness ConfirmabilityConfirmability -This was possible through the keeping of all records Triangulation Reflexivity -As discussed -As discussed Peace and satisfaction is experienced by therapists and survivors of armed robbery within therapy.A survivor reflected: ".. .It was not nice to talk about it, but you do feel better when you are finished... you feel more comfortable... and even more comfortable and later on you start to forget it", "... she really helped us...I must say she was very good" and: ".. .moreorless with the third time I got a feel ing of peace..."Therapists do also experience peace and positiveness in therapy.Therapists stated:"Positive in the way that she could verbalise very well, she was anxious to verbalise..." and "...he was very aggressive about them but as time went on his attitude changed towards them because he realised... they did not partake in what happened to him".Survivors experience happiness when they start to add meaning to the crisis: ".. .1 can say it brought me nearer to my people... can I tell you... my feelings for my wife... after what happened I felt more close to my family..." Survivors of armed robbery who experience therapy as positive reflected as follows on empathy by the therapist: "And he understood what I said... and that gave me peace... that someone understands of what I am talking" and ".. .someonecan understand what I was going through... " Therapists see empathy as one of the most important as pects in therapy, as stated by a religious therapist: "... and they will tell you they are very angry with the Lord... and that you should be able to tell them 'That is okay' .. .ifI can put it simple... this person needs reassurance on every level..." Survivors of armed robbery do not know the trend and technique of the therapy, they are influenced by previous experience and stories and may have preconceived notions based on these.All these influence their co-operation and experience.It is ideal to discuss the trend and technique of therapy with the survivor to decrease the abovementioned and anxiety due to fear of the unknown.A survivor that terminated therapy after the first session, reflected as follows: ''Well I was expecting her to ask a lot of questions and to ask how my feelings are about this and you know typical picture of a psychologist showing inkprints and stuff... but she didn't... she just asked me what happened and I told her..."