Introduction
Trauma stemming from the experience of domestic violence itself is complex. It has significant adverse effects that spans across an individual’s physical, mental and socio-economic wellbeing [1,2]. Often recovery techniques are aligned to a medical model that addresses the harm through therapy and medication, focusing psychological and biochemical factors, most commonly, posttraumatic stress disorder (PTSD), depression, and anxiety. However, the effects are beyond psychological and extend to intertwine the mindset, physiological changes, and behavioural shifts and vice versa. For example, research confirms that victims of DV are more likely to misuse alcohol and drugs as a coping mechanism, and suffer from, amongst others, a multitude of symptoms including insomnia, and chronic pain [3-6].
Domestic violence can be perpetrated by both men and women; however, women are statistically more likely to be victims [7]. This disparity is influenced by various factors, most notably the persistent inequality between genders [8]. As a result, the severity and impact of domestic violence tend to be markedly greater for women with children becoming the invisible victims of DV [9,10]. Trauma recovery is the goal when addressing harm and generally there is a focus on symptom reduction. In the process of healing, survivors are faced with retraumatisation due to services failing to meet their needs, exacerbating negative feelings including guilt, shame and loneliness [11]. A systematic review of literature by Williams, etal., (2024), highlight a lack of a trauma and holistic recovery programme for survivors of domestic violence. Consistent with the findings of Kavanagh and Fassbender (2024), components of such a programme should seek to nurture the factors influencing recovery including formal support, social support, a sense of safety and stability through empowerment in the areas of financial security, stable employment, and secure housing, educational opportunities, involvement in helping others, spirituality or religiosity, engaging in self-care activities, reducing feelings of guilt, cultivating feelings of hope, and increasing self-worth [11]. These programmes should consider cultural context in its development [4,13].
Safe houses and shelters play a crucial role in meeting the needs of displaced women in the aftermath of DV. A large-scale systematic scoping review of therapeutic interventions in DV shelters identified 11 interventions employed within these settings. Only two published works were located within the South African environment, namely; Triple P (positive, parenting program) by Wessells and Ward, (2016) and Trauma-focused cognitive behavioural theory (TF-CBT) with art and play therapy by Woollett et al., (2020). These interventions more prominently focused on children’s trauma recovery and strengthening the mother-child relationship [9]. Nevertheless, these studies focus on recovery, which refers to the healing process following a negative or traumatic experience, emphasising resilience rather than the severe and deeply distressing circumstances that challenge a person’s core beliefs, as seen in PTG.
There still remains a gap in the number of PTG intervention studies in South Africa [16]. Interventions that facilitate PTG whilst effective in addressing one or a few negative outcomes, have been limited in holistic healing [17,18]. Mindfulness-based therapies, narrative therapies, and cognitive-behavioural therapy (CBT) have shown promise in fostering posttraumatic growth (PTG), however the effectiveness of these approaches in addressing the unique needs of domestic violence survivors is inadequately explored [18,19]. Thus, there is a need for a holistic, survivor-centred, culturally responsive and empowerment-focused intervention.
The Restorative Empowerment Programme (REP) is a novel intervention, inspired by Warrior Progressive and Alternative Healing Heroes (PATHH), a programme that seeks to facilitate posttraumatic growth amongst American combat veterans and first responders. It involves reflecting on the past, establishing current perspectives of oneself, forging new belief and taking actions towards that belief. Warrior PATHH has had significant successes including a 56% reduction of PTSD symptoms, a 57% reduction in anxiety, a 21% increase in compassion and overall, 58% increase in posttraumatic growth [20].
Problem Statement
Despite ongoing efforts to enhance awareness and prevention, the predominant focus of support has been on addressing the psychological trauma resulting from violence [1]. Many studies focus on the negative outcomes of trauma [21-24]. However, there is also research that shows that there are positive outcomes of trauma [25-28]. The problem of domestic violence is persistent and escalating in South Africa [58]. Whilst literature on PTG and survivors of domestic violence grows; there still remains a gap in the number of intervention studies in South Africa [16]. Interventions that facilitate PTG whilst effective in addressing one or a few negative outcomes, have been limited in holistic healing [17,29,18].
Ideally, a comprehensive understanding of PTG and the factors that influence it would be invaluable in developing context-specific initiatives to address trauma and facilitate the healing journey. Studies on PTG across the world are largely quantitative and most studies are within a western culture and context, limited in terms of diverse populations like those found in South Africa [30,31]. While interventions such as mindfulness-based therapies, narrative therapies, and CBT can be recognized for fostering posttraumatic growth (PTG), there still remains the gap in addressing the unique needs of domestic violence survivors [18,32].
The Warrior Progressive and Alternative Training for Healing Heroes (PATHH) programme offers a promising holistic approach to address the complex needs of domestic violence survivors. The Restorative and Empowerment Programme that will be employed in this study will be adapted from the Warrior PATHH programme. Similarly, it comprises a comprehensive intervention involving physical, and psychological challenges, experiential learning as well as community support which is important for growth and healing. The programme may promote long-term resilience and sustainability for survivors through the integration of newfound skills into their daily lives and continued engagement through the process [59,60]. However, empirical evidence on the programme's effectiveness in promoting PTG is limited. This study aims to fill this critical knowledge gap by rigorously looking into an evidence-based intervention to facilitate posttraumatic growth among survivors of domestic violence.
Theoretical Foundations
The evidence-based intervention baseline is embedded on the Posttraumatic Growth Theory and the Empowerment Model.
Post-Traumatic Growth (PTG) Theory
Post-Traumatic Growth (PTG) Theory, developed by Tedeschi and Calhoun in the 1990s, posits that individuals can experience profound positive psychological changes following trauma-changes that go beyond resilience or basic coping strategies [34]. Rather than merely returning to baseline functioning, survivors may develop new beliefs, perspectives, and behaviours shaped by their traumatic experiences. These transformations are reflected across five core domains:
Believing in New Possibilities: Trauma may challenge and disrupt pre-existing beliefs, prompting individuals to reconsider what is possible in their lives. This may lead to the pursuit of opportunities previously seen as unattainable [36,37].
Finding Personal Strength: Survivors often report an increased sense of inner strength after overcoming adversity, either by drawing on existing coping strategies or by developing new ones when prior skills are insufficient [35].
Ability to Relate to Others: Experiencing trauma can lead to deeper, more authentic relationships, as survivors often become more empathetic and willing to share their experiences, enhancing trust and connection [35].
Spiritual Change: Traumatic events can trigger existential questioning and spiritual exploration, leading many survivors to deepen their spiritual beliefs or reframe their understanding of life and purpose [35].
Appreciation for Life: An enhanced appreciation for life often follows trauma, where individuals begin to value everyday experiences and redefine what is meaningful. This shift is associated with greater purpose, intentional goal-setting, and future-oriented behaviour [37].
Empowerment Process Model
Complementing PTG is the Empowerment Process Model (EPM), which conceptualises empowerment as a dynamic, cyclical process involving goal-setting, action, reflection, and resource mobilisation [38]. The model underscores the importance of agency and contextual awareness, survivors must not only define meaningful goals but also act upon them, assess outcomes, and adjust their strategies accordingly. [40] further adapts this model for survivors of domestic violence, emphasising the role of autonomy, resource access, resilience-building, and social support in recovery. Empowerment in this context is achieved through increasing personal control, self-efficacy, and access to supportive networks [40-44].
These theoretical models form the foundation of the intervention, which incorporates activities designed to foster decision-making, skill development, agency, and meaning-making. The intervention also prioritises community-building and self-reflection as mechanisms to support empowerment and facilitate PTG. A mixed methods research design is employed to capture both the measurable outcomes and the subjective experiences of transformation across these domains.
Intervention Development
Warrior PATHH is a peer-delivered 18-month programme developed and implemented by Boulder Crest Foundation; a non-profit organisation based in the United States of America. The programme is grounded in the principles of posttraumatic growth theory emphasising conscious efforts that lead to transformative and sustainable change in their lives [45,46].
Each objective of Warrior PATHH is aligned with scientific evidence aimed at fostering growth in the aftermath of trauma and was developed by experts in the field of PTG, including Dr Tedeschi and Dr Moore. The learning objectives set out specifically:
| Learning Objective | Description |
| Safe and Trusted Environment | Recognise the importance of a safe and trusting environment to facilitate healing |
| Education | Educate through recognising the role of the physical, psychological and spiritualty impact trauma and stress |
| Regulation | Intentional regulation of thoughts, feelings, and actions by recognising and identifying mind, body, spiritual wellness practices |
| Disclosure | Design ways for disclose to occur in a way that is constructive in strengthening interpersonal relationships |
| Story | Purposefully create a forwarding thinking outlook by reviewing, the past, the present and reinventing notions of the future |
| Service | Consciously develop a mission of service to themselves, their family, the group, and the community |
Source: (Goldberg, et.al, 2017)
The Warrior PATHH programme begins with a seven-day intensive immersive training followed by monthly focus group meetings and periodic assessments. It involves a series of learning and activities including equine therapy and amongst others, goal-setting a core part of the process [46]. The Warrior PATHH programme saw successes in two days which are often only take the medical model at least a year to achieve [46]. Studies show that intervention tend to achieve positive outcomes for PTG [47,48].
Adaptation Process
Adapted from the Warrior PATHH, the Restorative Empowerment Programme (REP) was intentionally curated to mirror the phases of PTG, offering a structured flow that balances gentle pressure with moments of emotional release. This design enables participants to integrate insights at a manageable pace, avoids premature or forced disclosure, and incorporates frequent regulation-based activities to promote psychological safety and sustained engagement.
The REP adaptation was conscious of the resource limitations, the nature of the participants, that is, survivors of violence, and safety concerns that pertain to activities within the South African context. For example, bonfires, archery, equine therapy, activities that required physical touch, and hiking, were excluded.
Activities were intentionally designed using local languages, familiar metaphors, and culturally relevant elements to ensure they felt natural, practical, and accessible to participants. For instance, the food and nutrition component focused on affordable, locally sourced meals rather than complex or unfamiliar recipes. Yoga sessions emphasised bodily movement in a culturally sensitive way, offering participants the freedom to choose comfortable hand positions instead of the traditional prayer pose with palms pressed together. Music used during sessions should be neutral and instrumental, avoiding lyrics or styles that could be culturally or emotionally triggering.
A notable adaptation from the original programme is the adjustment of its daily schedule. Given the realities of shelter life such as shelter-based tasks, childcare responsibilities, school pickups, job searching, and running essential errands, the REP was intentionally structured to conclude by midday, allowing participants to engage meaningfully in the programme without compromising their daily obligations. Each day of the evidence-based intervention is embedded in a series of theories; relational safety [39,49], cognitive-behavioural psychoeducation, Mindfulness-Based Stress Reduction (MBSR) and Somatic Regulation [50,51], Narrative therapy [32], Social Support Theory, Logotherapy [33], and Habit Formation and Continuity of Care [52].
| Focus: Establishing Psychological Safety (Relational Safety) |
| Day 1: Welcome and Orientation |
| Welcome Luncheon - Group introductions and intention-setting |
| Establish trust, ground rules, and group expectations |
| Reflection on hopes for the programme |
| Focus: Neuro-Literacy and Education (Cognitive- Behavioural Psychoeducation) |
| Day 2: Understanding Personal Experiences |
| Introduction to Yoga |
| Warrior PATHH inspiration |
| Building Relationships |
| Open and Honest Communication |
| Accessing Positive Memories |
| Empowering Wellness through sleep and nutrition |
| Focus: Emotional and Physical Regulation (Mindfulness-Based Stress Reduction (MBSR) and Somatic Regulation) |
| Day 3: Reflecting on Personal Narratives |
| Morning Check in |
| Introduction to Journaling and light yoga |
| Learning Transcendental Meditation (TM) |
| Where my story began |
| Art Therapy |
| Focus: Focus from Trauma Story to Growth (Narrative Therapy) |
| Day 4: Embracing Personal Growth |
| Morning Check in |
| TM First Day Check-in |
| The Struggle |
| Group Meditation |
| Focus: Constructive Self-Disclosure (Social Support Theory) |
| Day 5: Integration and Moving Forward |
| Morning Check in |
| Relationships, Communication and Connection |
| TM Check in |
| Reflective Songwriting/Song Playlist/Prayer/Poetry |
| Focus: Redefining Identity (Logotherapy) |
| Day 6: Bringing It All Together |
| Morning Check in |
| Soundtrack to my new story |
| Taking it home |
| Final meditation |
| Sustained Transformation (Habit Formation & Continuity of Care) |
| Day 7: Reflection and Integration |
| Letter to future self |
| Group reflection on lessons learned and feedback |
| Close out- guided meditation and move-your-body/dance off |
Study Design and Methods
A convergent parallel mixed methods design will be employed involving the simultaneous collection of qualitative and quantitative data over a 12-month period. This approach will result into two separate data sets that will be analysed independently but ultimately integrated to inform one another. Qualitative data will involve two individual, face-to-face interviews, one before and one after the intervention conducted in a private room in the shelter to ensure confidentiality and minimal disruption. Each interview will last approximately one hour and will explore participants’ experiences of PTG. Qualitative semi-structured interviews will be conducted before and after intervention. Additional data will be collected through field notes and facilitator observations to complement participant interviews and quantitative measures. Interview data will be analysed using thematic analysis, following the approach outlined by Braun and Clarke (2006). Quantitative data will be gathered using the Posttraumatic Growth Inventory (PTGI), administered online via WhatsApp or email at six intervals: pre-intervention, and at months 1, 3, 6, 9, and post-intervention. Support will be provided for participants with low literacy, including telephonic assistance and interpreter services, with completion estimated at 10 to 15 minutes per session.
A purposive sampling strategy will be used to recruit survivors residing in the shelter. A total of 15 participants will be selected to take part in the study across the baseline, the post-intervention and follow-up phases. Posttraumatic Growth Inventory (PTGI) will be administered at multiple time points (baseline, 1, 3, 6, 9, 12 months). The quantitative data collection tool will be the PTGI; which is a self-reporting 25-item survey that allows researchers to assess a persons’ views about themselves, about their beliefs, their relationships and how they cope with trauma [34]. Each item is assigned a score from 0 (I did not experience this change as a result of my crisis) to 5 (I experienced this change to a very great degree as a result of my crisis). Overall, the questionnaire shows a “great internal consistency (α = 0.90) and an acceptable test-retest reliability r = 0.71.” [33]. The questionnaire will be used to measure the levels of PTG before, during and post intervention. The Post-Traumatic Growth Inventory (PTGI) scores will be examined using descriptive analyses to track changes over time. Finally, findings will be integrated to provide a comprehensive understanding of both intervention outcomes and the meaning-making processes experienced by participants
Setting and Participants
The evidence-based intervention should be delivered in a fixed site located akin to the Warrior PATHH programme. Situated in an urban area, the venue accommodated communal dining, and designated indoor and outdoor spaces for group-based therapeutic activities. The setting offered a stable, predictable environment across all seven days, supporting relational safety and nervous system regulation. Access to the venue was controlled to ensure privacy and participant safety, while maintaining a non-institutional, trauma-informed atmosphere.
The goal is to foster a consistent peer environment, that is, survivors living and healing together with people who truly understand because they have shared similar experiences. Research shows that many women experiencing domestic violence deliberately isolate themselves during the abusive relationship and often lack a supportive family or community when they leave a situation of violence [53,54]. A Gauteng study noted that levels of social support are significantly lower among abused women compared to non-abused women, and that this isolation is strongly linked to higher rates of depression, suicidal feelings, and lower use of services [55]. Another qualitative study from shelters in South Africa reported that awareness of shelters and ongoing social support were critical in enabling women to leave abusive relationships, highlighting the importance of community even after they exit [56].
A shelter-based setting provides a physically secure space, where basic needs such as accommodation and food are already met, allowing participants to focus on emotional healing without the immediate pressures of survival. The ethical context and relevance of working within a safe, semi-structured environment lie in its capacity to support trauma-informed, dignity-preserving engagement with participants who have experienced domestic violence. It offers a consistent yet flexible daily rhythm creates predictability that fosters psychological safety, while allowing facilitators to respond dynamically to participants’ emotional states and readiness. This environment respects the complexity of trauma recovery by minimising re-traumatisation risks, supporting autonomy, and promoting meaningful participation at a pace that honours each woman’s lived experience.
The sample will consist of all female residents at the shelter, who have experienced domestic violence, are 18 years of age or older, and are willing to participate in the study by providing signed informed consent. Those who are unable, for any reason, to remain for the full duration of the data collection process or if they are unwilling to participate in the study would be excluded.
Facilitation Approach
The programme is delivered by a multidisciplinary team responsible for facilitating workshops on yoga, meditation, nutrition, and holistic wellness. The intervention was mindful of local context in the workshops such secular music background music for yoga sessions, and deliberate in discussions on nutrition of local cuisine tinned fish chutney, mfino, dombolo, phutu and magwinyas. Survivor-led reflection and sharing circles form a central component, creating intentional spaces where participants can safely express their experiences and insights at their own pace.
Ethical Considerations
Participants are recruited voluntarily, with informed consent processes that account for trauma sensitivity, literacy levels, and cultural understandings of healing. Survivors are empowered to set personal boundaries and participate at their own pace, with the option to decline or pause involvement at any stage. Safety is paramount. The intervention is structured to prevent emotional overwhelm, using gradual exposure, grounding techniques, and ongoing emotional check-ins. A debriefing protocol is embedded for both facilitators and participants to ensure containment and support.
The programme's rhythm which involves alternating between expressive, cognitive, and meditative activities, fosters psychological resilience without pushing participants beyond their capacity. These components were developed and later reviewed and approved by the Boulder Crest Foundation. Executing teams are briefed and trained making provisions for refresher training prior to manage working with survivors of DV, and in preparation for the implementation to ensure alignment with the programme’s trauma-informed curriculum. Formal written ethical clearance must be sought from the relevant academic ethics committee. Necessary permissions will be sought from the participating shelters to gain access to the research site.
All participants are to be provided with clear and accessible information about the study to enable them to make an informed decision regarding participation. This will include the intervention’s title, purpose, aims and objectives, and an explanation that participation is voluntary and that individuals may withdraw from the study at any time without consequence.
Participants will be informed that they are free to withdraw from the study at any point before, during, or after the intervention or data collection without facing any negative repercussions. Both verbal and written consent will be obtained to confirm voluntary participation. Where needed, interpreter services and consent documents in the participant's preferred language will be provided to ensure understanding throughout the study period. No personal identifiers will be collected. Participants will be assigned numerical codes for all interviews and data documentation. The researcher will maintain strict confidentiality in accordance with data protection regulations, including the POPI Act (2013). All data will be securely stored on a password-protected device during the study and transferred to a secure external drive after completion. The data will be retained for five years before being securely deleted. All individuals involved in data collection or facilitation will sign a non-disclosure agreement and be required to adhere to confidentiality protocols.
Given the sensitive nature of the study, steps will be taken to minimise any potential psychological distress. A trained counsellor will be available onsite to support participants who experience emotional discomfort at any stage of the research. Shelters often have their own in-house counsellors and social worker familiar with the individual’s cases and is in the best position to support participants. Participants will be made reminded of this support service and how to access it.
Relevance, Value, and Uniqueness
Restorative Empowerment Programme (REP) is the first documented adaptation of a restorative model inspired by Warrior PATHH for South African DV survivors. Centered in empowerment, peer reconnection, and trauma recovery rather than traditional therapy, this intervention is adaptable, low-cost, and culturally grounded model suitable for resource-constrained settings. Developed with pragmatic constraints in mind, REP is mindful of the resource realities of South African shelters and community-based trauma recovery settings. Unlike high-cost, resource-intensive interventions, this model purposefully excludes activities such as kayaking, equine therapy, and hiking. The evidence-based intervention balances the need for immediate immersive healing with the importance of sustained post-intervention support, delivered in a scalable and low-cost manner. The programme draws on existing local networks of psychosocial support. Facilitators can be sourced from within the community or affiliated with partner organisations, making the model replicable in both urban and rural South African contexts. Sessions require minimal infrastructure, that is, quiet spaces, basic art supplies, skilled and knowledgeable facilitators, and a secure environment, making implementation feasible even in resource-constrained shelters.
Limitations and Mitigation
Sample size
The pioneering execution of REP programme utilises a purposive sample of 15 female participants residing in a shelter, selected based on their lived experience of domestic violence and willingness to participate. While the small sample size limits the generalisability of findings to broader populations, it aligns with the intention of prioritising depth of insight over statistical representativeness.
Attrition
Attrition is a common challenge in intervention studies with vulnerable populations; however, proactive measures were employed to mitigate dropout. Regular check-ins, flexible scheduling, and trauma-informed facilitation practices including sensitivity to emotional triggers, provision of psychological support, and the creation of a safe, predictable environment with hopes to retain participants.
Child care and maternal responsibilities
Providing childcare for non-school-going children as part of the research plan, along with snacks and simple activities, would reduce distractions and would be a practical support mechanism during the programme. This would allow mothers to participate fully in the sessions, knowing their children were safely engaged and cared for nearby.
Adaptation of the Warrior PATHH
Cultural adaptations would further enhance the intervention’s relevance and acceptability. Activities were delivered using familiar metaphors, local languages, and accessible practices, making the content feel relatable and inclusive. These adaptations foster participant engagement and reduce the risk of withdrawal by affirming cultural identity and respecting individual comfort levels.
Implications for Practice and Future Research
The findings from this intervention will highlight the value of integrating restorative, empowerment-based programmes into public health and shelter-based trauma care for survivors of domestic violence. The structured yet adaptable nature of the programme allows for replication across similar settings, particularly in low-resource environments. To support sustainability, there is a clear need for the development of facilitator training models that embed trauma-informed principles, cultural sensitivity, and strengths-based approaches. Equipping community-based practitioners with these skills can expand the reach and relevance of posttraumatic growth-focused interventions.
Future research should include larger-scale trials and longitudinal studies to evaluate the programme's long-term impact on resilience, reintegration, and wellbeing. Ongoing exploration of cultural adaptations and survivor-led co-design processes will further strengthen its applicability across diverse populations and other forms of trauma.
Conclusion
Barriers and facilitators are systematically examined to inform future adaptation, scalability, and equitable access across diverse settings. This approach ensures the methodology generates actionable knowledge for replication and broader dissemination, beyond testing effectiveness in a single context. While inspired by the Warrior PATHH programme originally developed for military veterans in the United States, this intervention represents a novel adaptation tailored to the lived realities of female survivors of domestic violence in South Africa. Its uniqueness lies in its hybrid framework, integrating evidence-based psychosocial support with holistic healing practices. The model departs from pathologizing or solely problem-focused interventions, instead embracing a strengths-based, posttraumatic growth orientation. The programme repositions participants as active agents in their recovery journey. Through narrative reframing, expressive arts, and meaning-focused rituals, participants engage in a structured process of reclaiming identity and purpose. This is reinforced by practices rooted in self-regulation and embodied awareness.
This blend of modalities, Eastern and Western, individual and group-based, verbal and non-verbal results in a uniquely layered intervention that supports emotional regulation, cognitive restructuring, and identity reconstruction in a holistic and empowering manner. It holds potential for integration into social services, gender-based violence programmes, and shelter systems across the country.
Declarations
Conflict of Interest
None declared
Data Availability
All data supporting the findings of this study are available within the paper.
Authors' contributions
Design and conceptualization: SZ; Data collection and Methodology: SZ, MBR, MH Writing: SZ, MBR, MH Writing; Review and editing: SZ, MBR, MH
Acknowledgments
The authors want to thank the Boulder Crest Foundation for their support in sharing the invaluable Warrior PATHH curriculum to support this adapted design.