Traumatic Stress in South Africa

Front matter

DEBRA KAMINER AND GILLIAN EAGLE

Traumatic Stress in

South Africa

Table Of Contents

3. POSTTRAUMATIC STRESS DISORDER AND

OTHER TRAUMA SYNDROMES o.oo ccccccccssccsssecussseussessssesnnsseennssseeneee 28 Posttraumatic Stress Disorder ene 29 The effects of prolonged trauma exposure OF abuse oo 44 The effects of community violence: a continuous traumatic stress SYNATONDEP iii 48 South African research on the psychiatric effects Of QUIN noii 49 COPIA SION ESEE ETE tote ttc tate eta east 58 4. TRAUMA AS A CRISIS OF MEANING...

Shattered assumptions and the search for comprehensibility.... Beyond comprehensibility: the search for significante...

Chapter 1

INTRODUCTION he aim of this book is to address the pressing and socially relevant

topic of traumatic stress in South Africa. Given the high levels of exposure to trauma and violence of various kinds in this country, there is naturally serious concern about the mental health impact and implications of this exposure.

South African citizens are widely and commonly confronted with anecdotal accounts of traumatic events, both in the course of their everyday lives and in the mass media, often articulated in the discourse of living in a dangerous and traumatised society. Along with this awareness of the frequent occurrence of trauma is a preoccupation with its psychological consequences. The notion of ‘posttraumatic stress’ has entered the public domain to the extent that this terminology is in common usage and is even used to describe the state of characters in popular local television dramas or ‘soap operas’. It is also noticeable that in media accounts of traumatic events there are frequently references to the fact that victims are receiving debriefing or counselling, suggesting that trauma intervention is offered by many practitioners of various levels of skill to large numbers of trauma survivors, with an assumption that such intervention should take place as a matter of course. The increasing awareness of and prominence given to posttraumatic stress conditions and related interventions has had benefits and costs. Although the public may be better informed about some aspects of traumatic stress and victims may more readily access and seek assistance, there are also misconceptions and problematic practices. Common sense or folkloric knowledge of traumatic stress can easily become dated, distorted or misinterpreted. Access to up-to-date, well substantiated and clearly presented information about traumatic stress is important at this point in time, both in terms of doing justice to the international advancements in traumatic stress knowledge and in terms of improving everyday practices in South Africa. In response to this need, this book presents an overview of aspects of trauma prevalence, impact and treatment that is intended to be both scholarly and accessible. This text aims to be mindful of the complexities of working with trauma survivors living within a context of multiple dangers.

Although the term trauma is often associated with medical conditions, as in physical trauma to the body, this book focuses on psychological trauma or trauma to the psyche. The origin of the word trauma lies in a Greek word meaning ‘to tear’ or ‘to puncture’!. In the case of psychological trauma this understanding is reflected in a notion of psychological wounding and the penetration of unwanted thoughts, emotions and experiences into the psyche or being of the person. Traumatic experiences are usually unanticipated and by definition place excessive demands on people’s existing coping strategies. Thus traumatic events create severe disruptions to many aspects of psychological functioning.

The term ‘trauma’ has been used to refer both to stimuli of a catastrophic nature (‘the assault was a trauma in her life’) and to the severe distress produced by such an event (‘she experienced trauma as a consequence of the assault’), and in this book it is similarly used to refer to both events and responses. As will become clearer in the later discussion of the impact of trauma, this dual meaning perhaps makes sense when one appreciates that trauma is characterised by the coupling of a dreadful experience with a subjective experience of dread -the outcome and its cause are inextricably intertwined. In this respect traumatic stress is a very specific type of stress, distinguishable from other forms of stress by the severity of both the stressor and the response. The study of traumatic stress is a distinct field of theory and

INTRODUCTION research with some overlap with the stress field, but with a largely independent conceptual base and orientation. The field of traumatic stress (or traumatology as it is sometimes referred to) encompasses a broad range of issues and has generated a substantial body of psychological writing, particularly since the 1970s, with ever-widening interest.

In South Africa, psychological interest in traumatic stress has specific origins which have to some extent shaped the kinds of knowledge generated here. For many South Africans working as both researchers and interventionists in the traumatic stress field, interest in the phenomenon was generated out of a ‘political’ investment. Whether this investment had its origins in anti-apartheid resistance politics or was informed by commitment to a general human rights agenda, many South African trauma researchers and practitioners have been drawn to the field out of moral, rather than purely academic, concerns. Much of the early work in the trauma field in South Africa, reflected in writing from the 1970s and 1980s, was not conceived of necessarily as falling under the umbrella of ‘traumatic stress’. For example, during this period traumatic stress terminology was not widely employed in discussions of the work of the volunteer-based Rape Crisis and People Opposing Women Abuse (POWA) organisations or the work of therapists providing support to ex-detainees and torture survivors. Nevertheless, in hindsight, it is apparent that the activist work engaged in by subgroups of psychologists, doctors, volunteer counsellors and other mental health practitioners was indeed traumatic stress intervention and contributed to the initial observation and documentation of traumatic stress phenomena in this country. As the diagnosis of posttraumatic stress and related conditions became popularised in the United States and internationally, the domain of traumatic stress studies became better defined and constructs from within this repertoire became more widely employed in South Africa. Also, with political change, the study of traumatic stress became open to more purely academic interests. However, the activist origins that shaped the early generation of knowledge in this field have been retained to some extent. As much of the case material and empirical research cited in this book reflects, looking at society through the lens of traumatic stress highlights social problems and relations of oppression. Indeed, as the American psychiatrist and feminist activist Judith Herman noted, ‘to hold traumatic reality in consciousness requires a social context that affirms and protects the victim and that joins victim and witness in a common alliance’. Engaging with traumatised individuals means taking on board the origins of their plight and this may well entail a profound comprehension of abuses and inequities in society. Whether as an academic or a practitioner, working in the trauma field requires engagement with the relationship between personal and social ills. Thus it is still possible to align research and activist interests in studying trauma, even if the political context has changed.

South Africa’s history of political violence coupled with its contemporary high rates of violent crime, sexual and domestic violence and road accident injury (amongst other issues), has unfortunately meant that the country represents, in some ways, ‘a natural laboratory’ in which to study the impact of traumatic events and their consequences. Changes in the social fabric of South African society tend to be reflected in shifts in the focus of traumatic stress research, with researchers engaging with new issues and populations of interest in order to stay abreast of contemporary historical developments. For example, there is currently a strong interest in the interface between HIV- and AIDS-related issues and aspects of traumatic stress. New social agendas constantly replace those of the past, although some issues, such as the problem of sexual violence, seem to endure.

While there are clearly broader debates informing the trauma field, such as those concerning the causes of endemic interpersonal violence in South Africa and appropriate strategies for preventing traumatisation, the focus of this particular text is on the topic of trauma itself, with a thorough examination of trauma prevalence, impact and intervention. While recognising that the causes and consequences of trauma cannot always be easily separated, it is the latter that is of primary interest in this text, together with a range of other aspects of traumatisation.

Over time there has been increasing formalisation in the execution and documentation of research related to traumatic stress in South Africa. Although there are still enormous gaps in the knowledge base concerning traumatic stress in this country, there is increasing

INTRODUCTION investment in both quantitative and qualitative research. Perhaps because early trauma interventionists prioritised social activism over publishing, little of this work was documented in formal academic texts and journals. Rather, knowledge was captured in the form of manuals, minutes of meetings and congress proceedings. Much of this material lies untapped as a historical record of early trauma work in South Africa. In addition, there is also a large body of knowledge held within current non-governmental organisations (NGOs) that is slowly becoming increasingly more rigorously documented and presented. While there has been a very strong interest in traumatic stress research across a number of South African universities in the last two decades, much of this research has been captured in the form of student research projects, masters theses and doctorates and has not been published and widely disseminated beyond this. Within this book we attempt to draw upon a wide a range of sources of knowledge in order to provide as rich a picture of the traumatic stress terrain in the country as we can. However, one of the strands running through the various chapters is the need for more directed research and research publication in a range of areas, as well as the need for increased integration of knowledge across the field. One of the important contributions of this book is that it offers a cohesive picture of trauma prevalence, impact and intervention in South Africa and in this respect provides a unique synthesis of existing knowledge.

Although this book has a strong focus on South African issues, it is not parochial in its outlook. The text covers seminal international work in the trauma domain as well as contemporary international debates and up-to-date research. The international traumatic stress research field is rich and vibrant and the book aims to reflect this, while also using a critical lens to evaluate the relevance of the international traumatic stress knowledge base for South African conditions. While the implications of trauma theory for the South African context are unpacked, South African phenomena that have potential to contribute to international theorisation are also highlighted. Although South African concerns are not necessarily unique to this setting, there are contextually driven trauma imperatives that require innovation in theorisation and intervention. South African society is marked by high levels of exposure to traumatic events, the likelihood of multiple exposure and the possibility of reexposure to such events, and by constraints in trauma intervention accessibility and availability. In addition, trauma takes place against a backdrop of extreme wealth disparities, powerful race sensitivities and cultural hybridity. Trauma theorists and practitioners have grappled with, and continue to explore, the implications of these local trauma characteristics for the presentation of traumatic stress conditions and optimal intervention. Engagement with some of these issues is a major aim of this book.

Having provided some broad background to the book, the main content will be briefly described so as to orientate the reader. Chapter 2, which follows, provides a picture of the scope of the problem of trauma exposure in South Africa. The prevalence of different kinds of trauma is reviewed, and the specific populations in South Africa who are most at risk for experiencing different forms of trauma are highlighted. Comparison is made to international literature on rates and patterns of trauma exposure, and some of the gaps and difficulties in accurately assessing local prevalence rates are noted. In Chapter 3 the mental health impact of traumatic events is presented, with a particular focus on the formally diagnosable condition of Posttraumatic Stress Disorder (PTSD)? The symptoms and dysfunction associated with PTSD and related conditions are discussed, with some emphasis on the fact that victims or survivors of trauma may present with a range of mental health problems beyond PTSD. Some critiques of the diagnostic perspective are also raised. The chapter concludes with a synthesis of South African research on the impact of trauma. In Chapter 4 the discussion of the impact of trauma is broadened to include a focus on the disruption of the survivor’s meaning systems and what this entails for psychological adjustment. Individual and contextual influences on meaning-making are emphasised. Chapter 5 then moves on to look at some of the mechanisms for addressing the impact of psychological trauma, with a primary focus on various forms of psychotherapeutic intervention for individual survivors. Group and community initiatives are also considered, as well as some particular issues raised by working in the South African context. In Chapter 6 much of the broad material covered previously in the book is revisited, but with a particular focus

INTRODUCTION on children. Issues pertaining to the prevalence, impact and treatment of traumatic stress in the child and adolescent population in South Africa are explored. Finally, in Chapter 7, some overarching thoughts on the nature of trauma in South Africa and possible future directions for trauma research are offered. We trust you will find the coverage stimulating and the book engaging to read.

Chapter 2 he South African media is consistently filled with local stories of crime, violence and injury. Internationally, too, South Africa has an increasingly dubious reputation as a highly dangerous place. But are these images of South Africa supported by objective, systematic evidence? Just how dangerous is our society when compared with other countries? What forms of trauma and violence pose the greatest burden to our society? And is South Africa equally dangerous for everyone? Certainly, South Africa is one of the few countries in the world that has endured protracted political violence as well as high rates of criminal violence, domestic abuse and accidental injury. This translates into a large number of trauma survivors in our society, with one nationally representative survey reporting that 75 per cent of respondents had experienced a traumatic event in their lifetime and over half had experienced multiple traumas.! The same study also established that there are many South Africans who have not experienced a trauma directly, but have been indirectly traumatised through the sudden death of a loved one, hearing about a trauma that occurred to a person they are close to, or witnessing a traumatic incident. It is therefore apparent that very few South Africans live lives completely untouched by trauma and, for many, exposure to potentially traumatic experiences is an inescapable part of daily life.

While no one in South Africa is immune from trauma, some people are more at risk than others of experiencing certain kinds of trauma. Understanding the prevalence of different forms of trauma in the population is an important first step in developing strategies to reduce the burden of trauma in our society. This chapter will review patterns of exposure to the most common forms of violence and accidental injury, as well as indirect and multiple trauma exposure.

Violence

As is the case elsewhere in the world, gender is a strong predictor of whether or not South Africans will be exposed to a particular form of violence. As we shall see, certain types of violence in South Africa are more likely to occur to women and others are more likely to affect men. Beginning in 2002, the South African Stress and Health (SASH) study conducted a survey of trauma exposure in a nationally representative sample of 4,351 South African adults.? The rates of exposure to different forms of violence that were reported by men and women in the SASH survey are presented in Table 2.1. Each of these forms of violence exposure will now be considered in some detail.

Political violence

Politically motivated human rights abuses are a feature of many socio-political systems worldwide. Amnesty International has documented the commission of human rights violations such as abductions, torture, genocide and detention without trial in 153 countries, with victims numbering in the hundreds of thousands.’ Although political violence is no longer a common feature of South African society, many South Africans have survived the political violence that characterised the apartheid era. During the apartheid years, the South African state consistently denied or minimised rates of state-perpetrated violence, and it was only as the South African Truth and Reconciliation Commission (TRC) process unfolded in the mid-1990s that the levels of political violence to which South Africans had been exposed truly became clear.

Table 2.1 Prevalence of exposure to different forms of violence in a nationally representative sample of South African adults

Males (%) | Females (%) | Total (%)

Political violence

Severe ill-treatment 2.7** 0.6 1.6 Detention 2.4** 0.3 1.3 Torture 1.34% 0.2 0.7 Criminal violence 251912 11.6 18.2

Gender-based violence

Physical abuse by intimate partei 1.3 13:6** 7.9 Rape 0.3 3.7 EX 2.1 Other sexual assault 1.0 2.1* 1.6 Physical abuse during childhood 123 7 12.0

* Significantly higher level than counterpart at p < 0.05 level * Significantly higher level than counterpart at p < 0.0001 level Source: Kaminer et al., 2008

According to the evidence collected by the TRC, forms of political violence and traumatisation that were particularly common in South Africa during apartheid included the political detention and torture of those who were active in the anti-apartheid struggle, the abduction and murder of suspected political activists, stoning, shooting and beating of people engaged in political protests, and the intentional destruction of homes and property.’ As the TRC noted in its final report, these forms of political violence were carried out by members of the state security forces in an attempt to suppress anti-apartheid activity, and the victims of these forms of violence were primarily black South Africans.’ In particular, male youths were most commonly the victims of organised state violence, since they were often on the ‘front lines’ of the struggle against apartheid. And in the final years of apartheid, possibly as the result of provocation by state security forces, there was also a high level of violence between different political factions in black townships, again affecting mostly male youths.

Detention without trial was the most pervasive form of repression carried out by the South African state during the apartheid years. Political detention could be an extremely traumatic experience, not only because the conditions in detention were very harsh, but also because apartheid security laws meant that detention could go on indefinitely. Many South Africans were detained for up to three years without trial. In the SASH survey, 2.4 per cent of men and 0.3 per cent of women reported that they had been detained under apartheid security laws, indicating that, today, many tens of thousands of South Africans are ex-detainees. The vast majority of detainees were young men, but, between 1960 and 1990, some 10,000 women and 15,000 children younger than fifteen years old were also detained.°

Many of those who were detained during apartheid were subjected to torture, for the purposes of obtaining information or a confession and punishing the person for suspected anti-apartheid activities.’ According to testimonies given to the TRC by torture survivors, the forms of torture employed by South African security forces included beatings, electric shocks, suffocation, drowning, deprivation of food and sleep, exposure to the elements, forced posture and excessive physical exercise, attacks by dogs and sexual abuse. In addition, many forms of psychological torture were used, such as falsely telling a detainee that a family member or comrade was dead, forcing a detainee to observe the torture of a fellow detainee, and emotional humiliation and degradation. Over 5,000 incidents of torture were reported to the TRC by about 3,000 people, mainly concerning the violation of black men between the ages of thirteen and thirty-six years old.* In the more recent nationally representative SASH survey, 1.3 per cent of men and 0.2 percent of women in the sample reported having been tortured,’ a statistic which suggests that several thousand South Africans have survived torture. But these figures probably represent only a minority of all torture experiences in the South African population. It is possible that some torture survivors in South Africa, as in other countries, have never revealed their torture experiences to anyone, due to a deep sense of shame and humiliation, feelings of guilt for having given evidence against their comrades as a result of torture, or fear of reprisals by agents of the former government.

During apartheid, many South Africans were exposed to political violence in their communities, at the hands of the security forces or as the result of conflict between different political factions in the community. The TRC termed those forms of violence which occurred outside the context of detention or confinement ‘severe ill-treatment’. The most common forms of severe ill-treatment that were reported were arson (for example, homes or property being set on fire), being beaten, and being shot by security forces during mass protests.!° At the TRC, severe ill-treatment was the category of violation most commonly reported by women, particularly those in the 37-48-year age group.'! In the SASH survey, political violence that occurred outside the context of detention and torture was the most common form of political trauma reported by both men and women.”

Political violence in South Africa, whether it occurred in the context of detention or in the broader community, was often fatal. Nearly 10,000 politically motivated killings were reported to the TRC by surviving family members of the victims,” and these are likely to represent only a portion of politically motivated deaths during apartheid. The victims of these killings were predominantly young black men. These sudden, violent deaths left many more thousands of family members suffering from traumatic bereavement. In addition, many families endured the trauma of having a family member disappear without explanation or return, as the result of being abducted (and, according to later investigations by the TRC, subsequently killed) by state security forces. A project of the Centre for the Study of Violence and Reconciliation (CSVR) concerned with the TRC and its long-term impact has established a database to record such disappearances and has also documented some of the experiences of family members of the disappeared."

The high rates of exposure to political violence in the South African population are an indication of the degree to which the struggle against apartheid was a mass, community-based, nationwide struggle that was not restricted to a small group of political activists or to particular regions of the country. While black male youth and children were often on the ‘front lines’ of this struggle, adult men and women were also targets of political violence perpetrated by the state. As a result, there are few, if any, segments of the current adult black South African population that have not been directly exposed to the political violence of the apartheid years.

Although the excesses of apartheid era violence are now in the past, contemporary South African society is not free of political violence. Some of this violence has its roots in the past. For example, there is still periodic conflict in KwaZulu-Natal between African National Congress (ANC) and Inkatha Freedom Party (IFP) office bearers and supporters. Other issues are more recent in origin. Conflict between citizens and the state has resulted in violence in certain instances, and worker and community protests have been harshly subdued on occasion, with reports of police personnel using rubber bullets and tear-gas to disperse protestors. The xenophobic attacks against people who have settled in South Africa from other countries that occurred nationwide during 2008 resulted in deaths and injuries, and in broad terms are a form of political violence, as many of these attacks were driven by perceived competition for jobs and resources.

Researchers at the CSVR have also pointed out that it is sometimes difficult to draw the line between political and criminal violence. For example, there is some evidence that alienated ex-liberation soldiers have become involved in violent crime,” and high levels of criminal activity in South Africa have their roots in the long political history of colonisation and oppression that has created major wealth disparities, high unemployment levels, and a fracturing of traditional family and community structures. We turn now to the prevalence of criminal violence in South Africa.

Criminal violence

In a 2007 review of violent crime in South Africa compared with elsewhere in the world, Altbeker concluded that ‘South Africa ranks at the very top of the world’s league tables for violent crime.’!* This situation has most likely arisen as the result of a complex interplay of factors that are unique to South Africa, which Altbeker and others” have discussed at length.

For several years since the late 1990s, South Africa has had one of the highest murder and armed robbery rates globally.'* In a study of the global burden of disease, South Africa’s homicide rate was more than five times the global average and 30 per cent higher than that of other countries in Sub-Saharan Africa.’ In Canada, Australia and many western European countries, murder rates average less than two people per 100,000 in the population. In the United States, which is commonly criticised for its ‘gun culture’, there are approximately five murders per 100,000 people. In those economically developing countries for which some statistics are available (such as India, Chile and Nigeria), murder rates range from three to about twenty per 100,0000. However, in South Africa in 2006 the murder rate was forty-one people per 100 000, which translates into approximately fifty murders every day.”° This in turn means that, each day, there are hundreds of South Africans who are deeply traumatised by learning of the violent death of a loved one.

In the SASH survey of adults in South Africa, 18 per cent of participants reported being a direct victim of a non-sexual violent crime.?! However, men were at greater risk of criminal victimisation than women: 26 per cent of men reported exposure to criminal violence, compared with 12 per cent of women. Mortality surveys in South Africa have also found that young men are by far the most frequent victims of violent assault.” This is in line with research in other countries, such as the United States, Canada and Mexico, which have consistently found that men are most frequently the targets of violence outside the home, and particularly of attacks involving a weapon.” However, in South Africa a substantial portion of violence between men appears to occur outside of the context of traditional criminal activities such as committing a robbery. Given the high level of involvement of young South African men in gang activity,” it is likely that many violent assaults and homicides occur through inter-gang violence. In addition, there is evidence from mortality surveys to suggest that violence between South African males often happens in the context of entertainment and is related to high levels of alcohol consumption during recreational periods such as weekends and holidays.” As such, male-on-male violence in South Africa is not always criminal in nature (that is, perpetrated during the commission of a crime) but rather is an expression of normative notions of masculine behaviour that include the carrying of weapons, gang membership, risk-taking, defending one’s honour, and excessive alcohol consumption.”

At the same time, there is also a high incidence of violence during the commission of more traditional criminal activities in South Africa. Robberies in South Africa are much more likely to involve the use of a weapon than robberies in other countries. Some surveys have found that as many as 80 per cent of serious robberies reported to the South African Police involve the use of a firearm, compared with less than 20 per cent in economically developed countries. Robberies also frequently involve the use of other weapons such as knives.” In addition to armed robberies that occur in the victim’s home, in the street or on public transport, armed car hijackings and cash-in-transit heists are prominent forms of victimisation in South Africa. In the SASH study, participants living in urban areas were more likely to have experienced a violent crime than those living in less urbanised regions,” which is in keeping with the trends in other countries. Interestingly, while studies in the United States have found that members of minority ethnic groups in the population tend to be more exposed to criminal violence,” in the SASH study there were no significant differences across race and language groups in the percentage of South African adults who had experienced a violent crime outside the home.*®

While the SASH study focused on adults, there is also evidence that South African youth are at high risk of being exposed to criminal violence. In a school survey of Grade 10 learners at both low and high socio-economic status schools in the Western Cape, almost a third reported that they had been robbed or mugged.’! In a national youth victimisation survey of over 4,000 adolescents, 9 per cent had been robbed, 10 per cent reported a housebreaking at their home, and 10 per cent had experienced a car hijacking.” Overall, young people in South Africa are twice as likely as adults to be victims of at least one crime, with boys being more at risk of non-sexual crimes than girls.”

Gender-based violence

While South African men are most likely to be the victims of criminal violence, South African women and girls are at high risk of experiencing intimate partner abuse and sexual violence or coercion. The term ‘gender-based violence’ has several definitions (including emotional and economic abuse of women), but for our purposes here, it will be used to refer specifically to physical and sexual assaults against females by males. Gender-based violence includes physical and sexual assaults perpetrated by intimate partners (commonly termed domestic violence or intimate partner violence), as well as physical and sexual assaults by non-partners.