CONCEPTUAL PAPER
 
CHAPTER I: INTRODUCTION
 
Studies on psychological trauma have identified social workers as “first responders” in numerous work settings as subject to secondary traumatic stress, or Secondary Post-Traumatic Stress Disorder (SPTSD), which can not only hinder their work, but also prove debilitating. SPTSD encompasses a spectrum of work-related reactive states: burnout, depression, feelings of being overwhelmed or unsafe, losing trust for other people and/or institutions, experiencing personality shifts such as cynicism or social withdrawal, and disconnection from things or people once important to one’s life (Ziberoff and Hartman, 2015). One study showed that “15 percent of social workers engaged in direct practice report Secondary Traumatic Stress symptoms at a level that meets the diagnostic criteria for PTSD” (Bride, 2007). According to Bride: “First responders are highly susceptible every day to exposure to stressful or traumatic incidents that will affect their own mental health, and they are often overlooked in terms of needing or receiving treatment.” These statistics and studies were referring to social workers in the developed world, often collectively called the West.
Social workers do not only engage in their duties in the West, however. Internationally, North Africa and the Middle East (MENA) region societies have been described as possessing a history of approximately 80 years with the profession of social work, having often adapted colonial or Western approaches to the practice. Social workers in the developing world overall, including MENA, have applied Western approaches with success usually derived from selective applications in communities (Graham and Al-Krenawl, 2013). There are few studies on the ill effects of stress suffered by social workers working professionally in societies in the MENA region, even though they are engaged in settings in societies facing dramatic conflict; some accounts reveal the trauma experienced by volunteer social workers engaged in relief operations, such as refugee camps (Hardy, 2016).
However, as the nightly news exemplifies, and has been documented in a prolific number of broadcast and news periodicals, year to year to year, there are abundant opportunities for extreme stress-producing experience for social workers in the MENA region. Geographically, the region extends from Morocco eastward through Algeria, Tunisia, Libya, Egypt and the Sudan (some maps include Somalia on the east African coast); northeasterly to Jordan, Lebanon, Iraq, Iran in the central MENA territory, eastward still to include Bahrain, Qatar, the UAE, Oman, Yemen and Saudi Arabia in the Gulf States region; and Afghanistan and Pakistan, farther east (ResearchGate.net, 2017).
MENA countries are diverse from one another, for the most part, but possess unifying features, such as the embrace of Islam and its authoritarian religious system of government, Sha’ria law, as well as populations which are largely heterogeneous and youthful. As in other parts of the developing world, some countries here have difficult histories of European colonialism and/or Western-initiated militarization, intervention, or war. Some MENA countries have confronted unanticipated challenges maintaining their traditional cultural identities as development partnerships with the West have grown to dominate economic priorities and pit these against cultural autonomy and/or development of sustaining industries beyond those on which the West is focused, such as oil. Some have had difficulties organizing themselves politically, economically or socially as globalism has pushed them into a future they allowed, but which they did not strategically plan. It was not by way of strategy, for instance, that the Kingdom of Saudi Arabia has welcomed cultural shifts that many believe are destroying the traditional Wahabbist culture, causing in-fighting between groups, and within families as strong, binding traditions are perceived as threatened. Fallout in the Saudi Kingdom, for example, has been seen in a significant increase in domestic violence (Al Arabiya, 2016).
In addition to internal changes to social and/or family structures, there are any number of uncertainties impacting societies, which are of an external nature. The MENA region is a hot spot for ongoing civil and foreign-instigated wars, mass kidnappings, Islamic State encroachment, and/or military occupations by U.S., Russian or allied military forces. All have combined to foster an atmosphere of extreme chaos and unpredictability in certain parts of the MENA region. This has escalated since the end of the short-lived Arab “spring.”
 
            Statement of the Study Issue
A survey of specific challenges to individuals serving in a social worker capacity, whether professional or as a volunteer in the MENA region, is likely to reveal circumstances that seem volatile as compared to the experience of U.S. practitioners; and many experiences, in fact, which would unquestionably provoke Secondary Post Traumatic Stress among social workers or other professionals in the same scenarios. This study seeks to unveil special challenges that exist in the region, through a systematic review of scholarly work detailing cultural, social, political and family landscapes in the MENA region that demand the involvement of social workers, and the continuing therapeutic supports they bring.
Today, on a professional or volunteer basis, as it is typically volunteers who provide social work or related services in refugee camps (Hardy, 2016) social workers provide assessments, assist with stabilization and connect resource organizations with distressed people. Those assisted may be victims of a very broad spectrum of issues. Some are the victims of socially sanctioned traditional violent behaviors; others may be victims of violent or criminal acts which for reasons pertaining to political instability, neglect, terrorism, war, and/or social dissolution, have few protective or restorative resources (Hardy, 2016). Negative outcomes for social workers dealing with such challenges include being predisposed to Secondary Traumatic Stress and its subsequent states, various forms of shock and related syndromes such as inability to recover, drug or alcohol addiction, and/or denial and withdrawal, etc. (Zimberoff and Hartman, 2015).
Two primary research questions are established for the study to investigate:

  1. To what extent do MENA region social workers experience secondary traumatic stress disorder (STSD) during the course of their work experience and what forms are most prevalent?
  2. Are female MENA-region social workers more or less adversely affected by secondary post-traumatic stress than male professionals in the same field, clinical, or other settings?

 
Purpose of the Study
This study will report findings on social workers currently involved in their profession, whether paid or volunteer, in the MENA region, toward uncovering these caregivers’ true experiences. Other findings anticipated are the extent of SPTS or similar job-related syndromes, in the course of difficulties social workers face doing critical and life-salvaging work in circumstances to which they are assigned, or in which they serve as paid professionals or volunteers. Findings will be interpreted in light of a systematic review of literature and theoretical perspectives toward presenting new solutions and recommendations for ameliorating SPTSD in MENA region social workers, who deal with some of the most difficult human scenarios in the world.
In posing key research questions by way of a structured survey for social workers engaged in various human need occupations in MENA region environments, the study will uncover a wealth of new qualitative data for analysis and insights from theoretical frameworks. This qualitative data will be analyzed in the interest of new modes of treatment, supports and resilience-boosting strategies for strengthening social workers, while giving them additional tools for coping with SPTSD, shock, and related manifestations endemic to their work, serving the needs of people in volatile social or cultural circumstances that may involve intense and/or prolonged exposure to violence, abandonment, physical abuse or torture, homelessness, and enduring harsh conditions as refugees from war-torn regions.
Social workers engaged as first responders will be the targeted population of the study’s interest. They will be asked to address their reactions, needs, and self-care concerns in situations they have encountered in the course of their work in the MENA region. Resulting analysis will lead to new professional challenges being delineated as the profession grows further still to assume its important role among MENA cultures, in various stages of social transformation.
 
involving cultural or political upheaval, economic hardships, ongoing military conflicts such as civil war and terrorism, and in general being in the throes of regional progress in a globalized world perceived by many within MENA territories to be dominated by Western hegemony. The regions the study will focus on, in particular, will have social workers engaged in demanding circumstances in war torn regions; and in the traditional culture of Saudi Arabia, a nation poised to undergo radical socioeconomic changes, which may exacerbate family violence.
Significance of the Study
The social workers of concern to this study are on the front lines of societies confronting the trauma of various degrees of sociopolitical change and resulting upheaval. Populations facing widespread emotional trauma are not new to the world, but rarely have so many fled, without recourse, their homelands for destinations culturally completely new to them, in Western societies, where they remain homeless, crowded, hungry, and facing monumental adaptation challenges (Hardy, 2016).
Social workers exposed to the relentless demands of helping millions make such difficult transitions creates a “huge learning curve for social workers in understanding the massive journeys people are making and the situations they have come from…” (Ibid). The knowledge shared from their experiences “will be vital,” as crises show signs of continuing for the foreseeable future. It is vital to assist social workers in gaining new tools with which to maintain their own strength, sanity, professional wherewithal, and resilience.
 
CHAPTER II: REVIEW OF LITERATURE
Historical Background
Secondary traumatic stress is a recognized concern in the social work profession. The syndrome also goes by terms including “vicarious trauma, compassion fatigue, burnout and Post Traumatic Stress Disorder, also known as a Post Traumatic Shock Response” (Zimberoff and Hartman, 2015). The identification of shock “as a primary physiological symptom of traumatic stress” is key to enhancing the resilience of social workers and promoting the valuable notion of “trauma stewardship” or care (Ibid). In order to address such “shock” in social workers in the course of their work, recognizing the symptoms are critical. “Secondary traumatic stress is an occupational hazard of providing direct services to traumatized populations,” note Zimberoff and Hartman (2014); they present the formal definition as follows: “Secondary traumatic stress is the natural, consequent behaviors and emotions resulting from knowledge about a traumatizing event experienced by a significant other. It is the stress resulting from helping or wanting to help a traumatized or suffering person” (Ibid). On the front lines of individuals at risk for experiencing SPTS in the course of their work are, as cited by Zinderoff and Hartman: therapists, mental health and social workers (2014; 2015). Also at risk are psychologists and psychiatrists, teachers, nursing home workers, doctors and nurses, police officers, firefighters, emergency room workers, 911 operators, and combat veterans, and any “who may encounter secondary stress and trauma as part of their daily work.” This means school counselors, church or nonprofit care center youth attendants, daycare personnel, and even sports coaches, i.e., anyone who is involved with children, families or at risk groups. Secondary traumatic stress is also recognized as a “negative transformation of the helper’s inner experience, resulting from empathetic engagement with clients’ and coworkers’ trauma material which is also called the “contagion of shock” and is “exacerbated by regulation, insurmountable restrictions, ad being held accountable for behaviors of clients (Zinderoff and Hartman, 2015).
Thus, the experience of shock or Secondary Traumatic Stress can be an objective or subjective phenomenon, exhibited by outward reactions and signs or symptoms; as well as effecting inner transformations that alter a care worker’s perceptions of her job, client/s, employers, or, in volunteer situations, how the worker views those caught up through no fault of their own in difficult or life-altering transitions, such as fleeing terror or violence, dealing with rape, torture or death of loved ones. Those who exhibit Secondary Traumatic Stress may be professionally engaged in work settings dealing with substance abuse, emergency care, mental health, nursing, domestic violence, health care, child protective services, sexual assault services, clinical social work, the military or other fields (Ibid). The onset of Secondary Post Traumatic Stress can arise in a diverse number of work settings or professional fields, or in volunteer care giver settings, but the symptoms usually reflect the Post Traumatic Stress Disorder (PTSD) or despondency experienced by victims of trauma. Notable symptoms of Secondary Traumatic Stress have been listed by Bride, Robinson, Yegidis & Figley (2004) and include the following (not a complete list): Absenteeism on the job; drinking or other substance abuse; being distracted; having a hard time sleeping; conflicted relationships; loss of empathy; feeling the urge to sleep; arriving late or leaving early to the job; forgetfulness; impatience toward those one is supposed to help, or colleagues.
Incidences of shock or SPTS fall into two primary categories as described by Wilson and Lindy (Zinderoff and Hartman, 2014; 2015). These include Type I, in which the afflicted care worker exhibits avoidance behavior or detachment which is associated with parasympathetic over-activation; Type II is aligned with an active over-identification with the victim, which is accompanied by a sympathetic over-activation. Zinderoff and Hartman list complicated transference reactions in Table I.
Table I. Problematic Countertransference Reactions of SPTS
Somatic reactions / sleep disturbance
Intense emotional reactions (depression, confusion, fear, anxiety and / or rage
Over-identification or detachment from client or those being helped
Intolerance of working with non-traumatized clients, viewing lesser problems as                            less significant
Preoccupation with those they “failed” to help
Loss of appropriate boundaries
 
            As reported by Brian Bird (2007), social workers “may indirectly experience” post-traumatic (secondary) stress and be vulnerable to much higher (double) the risk after repeated exposures to trauma victims. Bird studied social workers experiencing trauma themselves in the wake of treating those most impacted, injured, or facing loss from terror attacks during Sept. 11, 2001 in New York City, and following the landfall in New Orleans, Louisiana, of Hurricane Katrina in 2004. Bird studied social workers serving as first responders in cases of violence such as rape and incest. Bird’s findings indicated that while 7.8 percent of the general population “experience PTSD over a lifetime,” incidence of PTSD among social workers was double that figure. Exposure to trauma victims repeated over time, Bird found, produces thoughts and images in the social worker which become problematic and lead to the syndrome which is the subject of this study, SPTS. The study by Bird was the first to analyze incidence of SPTS in social workers from a broad sample, and not focusing exclusively on victims of combat during war, or excessive community violence.
Bird’s findings found that among 300 practicing social workers from diverse fields within the profession, “40 percent thought about their work with traumatized clients without intending to; 22 percent reported feeling detached from others; 26 percent felt emotionally numb; 28 percent had a sense of foreshortened future; 27 percent reported irritability; and 28 percent reported concentration difficulties” (Bird, 2007). Indirect versions of the disorder were characterized as unbeknownst to the victims. “Social workers hear about burnout and they may hear about self-care but they are not hearing about secondary post-traumatic stress disorder.” Thus, the literature indicates that there may be need for outreach, training, and workshops to help social workers understand any symptoms or reactions they may have that indicate any degree of SPTSD, in the interest of their own mental health.
Study Question 1: MENA Social Workers and SPTS
            The profession of social work in the MENA Region has been studied by Graham and Al-Krenawl (2013), resulting in observations of relevance to this study. Much as colonial patterns of government were adopted by newly independent former colonial nations, Western models of social work have been practiced in various developing societies with mixed results (Graham and Al-Krenawl, 2013; Heady, F. 1985). Though there exist wide cultural, social and political variations among countries in the MENA region, and even between countries characterized as the Middle East proper, the region as a whole is recognized as part of the developing world. MENA region societies are different in innumerable ways from the Western cultures in which social work academic development was first expounded and put into practice.
Thus, the rise of the social work profession in the MENA region has unfolded over decades, coming into its own in a modern era fraught with myriad conflicting cultural forces in a developing region with its share of embedded culture-specific biases, turmoil, violence, and challenges that differ in most ways from social problems of the West. Yet the MENA region also encompasses “Western” social scourges as cultures converge, assisted by globalizing forces like satellite technology, consumer electronics, media and popular culture, international trade, political and cultural alliances, transportation advances, and other progress.
Social workers in the MENA region can find themselves on the front lines of refugee relief, assisting families torn apart by change, or trying to broker a 12-year-old girl’s plea not to be forced from her home as the bride of a 55-year-old man. The scope of challenges are almost beyond the comprehension of the West, and yet, the profession’s recognition of Secondary Post-Traumatic Stress and the risks it poses to caregivers create an opportunity to truly help these professional helpers.
MENA political and/or societal structures range from modern commerce-laden cities like the UAE’s Dubai and Abu-Dhabi; authoritarian religious monarchies such as the Kingdom of Saudi Arabia; to rural tribal societies in Iraq; to militarily sophisticated governments with infamous insurgents like Pakistan and Afghanistan and their respective Taliban and Al-Queda; to military-backed dictatorships such as that of Bashir Al-Assad of Syria; to democratic governments such as that of Israel. In the midst of great social, political, economic and cultural discrepancies, social welfare in the MENA nations as a whole tends to be “instrumental, selective, and not comprehensive” (Graham and Al-Krenawl, 2013).
Some blame colonialism or imperialism, in its traditional and latter day forms, for the geopolitical conflicts, socio-economic inequalities, poverty and political or social unrest, human rights shortcomings, or oppression/repression of individuals and/or groups that exist in multiple sectors of the MENA region. Others point to the conflicting demands of modernization with tradition, as western economic forces exert hegemony with the continuing intensification of globalization. Whatever the triggering mechanisms creating social unrest, impacts on families are increasing as are social problems in the MENA region.
 
Study Question 2: MENA Region Social Worker SPTSD Impacts by Gender
Social workers may find themselves immersed in trying to help, treat or provide support in any or many of these situations, or in scenarios entailing any combination, of such scenarios, notwithstanding the domestic violence, rising divorce rates, or substance issues that characterize societies caught between deep traditions and rapid cultural shifts, economic uncertainties, threats to patriarchal social structures, and political instability, religious oppression or individual persecution. These prospects are notwithstanding the refugee crisis in the Middle East, with attendant widespread refugee camps, as over one million migrants fled the region of Syria alone as of 2016 (Hardy, 2016). Especially difficult challenges exist for social workers: systemic subjugation of women in religious and/or patriarchal societies, gender segregation, culturally enforced religious codes and roles, and in the worst cases, scathing human rights abuses, families separated by war, terrorism, ritual mutilation of girls, female infanticide, legal murder of wives and/or daughters, beating of wives for superficial infractions, and lack of rights in the face of rape, incest, forced marriages of children, or even prolonged war, famine, human trafficking, kidnapping, and systemic torture and/or child molestation.
Social workers are overwhelmingly comprised of women, according to statistics recorded over the past 15 years (Kammer, 2016). Some describe the lack of gender diversity in social work as a “problem” in that too few men create gaps in relational capacity of the profession to men and the problems they experience. Others opine that a profession mostly comprised of females risks asking whether men “even belong” (Kammer, 2016). However, it is a longstanding trend. Statistics from the Council on Social Work Education statistics on Master’s degrees in social work reveal that in 1964, male students earned 42.1 of MSW degrees in the United States, while in 2015, only 13.3 percent of MSW recipients were male (Ibid). International social workers find increasing opportunities in the Third World, with Non-Government Organizations that deal with border-related populations in crisis or transition; serve peacekeeping, humanitarian or emergency missions dispatched by the United Nations or other multi-lateral organizations; serve on international rescue bodies; assist with child relief and /or women’s welfare concerns; serve international public health agencies; work with human trafficking investigations and combat organizations; assist refugees, women and poverty stricken populations; provide special services for the aged; and populations experiencing famine (Cronin, et al 2017). The United Nations recognizes the role of international social workers as integral to its mission, which includes “identifying regional and global aspects of social need and injustice,” and stresses the ongoing significance of NGOs in underpinning advocacy for social needs, and employs consultants (most of whom are presumably women) from 2,700 NGOs, many of which provide social work services (Cronin, et al. 2017).
For purposes of this study, the fact of more women working in the profession, domestically in the United States and in international occupations, including in the MENA region, exposes more women to SPTS and related shock and associated states, to which social workers can be vulnerable.
Because the social workers assisting families in MENA regions are women, and witness sometimes violent, war-addled, or disruptive social change in nations that are recognized as patriarchal, i.e., male dominated, the circumstances of their occupations are likelier to expose them to overt violence or atrocities concerning their own gender, as well as female children. They may witness, and assist, intense scenarios that disproportionately impact, and victimize, women and girls, such as rape in certain societies where rape is not recognized as a crime perpetrated by males, but brought on by women being “in the wrong place at the wrong time,” or inappropriately dressed, as is not uncommon in Pakistan, Iran, Saudi Arabia, Yemen, the UAE, Egypt, or any number of nations subject to Sha’ria law.
Conflicts such as domestic violence are on the rise among traditional families, perhaps confronted with the “deep change” of seeing women eclipse men in terms of professional opportunities. Reports from Al Arabiya, a news organization that covers the Middle East, the largest number of domestic violence cases ever recorded were seen in the Makkah region in 2016 (Al Arabiya, 2016). The reason cited was “growing tension, depression, unrest and lack of self-confidence among men.” Because the Makkah region is more multi-cultural than heterogeneously Arab, cultural conflict has perhaps been more prevalent here. The Al Arabiya news outlet reported:
“Saudi Arabia’s Justice Ministry said courts received 1,498 domestic violence cases during the past Islamic calendar year with Makkah region registering 480 cases including torture of wives and children and abuse of one of the parents. There were 15 cases in which brothers were found to be guilty of torturing their sisters. The Arabic daily explained the major cases as husbands and brothers beating their wives and sisters, humiliating them, locking them inside rooms, usurping their legitimate rights, taking away salaries of wives and sisters and a neglect of children and wives. Social care centers in the region reported two girls being tortured and abandoned by their families. There were two other cases involving torture of children…..the Riyadh region placed second with 333 domestic violence cases followed by Jazan 140, the Eastern Province 116, Asir 110, Madinah 99, Qassim 43, Tabuk 41, Al-Jouf 32, Northern Borders Region 17 and Najran 12. The ministry said cases of domestic violence brought to criminal and civil courts in Makkah region included those related to rape, torture and denial of rights.”
Such horrendous issues, it is reasonable to assume, are the result of cultural disruption and challenges to patriarchal authority. At the center of these conflicts are social workers, working in social care centers, repositories of girls and women attacked by their male family members. It may be assumed that many, if not most, such cases go unreported. This study will be significant in its findings regarding social workers on the front lines of domestic “war,” which it will be postulated, is as vital on its own merits as the experience of SPTS in everyday society’s MENA region social workers as experience in war-torn areas where populations suffer overt shock, are displaced, injured and/or sick, starving, and enduring major family disruption and death.
Afrocentric Perspective
Afrocentric perspective is an “emerging paradigm in social work” (Schiele, 1996). This paradigm is of immense value in evaluating social, economic, political and inter-cultural factors relating to populations of persons of African descent. The Afrocentric Perspective is recognized as of great value to social workers assisting individuals and populations of color, and go far in ameliorating the exclusion African peoples have been subjected to throughout most of history. The lack of value assigned to black cultural values has led to little theoretical knowledge in relation to the actual perspectives of subjugated Africans and their descendants, which Afrocentric ideas can help remediate in modern social work settings (Schiele, 1996).
These populations have been singled out for centuries for brutal exploitation by white populations of European descent, and no corner of the world with African-descended people is free from the centuries-old effects of colonial domination, slavery, murder, genocide and exclusion to which African-originating peoples have been subjected. Today, there is evidence of substantial racism in the MENA region. As Arab and African nations have long been subjected to “racism and imperial conquest” from Europeans and their descendants in the United States, racism has always been a “problem in the Arab world,” according to many (Nashed, 2017).
Abulhawa (2013) acknowledges that anti-black racism is endemic in the Arab world, and has grown out of a history that included the Arab slave trade; and today includes anti-black racism that persists, and is widespread. Drawing a correlation with U.S. racism, Arab nations “import” African and Southeast Asian laborers and neglect the enforcement of discrimination and/or anti-exploitation laws. Such imported labor is commonly subjected to passport theft, forced nearly inhuman conditions, long hours, being forbidden to leave a dwelling, and sexual or physical abuse.
Nashed elucidates how lives of the darker skinned members of the society are devalued, by many accounts: one report tells of a Kuwaiti woman who was trying to kill an Ethiopian domestic worker in her home, and the victim was only able to save herself by falling from a window. “These are not isolated incidents….many Arab countries have maintained the Kafala, or sponsoring system, which ties the legal status of low-wage migrant workers directly to their employer…giving the latter power to take away workers’ passports, withhold their salaries, and subject them to harrowing abuse” (Nashed, 2017). Nashed writes: “Such abuse is common among refugees and non-Western migrants in MENA nations “who are routinely abused by the state, their host community, and even aid organizations founded to help them.”
 
 
Theoretical Frameworks
The Freudian phenomena of countertransference is a theoretical framework which is known to apply to therapists and social workers who cannot apply objectivity to the client or subject entrusted to their professional care (Girard, 2016). Transference is the act of unknowingly, or subconsciously, transferring one’s feelings from a past, personal situation to one’s therapeutic counselor or caseworker. Countertransference occurs when the social worker transfers their past experience or current emotional state to the client (Girard, 2016). Countertransference is integral to social worker and therapeutic professionals’ training and is known to encompass ethical issues related to client confidentiality, boundaries, conflicts of interest, informed consent, and documentation. In a worst-case scenario, a social worker may “lose it,” compromising the ability to serve a client’s needs appropriately (Reamer, 2011).
Countertransference can manifest as an unusual intensity of feelings or empathy for the victim a social worker is assisting, and causes a discreet lack of objectivity which is needed for competent assessment and treatment. The phenomenon of countertransference can create a complex orientation toward a social work client that is overly personal, controlling, worried, extends outside of therapeutic settings, or prompts emotional involvement, anger, or judgments unrelated to the professional relationship. It is also apt to complicate the outcome for the social work client, as confusion and/or emotional entanglement results. Most apt to happen unconsciously on the part of the social worker and received similarly without conscious awareness by a client, the ethical challenge is on the social worker to keep an awareness of the possibility of one’s thoughts or actions being inappropriate, overly personal, etc. (Reamer, 2011).
Countertransference may unconsciously occur as social workers engaged with very sensitive cases involving trauma, neglect, physical or psychological abuse, or other “close to home” set of circumstances, arouse in the social worker feelings of loss of objectivity, fear, obsession, or over-involvement. It is not an uncommon phenomenon and may lend credence to evaluating some cases of SPTS in social workers.
A second theoretical framework is Cognitive Behavior Therapy, a modality for treating severe cases of SPTS in social workers. The therapeutic method has been used to treat many forms of trauma in the past and is valuable for mitigating the threatening or harmful effects of processing trauma, stressful events or situations of an especially difficult nature, and is a “safe and effective” method by which to address many types of PTSD in all ages, with the drawback that up to 50 percent of those treated for PTSD by CBT methods fail to respond to it beneficially (Kar, 2016). The “nature of the study population,” has been observed to be a contingency in responsiveness to CBT for trauma, shock, and related responses that characterize PTSD. Yet its success has been significant in individual, group, and internet-based therapy and counseling (Kar, 2016).
CBT has potential in SPTS treatment for the same reasons it is applied in PTSD cases. CBT “works” by helping alter “maladaptive cognitive distortions” (Kar, 2016), also known as excessive fears or phobias or other cognitive states that result from PTSD, and therefore is a likely modality to be used in successful treatment for cognitive states that result in social workers exhibiting signs of distress, depression, anxiety and/or shock in keeping with SPTS.
 
 
Chapter III: METHODOLOGY
 
Research Methodology
The methodology for this research will take place as a systematic review of relevant literature, and propose methodology for field research incorporating two survey or questionnaire tools: 1) an unstructured, open ended survey of social workers and 2) a Likert Scale questionnaire for respondents that will add quantitative data among those reporting experience with SPTS symptoms. Survey and questionnaires will be anonymous, and care will be taken to carry all necessary Institutional Review Board (IRB) protocols for research involving human subjects (NIH, 2016; IRB, 2017).
The systematic review of literature will focus on the developing world and as such must ethically evaluate cultural phenomena with respect to cultural relativism, without judgment or bias. The review will seek to build a theory from the investigation practice and “not only from academia” however, as suggested by Uggerhoj (2011) and as such will be closely connected to the actual practice of ocial work in the MENA region. Through the systematic review of literature, combined with research tools, the study will combine insights found relevant to the MENA social worker’s own practical experience. A clear understanding of the many manifestations of SPTS in MENA region social workers will be sought, with an eye to applying the observations, data and theoretical perspectives in the literature to individuals working as first responders in social care centers in the MENA region.
Literature research will utilize specific keywords to find highly relevant data on precise study inquiries, backed by empirical or consensus based evidence and published within professional journals. A special effort will be made to find highly reliable research findings that have withstood scrutiny in peer review publications or presentations.
Through a systematic review of highly specific studies, the study will interpret high quality research that lends new insights to the identified problem, i.e., that social workers in the MENA region are likely experiencing a relatively high degree of direct or indirect SPTSD; and that women in particular fulfilling the roles of social workers in MENA region care centers, which deal with domestic violence, may be subjected to special risks regarding, and forms of, SPTS.
 
Inclusion Criteria
The research will create a formal study based on the experience of at least 40 professionals working in social care centers in major cities across the MENA region, including the capital cities of Saudi Arabia, Yemen, Jordan, the UAE, Egypt, and Qatar (with designated participant facilities to be announced as they agree to participate). The first, and most basic, criterion will give social worker respondents an unstructured, open ended survey in which they will be asked to detail their most intensive encounters with stressful client situations.
A second criterion will include a Likert Scale questionnaire on which they can mark, on a scale of SPTS symptoms or manifestations of shock, from one to nine, the level of difficulties they experienced with respect to the intense exposure they record in the open ended survey.
A third criterion will separate respondents who are female from those who are male. At least five percent of social workers enlisted will be male. After sorting responses by gender, results will be tabulated and presented for purposes of contrasting the experience of female and male social workers in the MENA region. Values of responses will give the study quantitative data that can lead to additional gender-segregated studies.
A fourth criterion will focus on the incidence of secondary issues to SPTS experienced during the exposures described. Respondents will be asked to describe any overt or subtle racism, sexism, or other relevant discrimination they experience working as social workers in the MENA region. They will be free to express their views as to whether racism or sexism played a role in the trauma they witnessed leading to symptoms of SPTS, or related symptoms.
Studies will be limited to those undertaken within the last 20 years (covering a period from July 1997 to July 2017). The purpose of limiting the constraint of time is to highlight the most recent contributions of relative research in the interest of resolving the issue, and to elucidate “gaps” relative today that new and future research may address.
 
Keywords
(1) Secondary Post Traumatic Stress; (2) social worker; (3) racism; (4) MENA; (5) mental health; (6) treating SPTS; (7) Shock; (8) trauma; (9) MENA region; (10) social care centers (11) PTSD states.
 
Excluded Areas
The experience of social workers involved in war zones, refugee relief organizations and camps, and areas afflicted by natural or man-made disaster, are excluded from this study. Such “most extreme” social work settings are already adequately covered in the media, including news periodicals, journals of the United Nations or other multi-lateral organizations, or their Non-Governmental Organization (NGO) partners. The effects of SPTS in these extreme conditions, including terrorism, population displacement, exposure to high rates of death and/or torture, are subjects for highly specialized analysis, and this study does not include social workers exposed to these all-too-plentiful scenarios in the MENA region. While it would be engrossing to read a study of social workers assisting young girls taken as sex slaves by the Islamic State, the limited nature of the present investigation is not appropriate to victims of torture or their social work helpers. It is much more appropriate to the “garden variety” dilemmas that surface in very patriarchal societies with regard to women seeking more autonomy. There is enough to provoke SPTS among social workers in “normal” MENA region societies. As an example, women only in the last two years gained the right to pursue a formal education without the permission of a male family member (Al-Sharif, 2017).
 
Limitations of the Study
The first major limitation encountered by the study herein was the lack of scholarly studies on professional social workers’ experiences in the MENA region, including experience of syndromes approximating SPTS in any social care center, clinic, hospital or non-war zone in the MENA region. If any scholarly accounts of social workers encountering coping problems in the course of their everyday job exist fro within MENA nations, they are well hidden; or perhaps uncatalogued in databases. Besides those addressing volunteer social workers’ roles in refugee camps (Hardy, 2016), the lack of scholarly studies on the social worker experience within MENA territories was the single most prominent limitation of this study.
Another limitation was that a high percentage of studies that did report social worker experience in the MENA region dealt with the very extreme circumstances of great international concern such as assisting with major disaster victims, victims of war-related sexual abuse and/or rape, people suffering from combat violence or trauma, human trafficking, and/or terrorism perpetrated by the Islamic State (just to name a few latter day scenarios). Social workers dealing with individuals or populations in desperate circumstances have valuable lessons to give, but the accounts revolving around “most extreme” social work settings marginalizes, if unintentionally, the everyday, common scenarios with which the social work profession is routinely engaged such as domestic violence, child neglect, and/or gender conflicts potentially injurious or deadly to women or girls. Feelings or reactions social workers encounter in more ordinary scenarios lacks scholarly documentation. Yet many violent circumstances are reported. For example, one Pakistani “starlet” was sensationally reported to be murdered by her brother for being too flamboyant and attractive a public personality. Another incident was bi-hemispheric as a Pakistani woman, living in the U.S. with her husband, endured severe, repeated beatings by the husband and attempted to escape him; whereupon his parents traveled by flight into the U.S. for the sole purpose of helping their son beat his young wife. In the U.S. the son and his parents were arrested, yet in Pakistan this is a “routine” occurrence. These are news accounts, which make headlines, but scholarly studies of social workers involved in multiple such “normal” circumstances in MENA region social care settings are scarce.
A final limitation was the exhaustive nature of a search for any documented incidents of known SPTS, involving male vs. female social workers within the MENA region. This resulted in almost non-existent scholarly literature on the negative outcomes from the experiences of social workers in clinical, social care center, or hospital settings, unrelated to terrorism, refugee experience or other “extreme” situations. The systematic review utilized did not contain meaningful studies on social worker experience within the MENA region. This prompted the necessity of developing a survey and Likert Scale questionnaire to gauge qualitative and quantitative data which has been impossible to locate. The research undertaken is indicative that a gap exists in MENA region data as to social worker experience of SPTS in settings or scenarios which are non-war zone related and characterized as common or numerous, are likely to be experienced by many care giving professionals in social work and health care settings. It is deemed that this study can resolve the lack of data, in its own limited way.
                                                 
CHAPTER 4:            STUDY FINDINGS
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