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Traumatic Stress in South Africa
By Debra Kaminer, Gillian Eagle, Lara Jacob Wits University Press
Copyright © 2010 Debra Kaminer and Gillian Eagle
All rights reserved.
ISBN: 978-1-86814-836-3
CHAPTER 1
INTRODUCTION
The 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 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 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 re-exposure 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 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
PATTERNS OF TRAUMA EXPOSURE IN SOUTH AFRICA
The 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.
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.
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Excerpted from Traumatic Stress in South Africa by Debra Kaminer, Gillian Eagle, Lara Jacob. Copyright © 2010 Debra Kaminer and Gillian Eagle. Excerpted by permission of Wits University Press.
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