Traumatic stress in South Africa

Gillian Eagle & Deborah Kaminer

2010

Wits University Press

Taking both a historical and contemporary perspective, the book covers the extent of and manner in which traumatic stress manifests, including the way in which exposure to such extremely threatening events impacts on people’s meaning and belief systems. Therapeutic and community strategies for addressing and healing the effects of trauma exposure are comprehensively covered, as well as the particular needs of traumatised children and adolescents. Illustrative case material is used to render ideas accessible and engaging. The book also provides a comprehensive and up-to-date overview of theory and practice in the field of traumatic stress studies, incorporating both international and South African specific findings.

Psychology

English

9781868145096

https://creativecommons.org/licenses/by-nc-nd/4.0/legalcode

Traumatic Stress in South Africa

Traumatic Stress in
South Africa

Debra Kaminer and Gillian Eagle

Wits University Press
1 Jan Smuts Avenue
Johannesburg
2001
South Africa
http://witspress.ac.za
© Debra Kaminer and Gillian Eagle, 2010
First published 2010
ISBN 978-1-86814-509-6 (print)
ISBN 978-1-86814-682-6 (ePDF)
ISBN 978-1-77614-167-8 (open Web PDF)
All rights reserved. No part of this publication may be reproduced, stored in a retrieval
system, or transmitted in any form or by any means, electronic, mechanical, photocopying,
recording or otherwise, without the written permission, except in accordance with the
provisions of the Copyright Act, Act 98 of 1978.
Edited by Lara Jacob
Indexed by Ethné Clarke
Cover design by Hybridcreative
Layout by Manoj Sookai
Printed and bound by Creda Communications
Wits University Press has made every reasonable effort to locate, contact and acknowledge
copyright owners. Please notify us should copyright not have been properly identified and
acknowledged. Any corrections will be incorporated in subsequent editions of the book.
Cover: Blue Head, 1993 by William Kentridge

The authors are deeply grateful for the thoughtful and
reflective comments provided by colleagues, friends
and loved ones during the preparation of this book.

TABLE OF CONTENTS

List of Abbreviations and Acronyms.......................................................ix
1. INTRODUCTION.......................................................................................................................... 1

2. PATTERNS OF TRAUMA EXPOSURE IN SOUTH AFRICA................ 8
Violence. .................................................................................................................................................... 9
Non-intentional injury.................................................................................................................. 22
Indirect traumatisation. ................................................................................................................ 23
Multiple traumatisation. .............................................................................................................. 24
Conclusion. ........................................................................................................................................... 25
3. POSTTRAUMATIC STRESS DISORDER AND
OTHER TRAUMA SYNDROMES............................................................................... 28
Posttraumatic Stress Disorder .................................................................................................. 29
The effects of prolonged trauma exposure or abuse.................................................... 44
The effects of community violence: a continuous
traumatic stress syndrome?........................................................................................................ 48
South African research on the psychiatric effects
of trauma................................................................................................................................................ 49
Conclusion. ........................................................................................................................................... 58
4. TRAUMA AS A CRISIS OF MEANING.................................................................. 60
Shattered assumptions and the search for comprehensibility. .............................. 61
Beyond comprehensibility: the search for significance.............................................. 72
Conclusion. ........................................................................................................................................... 79

5. TRAUMA INTERVENTIONS FOR INDIVIDUALS, GROUPS
AND COMMUNITIES............................................................................................................ 80
Individual psychotherapy and counselling........................................................................ 81
Pharmacotherapy ...........................................................................................................................103
Group psychotherapy ..................................................................................................................105
Common mechanisms and best practice...........................................................................108
Treatment of multiple and continuous traumatic stress.........................................110
Traditional / indigenous practices........................................................................................114
Social alienation as a product of traumatisation.........................................................115
Community interventions, rituals and memorials.....................................................119
Conclusion. .........................................................................................................................................121
6. CHILDREN AND TRAUMA...........................................................................................122
Prevalence of trauma and posttraumatic stress in children..................................123
The impact of different forms of trauma on children. .............................................129
Developmental differences in trauma presentations................................................132
Familial, social and community dimensions.................................................................135
Treating childhood trauma. ......................................................................................................139
Conclusion. .........................................................................................................................................145
7. CONCLUSION. ...........................................................................................................................146
ENDNOTES. ..........................................................................................................................................155
BIBLIOGRAPHY..............................................................................................................................185
ABOUT THE AUTHORS. ..........................................................................................................205
INDEX.........................................................................................................................................................207

List of Abbreviations and
Acronyms

ANC
African National Congress
ASD
Acute Stress Disorder
BPP
Brief Psychodynamic Psychotherapy
CBT
Cognitive Behavioural Therapy
CIDI Composite International Diagnostic
Interview
CISD
Critical Incident Stress Debriefing
CPT
Cognitive Processing Therapy
CSVR Centre for the Study of Violence and
Reconciliation
CT
Cognitive Therapy
DESNOS Disorders of extreme stress not otherwise
specified
EA
Employee Assistance
EMDR Eye Movement Desensitisation and
Reprocessing
IFP
Inkatha Freedom Party
IRCT International Rehabilitation Council for
Torture Victims
MVAs
Motor vehicle accidents
NGOs
Non-governmental organisations
NLP
Neurolinguistic Programming

ix

NPAT
National Peace Accord Trust
PE
Prolonged Exposure
PIE
Proximity, Immediacy and Expectancy
POWA
People Opposing Women Abuse
PSTD
Posttraumatic Stress Disorder
PTGI Post Traumatic Growth Inventory
SADF
South African Defence Force
SANDF
South African National Defence Force
SASH
South African Stress and Health
SIT
Stress Inoculation Training
SSRIs
Selective serotonin reuptake inhibitors
TFT
Thought Field Therapy
TIR
Traumatic Incident Reduction
TRC Truth and Reconciliation Commission
VKD
Visual Kinaesthetic Dissociation

x

Chapter 1

Introduction

T

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
1

Traumatic Stress in South Africa

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’1. 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
2

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
3

Traumatic Stress in South Africa

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’.2 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 AIDSrelated 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
4

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
5

Traumatic Stress in South Africa

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).3 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
6

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.

7

Chapter 2

PATTERNS OF TRAUMA EXPOSURE
IN SOUTH AFRICA

T

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.1 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
8

Patterns Of Trauma Exposure In South Africa

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.2 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 sociopolitical 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.3 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.
9

Traumatic Stress in South Africa

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

Females (%)

Total (%)

Severe ill-treatment

2.7**

0.6

1.6

Detention

2.4**

0.3

1.3

Torture

1.3**

0.2

0.7

25.9**

11.6

18.2

Physical abuse by intimate
partner

1.3

13.6**

7.9

Rape

0.3

3.7 **

2.1

Other sexual assault

1.0

2.1*

1.6

12.3

11.7

12.0

Political violence

Criminal violence
Gender-based violence

Physical abuse during childhood

* 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.4 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.5 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
10

Patterns Of Trauma Exposure In South Africa

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 exdetainees. 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.6
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.7
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.8 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,9
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
11

Traumatic Stress in South Africa

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.10 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.11 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.12
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,13 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.14
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
12

Patterns Of Trauma Exposure In South Africa

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,15 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.’16 This
situation has most likely arisen as the result of a complex interplay of
13

Traumatic Stress in South Africa

factors that are unique to South Africa, which Altbeker and others17
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.18 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.19 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.20 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.21 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.22 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.23 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,24 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
14

Patterns Of Trauma Exposure In South Africa

during recreational periods such as weekends and holidays.25 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.26
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.27 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,28 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,29 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.30
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.31 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.32 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.33

15

Traumatic Stress in South Africa

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.
In South Africa and elsewhere, reliable statistics on the prevalence
of gender-based violence are difficult to obtain because in many cases
violence against women remains unreported. This occurs for many
reasons, including women’s emotional and economic dependency on
the abuser, fear of further punishment by the abuser, lack of confidence
in the police and fear of being further victimised by the criminal justice
system, the absence of any nearby police stations, feelings of shame
and self-blame, or an acceptance of the abuse as normal, deserved or
a private matter that should not be disclosed.34 Furthermore, police
statistics tend to classify reported acts of gender-based violence under
more general categories such as assault or attempted murder, which
do not reflect the gender of the victim.35 In South Africa, there is a
substantial difference in the number of cases of sexual violence that
are reported to the police and the number of cases that are reported
by women participating in research studies (where women are usually
able to remain anonymous and can avoid any negative consequences
of reporting the abuse), with the number of reported cases being up to
nine times higher in the latter.36 So, while it is likely that communitybased research studies may also under-represent rates of gender-based
violence to some extent, they do seem to yield a more accurate picture
than official police statistics.
In 1999, a review of research surveys of physical violence against
women in close to fifty different countries (including economically
developed and developing countries) indicated high but varying
prevalence rates across countries, with between 10 and 50 per cent
16

Patterns Of Trauma Exposure In South Africa

of women reporting that they had been physically abused by their
partners.37 In South Africa, the nationally representative SASH study
conducted from 2002 found that 14 per cent of adult women reported
having experienced physical abuse by an intimate partner.38 Similarly,
a 1998 nationally representative survey of health issues among nearly
12,000 South African women aged between fifteen and forty-nine
years (the South African Demographic and Health Survey or SADHS)
found that about 13 per cent had been physically abused by an
intimate partner.39 However, in the national SASH survey 28 per cent
of men reported that they had physically abused an intimate partner,40
suggesting that rates of intimate partner abuse may be much higher
than female research participants admit.
There are significant regional variations in the reported prevalence
of intimate partner abuse in South Africa. In the SADHS survey of
women, the highest levels of intimate partner violence were reported
in Gauteng (17.8 per cent) and the Western Cape (16.9 per cent).41
A subsequent smaller survey, which focused specifically on genderbased violence in the three provinces of Mpumulanga, Eastern Cape
and Northern Province (and was therefore named the Three Province
Study) found much higher prevalence rates of intimate partner violence
in these three provinces than had been found by the SADHS study, with
substantially higher rates reported by women in Mpumulanga (28 per
cent) and the Eastern Cape (27 per cent), compared with the Northern
Province (19 per cent).42 Some studies among specific communities
in South Africa have found even higher levels of partner abuse. For
example, 50 per cent of the women attending an antenatal clinic in
Soweto reported that they had experienced intimate partner violence,43
80 per cent of a sample of women in rural communities in the southern
Cape reported experiences of domestic violence,44 and 42 per cent
of male municipal workers in Cape Town45 and about one third of a
sample of young men from seventy villages in the rural Eastern Cape46
reported that they had been physically abusive towards their female
partners. It is also apparent that many South African women in abusive
relationships experience a combination of different forms of abuse,
including physical, sexual and emotional abuse.47
While available statistics do not necessarily indicate that rates of
intimate partner violence are higher in South Africa than elsewhere,
17

Traumatic Stress in South Africa

there is some evidence to suggest that rates of sexual violence are
exceptionally high in South Africa compared with the rest of the world.
In 1995, the Human Rights Watch report labelled South Africa as the
rape capital of the world48 and a 1999 comparison of South Africa with
eighty-nine Interpol member states found that South Africa had the
highest ratio of reported rape cases per 100,000 in the population.49
While comparisons to other countries are somewhat limited by the fact
that the legal definition of rape varies across different countries, it is
clear that South African women are at enormously high risk of sexual
victimisation.
The results of research surveys (which rely on subjective perceptions
about whether one has been raped or sexually abused, rather than
on legal definitions) confirm that rates of rape and other forms of
sexual assault are high in South Africa, although not always higher
than those reported in other countries. The SADHS study referred to
earlier found that 7 per cent of the total sample of women had been
forced to have sex against their will, and the Three Province Study
reported similar prevalence rates of between 6 and 7 percent across
the three provinces. These rates are higher than the rape rates reported
in some national surveys in other countries, such as Mexico (3.9 per
cent), Chile (3.8 per cent) and Australia (5.4 per cent),50 but lower than
those reported in the United States (9.2 per cent) and Canada (15.5
per cent).51 Compared with the SADHS study, the more recent SASH
study in South Africa found a much lower reported rate of rape (3.7 per
cent) among women,52 as well as a lower rate of sexual molestation (2.1
per cent) compared with countries such as the United States (12.3 per
cent), Mexico (10.5 per cent) and Australia (10.2 per cent).53 While this
finding may possibly reflect a downward trend in the national prevalence
of rape in South Africa since the SADHS study was conducted, the
different rates of reported sexual violence and coercion are more likely
due to methodological differences across the studies, such as sampling
differences (for example, the SADHS study included women from
the age of fifteen years old, while the SASH study included women
from the age of eighteen), the use of different measuring instruments,
different forms of training provided to interviewers, and differences
arising from the translation of questions about sexual assault into a
number of South African languages.
18

Patterns Of Trauma Exposure In South Africa

Some studies indicate that women in specific communities in South
Africa are at a much higher risk of sexual violence than is reflected in
the national average that has been reported in the different surveys in
South Africa. For example, the study of women attending an antenatal
clinic in Soweto referred to earlier, found that 20 per cent reported
experiencing sexual violence by an intimate partner,54 and it appears
that younger South African women are at much higher risk of being
raped than older women.55
Although reliable statistics for violence against children are
particularly difficult to establish, South Africa does appear to have a
disturbingly high rate of childhood sexual abuse. In South Africa in
2004 more than 40 per cent of all rapes reported to the police, and
nearly half of indecent assaults, were perpetrated against children. In
numbers this amounted to almost 25,000 children, and since only about
one in twenty cases of child sexual abuse are reported, it is likely that
between 400,000 and 500,000 children are raped in South Africa every
year.56 Furthermore, sexual abuse of children is one of the few forms
of violence in South Africa that is actually increasing over time. This is
contrary to the trend in the United States, which has seen a decline in
rates of child sexual victimisation since the early 1990s.57
Some prevalence studies conducted with South African adult women
have asked retrospectively about their experiences of sexual abuse
in childhood. The SADHS study found that 1.6 per cent of women
reported having been forced to have sex against their will before the
age of fifteen,58 while the Three Province Study similarly found that 1.2
per cent had been raped, and 3.3 per cent had experienced unwanted
sexual contact, before the age of fifteen years.59 However, the average
rate of childhood sexual victimisation reported in very large surveys can
obscure the much higher risk to some girls as opposed to others. For
example, the survey of three secondary schools in the Western Cape
region, referred to previously in this chapter, reported that 17 per cent
of female adolescents had experienced a sexual assault,60 while a survey
of female secondary school students in the Northern Province found
that over 50 per cent had experienced unwanted sexual contact.61 Being
forced to have sex against their will by a dating partner was reported
by 28 per cent of a sample of female school students in the Transkei62
19

Traumatic Stress in South Africa

and by 28 per cent of a random sample of young women from Umlazi,
Khayelitsha and Soweto.63 Studies of female university students have
reported that between 23 and 53 per cent had experienced some form of
unwanted sexual touching (including rape) in childhood.64 These rates
are higher than those found in community-based studies with adult
women in the United States where, on average, about 20 per cent of
participants have reported being sexually abused in childhood.65 Most
rapes of young girls in South Africa are perpetrated by men known
to the victim, including relatives, neighbours and school teachers,66
and since most sexual violence is not reported to the police, many
young rape survivors face the trauma of ongoing daily contact with the
rapist.
In keeping with international findings, South African women are
not the only victims of sexual violence and coercion. In the national
SASH study, 0.3 per cent of men reported that they had been raped
while 1 per cent reported experiencing other forms of sexual coercion.67
Studies of male secondary school and university students have reported
that between 9 and 56 per cent have experienced unwanted sexual
contact in childhood,68 and another study found that, between 2001
and 2003, 131 sexually abused boys presented to a medico-legal centre
in KwaZulu-Natal.69 In an epidemiological study conducted in three
districts of the Eastern Cape and KwaZulu-Natal, 4.6 per cent of men
reported being raped in the past year.70
The reported rates of sexual violence in all the research studies
discussed above must be viewed as an under-representation of the true
state of affairs, since incidents of sexual coercion (particularly in marital,
dating and familial relationships) are likely to be under-reported.71
Although we must rely on research data as a guideline, it is likely that the
true prevalence of sexual violence and coercion experienced by South
Africans is unfortunately far higher than even our best data suggests.
For example, in the epidemiological study of men in the Eastern Cape
and KwaZulu-Natal, 27.6 per cent of the participants admitted to
having raped at least one person.72 As with intimate partner abuse, this
suggests that the true prevalence of rape in South Africa may be a good
deal higher than is revealed by studies that have asked women whether
they have been raped.
20

Patterns Of Trauma Exposure In South Africa

In addition, statistics on the prevalence of gender-based violence
do not necessarily reflect the severity of violence against women in
South Africa. The degree of violence associated with domestic abuse
and sexual assaults in South Africa appears to be particularly extreme.
With regard to intimate partner violence, South African women are
killed by their male partners six times more often than the international
average.73 For sexual assaults, one regional study found that rapes in
the Western Cape are twelve times more likely to be fatal than sexual
assaults in the United States,74 while there is also evidence to suggest
that the national prevalence of rape homicides in South Africa is higher
than that of all female homicides in the United States.75 Furthermore,
the emotional and physical trauma of rape in South Africa is often
exacerbated by assaults from more than one rapist, with gang rape
being reported by a quarter to one-third of all South African rape
survivors who presented to medico-legal clinics in Johannesburg76 and
by a third of all participants in a study of 250 rape survivors from three
provinces.77
Childhood physical abuse
The prevalence of physical abuse of children by a family member is
extremely difficult to estimate reliably   –  once again, police statistics
reflect only the reported cases, which represent a very small minority
of all incidents, and for a number of reasons it is extremely difficult
to interview children directly about their experiences of physical
abuse. One way to estimate rates of childhood physical abuse is to
ask adults whether they were abused in childhood. While this only
provides a picture of the prevalence of childhood physical abuse in the
past, rather than the present, it does give an indication of the number
of South Africans who may be living with the trauma of an abusive
childhood. In the SASH survey of South African adults, 12 per cent
of participants reported that they had experienced physical abuse by
a caregiver in childhood.78 This is several times higher than the rates
found in a national survey in the United States.79 With regard to who
is most at risk of childhood physical abuse by a family member, some
United States studies indicate that males are more vulnerable than
females, while others report that both genders are equally at risk across
21

Traumatic Stress in South Africa

all ages.80 In the SASH survey there was little difference in the rate of
childhood physical abuse reported by males and females,81 but reviews
of local hospital records suggest that the majority of children injured by
domestic physical abuse are boys under the age of five years.82

Non-Intentional Injury

Although it is difficult to obtain reliable and systematic data about
the prevalence of accidental injury, information from mortality studies
(which track the causes of fatal injuries in the population) suggests
that South Africa has a high rate of injuries due to accidental causes.
For example, like many other countries in Sub-Saharan Africa, South
Africa has a death rate from unintentional injuries that is about 30 per
cent higher than the global average, with our most common forms of
accidental injury being road traffic injuries and burn injuries.83
Road traffic injuries
South Africa’s death rate from traffic accidents (forty-three per 100,000
people in the population) is double the global average.84 Approximately
one quarter of all injury-related deaths in South Africa occur as the
result of road traffic accidents. Injuries to pedestrians, rather than
to vehicle passengers, are the most common form of traffic-related
injury in South Africa, accounting for about 40 per cent of all trafficrelated deaths.85 With regard to non-fatal traffic injuries, in 2005, it
was estimated that about one hundred South Africans were seriously
injured in road traffic accidents every day, and twenty of these were
permanently disabled.86 However, a traffic accident does not have to
result in an injury to be psychologically traumatic: as we shall see in
the next chapter, any event that is experienced as being life-threatening
can result in post-traumatic stress symptoms. In the SASH survey, 12.2
per cent of participants reported that they had been involved in a lifethreatening car accident.87
Those most at risk of being injured in a traffic accident are males
from socio-economically disadvantaged communities, who make up the
majority of pedestrians in South Africa. Indeed, road traffic collisions
were ranked as the fourth leading cause of death among South African
males in 2000.88 However, the number of deaths due to road traffic
22

Patterns Of Trauma Exposure In South Africa

accidents is much higher for both sexes in South Africa compared with
many other countries.89
Burn injuries
The main victims of accidental burn injuries in South Africa are
children. Burn injuries are a leading cause of injury, disability and nonnatural death among South African children, especially those between
the ages of one and five years old.90 One study conducted in the Western
Cape found that six children per every 10,000 in the population are
seriously burned, and noted that the risk of a burn injury is heightened
by conditions of poverty, which are characterised by overcrowding,
the use of a single room for cooking, washing and living, and the use
of non-electrical sources of energy like paraffin and candles.91 South
African children living in poor households are therefore most likely to
be the victims of a burn injury.
Among children, it is infants and toddlers who are most at risk of
being burnt, and scalding by boiling water is the most common form
of burn injury in this age group. While infant boys are generally more
likely than infant girls to sustain a scalding injury, in the toddler age
range females appear to be more vulnerable. Older children, and again
females in particular, are most likely to sustain flame burns   –  because
they are more mobile and independent than infants. Due to gender
role expectations girl children are more exposed to activities such as
cooking and the lighting of fires.92

Indirect Traumatisation

Research in countries such as the United States and Canada has
established that one does not need to be a direct victim of a trauma
in order to develop posttraumatic symptoms.93 Even being indirectly
exposed to a situation where someone else’s physical safety is under
threat can result in a similar response to that which is common after
being directly traumatised.94 Indirect forms of traumatisation include
witnessing violence or injury to another person (for example, an act of
criminal violence, a serious traffic accident or a burn injury to a child),
as well as hearing about a trauma that occurred to someone close,
such as a family member or close friend. A trauma to a close other is
23

Traumatic Stress in South Africa

particularly likely to cause distress and posttraumatic symptoms if the
trauma is fatal, resulting in a traumatic bereavement.95
Indirect forms of trauma exposure are very common in South
African society. In the SASH study, 28 per cent of the sample reported
that they had witnessed a traumatic event, such as someone being
injured or killed.96 This is comparable to rates of witnessing trauma
that have been found in other countries. Also consistent with findings
in other countries, such as the United States, Canada, Australia and
Mexico,97 South African men were more likely than women to report
witnessing a traumatic event, especially violence. It is possible that men
are more likely than women to witness violent incidents because, due
to traditional gender-role expectations, they spend more time in the
public sphere outside the home.
In the SASH survey, hearing about a trauma to a close other was
more common than witnessing a trauma, with 43 per cent of the sample
reporting such an experience. In most cases, the trauma involved the
unexpected death of a loved one, and women were more likely to have
experienced a sudden bereavement than men.98 This is not surprising
since, as we have seen throughout this chapter, South African males have
been the predominant victims of political violence, criminal violence
and accidental injuries, leaving many South African women to mourn
the sudden and traumatic loss of their partners, fathers, brothers and
sons.

Multiple Traumatisation

As can be seen from the information presented in this chapter so far,
there are many different forms of trauma that affect the South African
population, including trauma in the home and in the broader community,
and encompassing both direct and indirect forms of traumatisation. It
is therefore to be expected that many South Africans have survived not
just one traumatic experience in their lifetime, but several. Indeed, the
SASH survey found that 56 per cent of respondents had experienced
more than one trauma, and 16 per cent had experienced as many as
four or five traumas.99
Multiple traumatisation can occur over a long period of time and
presents the person with ongoing challenges to their attempts to recover
and move forward with their life goals. For example, a 23-year-old woman
24

Patterns Of Trauma Exposure In South Africa

living in Cape Town was admitted to a psychiatric hospital after being
raped by a friend of her boyfriend. When the clinician interviewed her,
it emerged that she had been sexually abused by her mother’s brother
for several years as a child. Then, when she was eighteen years old, she
was gang-raped while walking home from the bus-stop after work. She
had previously told no one about these experiences, but after the latest
rape she felt too unsafe to leave her house at all, believed that life held
no future for her, and had completely withdrawn from her work and
social life. In another example of multiple traumatisation, a 53-year-old
man was referred to counselling at a trauma clinic after being assaulted
and robbed by gang members with knives at a taxi rank one evening.
It emerged that in his twenties he had been detained and tortured by
security police over a period of three months because of his political
activities, and as a result of his torture-related injuries he experienced
severe back pain that limited his capacity to sustain employment.
Furthermore, he had experienced a traumatic bereavement when
his son died three years before in a car accident. Thus it is apparent
that those who are multiply traumatised may experience separate
incidences of both related and unrelated kinds of traumatic events. In
both instances the impact of later traumas is likely to be compounded
by prior exposure as will be discussed in more detail in subsequent
chapters.
Despite the popular belief that South Africans are exposed to
more trauma than citizens in other countries, experiences of multiple
traumatisation have been reported across many different countries.
Although it is difficult to make direct comparisons with the SASH survey
due to the use of different instruments to measure trauma exposure
across different studies, similar or even higher rates of multiple trauma
exposure have been reported in national surveys in the United States,
Canada and Mexico.100 Consistent across all these studies, including
the SASH survey, is the finding that men are at significantly higher risk
than women of being exposed to multiple traumas.

Conclusion

This chapter has focused on patterns of direct and indirect exposure
to some of the most common forms of intentional violence and non25

Traumatic Stress in South Africa

intentional injury in South Africa. There are, of course, other forms of
traumatisation that are common among the South African population.
This includes receiving a diagnosis of a life-threatening illness such as
HIV/AIDS,101 and injuries that are sustained as a result of work-related
accidents (particularly in the mining sector).102 Furthermore, natural
disasters such as floods, or the tornado that left many people homeless
in Cape Town in 1999, and the subsequent dislocation caused by these
events, are also traumatic. It is often the poor and marginalised who are
most affected by natural disasters. For example, those most likely to be
living below flood-lines and therefore most vulnerable to risk in heavy
storms are people living in informal housing. Finally, it is important to
note that being the perpetrator of violence or injury, whether accidental
or intentional, can also be experienced as traumatic.103
Research has not consistently supported the popular notion that
South Africans, as a whole, are exposed to more trauma than people
living in other countries, but there is an accumulation of disturbing
evidence that interpersonal violence in South Africa takes a more severe
and lethal form than the international norm. Almost half of all South
African deaths due to injury are the result of interpersonal violence,
which is four-and-a-half times the rate of violence-related deaths
internationally.104 Violence between young men (often in the context of
gang activity or alcohol-related entertainment), and sexual and physical
violence towards women and children all take a particularly brutal form
compared with such interpersonal violence in many other countries.
As such, the stereotype of South Africa as a particularly dangerous
society does appear to be supported by systematic evidence. However,
the greatest burden of trauma exposure falls upon South Africans who
have historically been the victims of political oppression (under the
recent apartheid system but also within the broader historical context
of colonisation), many of whom still continue to live in conditions of
poverty and disempowerment. In this sense, trauma exposure in postapartheid South Africa remains a deeply political issue, rooted in
historical dynamics of power and inequality.
Because the majority of South Africans have experienced at least
one trauma, and many have suffered multiple traumatic experiences,
it appears that trauma is not an extraordinary or aberrant event in our
26

Patterns Of Trauma Exposure In South Africa

society, but rather a commonplace one. This raises some important
questions. Just because trauma is common, does this normalise it?
Do people living in conditions of chronic violence and traumatisation
eventually become desensitised to trauma and find functional ways to
cope and adapt, or are they in fact more at risk for psychiatric disorders
and other problems in living? Do South Africans who live with daily
violence construct traumatised identities or subjectivities for themselves
(that is, do they think about themselves as being ‘traumatised’ or suffering
from ‘trauma’), in the absence of trauma-free norms against which to
measure their experience? Local research has begun to tackle some
of these complex questions, although there is still much that remains
to be understood about how South Africans adapt to conditions of
multiple and continuous exposure to potentially traumatic events, and
how historical oppression as well as ongoing conditions of poverty and
inequality contribute to the meaning and impact of trauma exposure
across different South African communities. The next two chapters will
examine what we currently know about the psychological impact of
trauma exposure, from both local and international research.

27

Chapter 3

POSTTRAUMATIC STRESS
DISORDER AND OTHER TRAUMA
SYNDROMES

I

n general, human beings have a remarkable capacity to adapt to
extreme stress from the environment. The majority of survivors of
potentially traumatic events experience a brief period of disequilibrium,
but do not develop lasting difficulties. However, a substantial minority
go on to experience severe and ongoing symptoms that cause much
distress and substantially restrict their ability to function in the world.
When trauma responses reach this level, they may be classified as a
psychiatric disorder. Posttraumatic Stress Disorder (PTSD)1 is the
most widely publicised trauma-related psychiatric disorder and it will
therefore be a major focus of this chapter, but there are several others
that are also commonly associated with traumatic events. In addition,
researchers have recently attempted to describe the psychological and
psychiatric effects of prolonged abuse at the hands of another person,
and the ways in which these differ from the effects of single traumas.
Despite significant advances in our understanding of trauma-related
syndromes, in this chapter we will also see that relatively little is known
about the effects of exposure to continuous community violence, a
context that many South Africans currently live in. Finally, this chapter
will review existing South African research on the psychiatric impact of
28

Posttraumatic Stress Disorder And Other Trauma Syndromes

trauma exposure in South Africa, and consider some of the gaps in our
local knowledge that require further attention.

Posttraumatic Stress Disorder
Normal trauma reactions versus PTSD
After a traumatic event, most people will experience some degree of
distress as they try to adapt to what has happened. Common reactions
include feelings of anxiety and mild depression, having distressing
thoughts and memories of the traumatic event, difficulty sleeping, and
feeling hyper-alert to any signs of danger. In order to manage these
symptoms, many trauma survivors may wish to avoid talking about what
happened, may withdraw from contact with other people, and may feel
emotionally numb when they think about the trauma.2 These reactions
can last for a few days, weeks or even months after the traumatic event
and then gradually fade, without severely impacting on the survivor’s
ability to continue with their normal daily functioning.
However, for some trauma survivors the above symptoms do
not gradually diminish over time and continue to create substantial
impairment in their work and social roles. Posttraumatic Stress
Disorder is a psychiatric diagnosis that has been developed to describe
such a response to trauma. PTSD was first introduced as a psychiatric
disorder in 1980, but since then the diagnostic criteria for PTSD
have been further refined through systematic clinical research, largely
based in North America. The current diagnostic criteria for PTSD are
presented in Box 3.1.
The first requirement for the PTSD diagnosis is that the person
must have experienced a traumatic event (either as a direct victim or
as a witness) that involved some form of physical threat. Historically,
the term ‘trauma’ has been used to refer to a wide variety of
experiences, including emotionally stressful ones. For example, in
the psychoanalytic tradition, the term ‘trauma’ is often used to refer
to emotionally damaging life experiences, such as having extremely
critical or emotionally unresponsive caregivers   –  in this sense, trauma
is an emotional injury, rather than a physical one. However, research
has shown that the specific syndrome of PTSD is typically linked to
29

Traumatic Stress in South Africa

Box 3.1 DSM-IV-TR Diagnostic Criteria for PTSD
A. The person has been exposed to a traumatic event in which both of the
following were present:
(1) the person experienced, witnessed, or was confronted with an event or
events that involved actual or threatened death or serious injury, or threat
to the physical integrity of self or others
(2) the person’s response involved intense fear, helplessness, or horror
B. The traumatic event is persistently re-experienced in one (or more) of the
following ways:
(1) recurrent and intrusive distressing recollections of the event, including
images, thoughts or perceptions
(2) recurrent distressing dreams of the event
(3) acting or feeling as if the traumatic event were recurring (includes a
sense of reliving the experience, illusions, hallucinations, and dissociative
flashback episodes)
(4) intense psychological distress at exposure to internal or external cues that
symbolise or resemble an aspect of the traumatic event
(5) physiological reactivity on exposure to internal or external cues that
symbolise or resemble an aspect of the traumatic event
C. Persistent avoidance of stimuli associated with the trauma and numbing of
general responsiveness (not present before the trauma), as indicated by three
(or more) of the following:
(1) efforts to avoid thoughts, feelings, or conversations associated with the
trauma
(2) efforts to avoid activities, places, or people that arouse recollections of the
trauma
(3) inability to recall an important aspect of the trauma
(4) markedly diminished interest or participation in significant activities
(5) feelings of detachment or estrangement from others
(6) restricted range of affect (for example, unable to have loving feelings)
(7) sense of a foreshortened future (for example, does not expect to have a
career, marriage, children, or a normal life span)
D. Persistent symptoms of increased arousal (not present before the trauma), as
indicated by two (or more) of the following:
(1) difficulty falling or staying asleep
(2) irritability or outbursts of anger
(3) difficulty concentrating
(4) hypervigilance
(5) exaggerated startle response
E. Duration of the disturbance (symptoms in Criteria B, C, and D) is more than 1
month
F. The disturbance causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning
Source: American Psychiatric Association, 2000.

30

Posttraumatic Stress Disorder And Other Trauma Syndromes

physically threatening experiences, rather than emotionally damaging
experiences that lack any perceived physical threat.3 This is why the
first diagnostic requirement for PTSD specifies that the person must
have experienced an event perceived to be physically threatening.
However, this criterion acknowledges that many people can develop
PTSD from witnessing traumatic events, even if they have not been
directly traumatised.
The diagnosis of PTSD also currently requires that the physically
threatening event must have elicited a reaction of intense fear,
helplessness or horror. This acknowledges that the person’s subjective
response to the event (how frightened they felt) is as important as the
objective degree of physical threat involved. For example, one person
may be mugged by an assailant who brandishes a firearm, and another by
an unarmed assailant who verbally threatens to harm the person, but the
second crime victim may feel subjectively more frightened and helpless
than the first. The assumption behind this diagnostic requirement is
that it is the subjective feeling of ‘helpless terror’4 during the trauma
that is implicated in the development of PTSD. However, this criterion
has been somewhat controversial, since there is not strong evidence
to show that a fearful response during a traumatic event predicts the
development of PTSD.5
In addition to specifying the type of traumatic experience that
qualifies a person to be considered for the diagnosis, there are three
clusters of symptoms for PTSD. The first symptom cluster includes
different forms of re-experiencing the trauma in a manner that the
trauma survivor is unable to voluntarily control. For example, the
survivor may find that throughout the day images and thoughts about
the trauma continually intrude into their consciousness, despite their
best efforts to block these out. At night, this intrusion may occur in the
form of nightmares about the trauma. In addition, whenever the person
encounters something that reminds them of the trauma (known as a
traumatic ‘trigger’) they feel intense distress and fear, and experience
physical symptoms associated with the body’s natural response to
danger (known as the ‘fight, flight or freeze’ response), including
increased heart rate, muscle tension and sweating.6 Finally, the survivor
may experience flashbacks about the trauma, especially when they
encounter a traumatic reminder or trigger. Flashbacks differ from
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Traumatic Stress in South Africa

normal memories as they involve intense sensory re-experiencing of the
trauma (smelling the same smells, hearing the same sounds, feeling the
same sensations on the skin), rather than just an image or thought about
the event. Through all these symptoms, the survivor finds themselves
perpetually stuck in the moment of the trauma. At least one form of
re-experiencing the trauma must be present in order to qualify for a
possible diagnosis of PTSD.
The second symptom cluster of PTSD involves avoidance symptoms.
In an attempt to manage the highly distressing re-experiencing
symptoms described above, the trauma survivor may attempt to avoid
any reminders of the trauma. For example, the person may make a
conscious effort to avoid places or situations that are associated with
the trauma. A hijack victim may try to avoid having to drive anywhere
alone (see the case study in Box 3.2), a child who has been mugged
outside his school may refuse to go back to school afterwards, and a
woman who has been raped while walking to her bus stop may feel
unable to walk that route again or to use any form of public transport.
This avoidance may not be restricted to the trauma-specific situation,
but may also generalise to the point where the person avoids leaving
their home at all, or only goes out when absolutely necessary, and this
may substantially restrict their participation in their usual activities.
Trauma survivors also often wish to avoid talking to others about
the trauma, as this makes them feel anxious and distressed all over
again. For many survivors, talking about or remembering the trauma
feels as dangerous as actually experiencing it. This may be hard for
family and friends to understand, as there is a popular notion that
trauma survivors should talk about what happened in order to feel
better. Survivors may also find that they attempt not to think about
the trauma at all, forcing themselves to think about something else if a
thought about the trauma enters their mind. Usually these attempts at
mental avoidance are only partially successful, and intrusive thoughts
and images repeatedly push their way into consciousness. In addition,
the survivor may try to avoid the distressing feelings associated with
the trauma by numbing themselves emotionally, resulting in feeling
cut-off or emotionally detached much of the time. At least three of
the avoidance symptoms listed in Box 3.1 must be present in order to
consider a possible diagnosis of PTSD.
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Posttraumatic Stress Disorder And Other Trauma Syndromes

The final symptom cluster of PTSD is an increased level of physical
arousal (known as hyperarousal) compared with before the trauma.
This physical arousal entails an ongoing state of the body’s ‘fight,
flight or freeze’ response, and involves difficulty sleeping, difficulty
concentrating on daily activities, being constantly on the look out for
signs of threat and danger (known as hypervigilance), being startled
very easily at loud noises or sudden movements, and becoming easily
irritable or angry in response to minor frustrations or perceived hostility
from others. At least two of these symptoms must be present in order
for the survivor to qualify for a possible diagnosis of PTSD.
As noted earlier, it is normal to experience many of these symptoms
for a while after the trauma, and their presence alone is not sufficient to
diagnose PTSD. To meet the diagnosis, the re-experiencing, avoidance
and hyperarousal symptoms must be present for at least one month
after the trauma and they must cause the person extreme distress or
interfere significantly with their ability to function at work or in their
social roles. A careful assessment by a psychologist or psychiatrist is
necessary in order to establish whether the full criteria for PTSD are
met.
The course of PTSD varies over time. Research indicates that about
half of the people who develop PTSD will recover within three months
(this is called Acute PTSD). For others, the symptoms will come and go
for months or years after the trauma (Chronic PTSD), and still others
may only develop PTSD six months or more after the actual trauma
(Delayed PTSD).7 A diagnosis that is closely related to PTSD is Acute
Stress Disorder or ASD. This diagnosis can be made if symptoms of
PTSD are present for less than one month and there are also prominent
features of dissociation, which may occur either during the traumatic
event or afterwards.8 Dissociation includes a sense of emotional
numbing or detachment, a reduced awareness of one’s surroundings
(for example, feeling as if one is in a daze), amnesia for certain aspects of
the trauma, feeling detached from one’s body or feeling that the world
is unreal or dreamlike. While many trauma survivors may experience
some symptoms of dissociation during or immediately after the trauma,
the diagnosis of ASD is only made if these symptoms cause significant
distress or create a serious impairment in the survivor’s ability to
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Traumatic Stress in South Africa

function after the trauma. If the symptoms of ASD last longer than one
month, the diagnosis may be changed to PTSD if the full diagnostic
criteria for PTSD are met.
Box 3.2 Case study of PTSD
Five months ago, Thandi was hijacked in her driveway after coming home from a
night class at the local Technikon. The hijackers were three men, each of whom
carried a gun. One of them held a gun to her head during the hijacking. Her
husband was not at home at the time, but her neighbours heard her screaming
for help after the hijackers had fled with her car, and they called the police.
Thandi’s car was later found abandoned several blocks away.
Since the hijacking, Thandi has been experiencing the following symptoms. Each
evening, as soon as it starts to get dark, she begins to feel highly anxious and
fearful. She refuses to drive anywhere at night, even with somebody else, and
this has meant that she has had to stop attending night classes. She is extremely
hypervigilant when coming home, often driving past her driveway three or four
times to make sure that no attackers are lurking there before she is willing to pull
in and park at her home.
Several times a day she has flashbacks of the hijacking, in which she can hear
the sounds of the hijackers shouting and of car doors slamming, smell the scent
of cigarettes on the breath of the hijacker who was holding a gun to her head,
and feel the cold sensation of the gun at her temple. The flashbacks are often
brought on when she hears the sound of men shouting or of car doors slamming,
or when she smells cigarettes on someone’s breath. During the flashbacks, her
heart thumps wildly, she shakes, and she feels like she cannot breathe. She also
has nightmares in which the hijacking is replayed. She wakes up and feels so
anxious that she cannot fall asleep again, and lies awake in a tense state, listening
out for any noises which might indicate that an intruder is on the property.
At work, she is unable to concentrate and often finds her attention drifting for
long periods of time. She has also become very irritable with her work colleagues
and they have taken to avoiding her unless they absolutely have to speak to
her.
Thandi’s husband has tried to talk with her about how she’s feeling, but Thandi
insists that she just wants to ‘forget about what happened and move on –
there’s no point dwelling on it’. She becomes angry when friends tell her to
‘talk about what happened – you’ll feel better’, and has started to avoid social
arrangements.

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Posttraumatic Stress Disorder And Other Trauma Syndromes

Explanations for PTSD
Research outside of South Africa has consistently found that PTSD
affects only a minority of trauma survivors. Although estimates vary
across studies, depending on the kind of methodology that was used, it
is evident that generally not more than 25 per cent of trauma survivors
develop PTSD.9 Several explanations have been offered to account for
the development of PTSD in some trauma survivors but not others.
As suggested by PTSD symptoms such as flashbacks and intrusive
images, traumatic memories have a very distinct quality compared
with normal memories. There are several theories about why the
traumatic memories that characterise PTSD are re-experienced in such
an intrusive, vivid and uncontrollable way by some trauma survivors,
compared with memories for non-traumatic events. For example, early
psychoanalytic theorists proposed that the re-experiencing symptoms
that often follow after a trauma are a form of repetition compulsion,
whereby the mind unconsciously attempts to achieve psychological
mastery over the traumatic event by replaying it repeatedly.10 This
attempt at mastery is part of the psyche’s natural attempt to adapt to,
and heal from, an intensely distressing experience. In the case of PTSD,
however, this mechanism does not fade over time as the person adapts
to what has happened, but rather continues to operate.
Other theorists have drawn on the concept of ‘schemas’ to explain the
re-experiencing symptoms of PTSD. A schema is an internal cognitive
structure or framework that organises and interprets information from
our environment. Our existing schemas, which have developed from all
our previous experience, provide a model of the world that guides our
behaviour.11 Schemas evolve through the dual processes of assimilation
and accommodation. In the former, experiences that are familiar to the
person’s working model of the world are categorised and incorporated
into their existing schemas, thereby strengthening these; in the latter,
schemas are modified in order to account for novel experiences that
cannot be categorised into existing schemas. Trauma theorists have
argued that, for some trauma survivors, the traumatic experience may
be too alien and too discrepant with previous experience to be either
assimilated or accommodated into their existing schemas, resulting
in the memory remaining disorganised.12 When an experience defies
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cognitive categorisation, its memory may be incorporated as a purely
sensory experience (sights, sounds, smells, bodily sensations and tastes),
rather than as a narratively organised memory, that is, a memory with
a coherent story to accompany it.13 We will return to this notion of
schemas in the next chapter, when we explore the ways in which people
try to make meaning from traumatic experiences.
These cognitive theories are supported by evidence from brain
imaging studies, which suggest that during a traumatic experience,
extremely high levels of emotional arousal may prevent incoming
information from being properly evaluated and categorised by a part
of the brain known as the hippocampus.14 Unlike other memories,
traumatic memories may therefore not always be stored in the brain as
a unified, integrated whole, but rather as sensory fragments.
But why do these unconscious, cognitive and neurobiological
mechanisms become chronically disrupted for some trauma survivors,
resulting in PTSD symptoms, while other trauma survivors develop
only transitory symptoms? A number of factors have been identified
that may contribute to the risk for developing PTSD. These factors are
both biological and environmental.
Certain types of trauma appear to be more likely to produce PTSD
than others. Studies in many different countries have consistently
found that experiencing a violent assault is much more likely to result
in PTSD than experiencing a traumatic accident or natural disaster.
Furthermore, of all the different types of assaultive violence, sexual
assault carries the highest risk of PTSD, for both men and women.15
The SASH survey in South Africa similarly found that, for women,
rape is far more likely to result in PTSD compared with other kinds
of assault (for example, criminal violence or domestic abuse), although
torture was the strongest predictor of PTSD for men.16 Interestingly,
despite the consistent finding that rape creates an exceptionally high
risk for PTSD, there is almost no research that has tried to establish
why this is so. Speculatively, this may be due to the intensely intrusive
physical nature of the act of rape, or to environmental factors such as
the lack of social support that rape survivors often encounter in their
communities and from the medical or justice systems. How precisely
these or other factors may increase the rape survivor’s vulnerability to
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Posttraumatic Stress Disorder And Other Trauma Syndromes

developing PTSD is still unclear   –  but clearly a matter requiring urgent
attention in the South African context.
The female gender also appears to create a substantially higher
risk for developing PTSD after a trauma. A number of studies in
countries such as the United States, Canada, Mexico and Chile have
indicated that women are at least twice as likely as men to develop
PTSD after a trauma.17 This holds true even when one takes into
account that men and women tend to experience different kinds of
trauma   –  in other words, this difference cannot be explained by the
fact that women may experience more of the kinds of traumas that are
likely to produce PTSD, such as sexual assault.18 It remains unclear
whether the higher risk for developing PTSD among women is due
to biological factors (such as hormonal differences between men and
women), differing environmental experiences (women are still generally
more economically, educationally and politically disempowered than
men, which may decrease their capacity to cope after trauma), different
ways of coping with stress (for example, due to sex-role stereotypes,
women may be more likely than men to acknowledge feeling fearful
and avoidant of frightening situations, and more likely to seek help
for these symptoms, so may be diagnosed with PTSD more often than
men), or some combination of these factors.19 Interestingly, however,
both the SASH survey in South Africa20 and an Australian survey21
found no significant difference between men and women in rates of
PTSD, suggesting that female gender may not necessarily pose a risk
factor for PTSD in all societies.
It has also been established that the brain structure and functioning
of trauma survivors who develop PTSD differ from those who do
not develop PTSD. Firstly, brain imaging studies show that trauma
survivors with PTSD have a significantly smaller hippocampus (an
area of the brain which, as we have seen, plays a critical role in the
categorisation and storage of incoming stimuli in memory) and an
excessively activated amygdala (an area of the brain that is involved
in evaluating the emotional significance of incoming stimuli).22 People
who develop PTSD after a trauma also appear to have a different type
of neurochemical response to the trauma than those trauma survivors
who do not develop PTSD. For example, the receptors in the brain for
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the stress hormone, cortisol, appear to be more sensitive in people who
develop PTSD after a trauma, compared with those who do not, possibly
making them intensely sensitive and hyper-responsive to external
events.23 This suggests that the neurobiology of PTSD is qualitatively
different from the neurobiology of the normal stress response   –  that is,
PTSD does not appear to be simply an extreme version of the normal
stress response.
There has been some debate about whether these neurobiological
features are inherited vulnerabilities that pre-date the trauma exposure,
or whether they develop after the trauma as a result of the long-term
impact of the extremely high stress levels that characterise PTSD.
Studies comparing PTSD among fraternal and identical twins who
have both survived trauma indicate that as much as 30 per cent of some
PTSD symptoms may have a genetic basis.24 Neuro-imaging evidence
from studies where one twin has been exposed to trauma and has
PTSD and the other twin has not been exposed to trauma indicates
that a smaller hippocampus is a familial vulnerability that creates a
greater risk for developing PTSD after experiencing a trauma.25 Some
people may therefore be physiologically more vulnerable to developing
PTSD.
Research has shown that people with early childhood histories of
trauma, and those with prior histories of mental illness or psychological
difficulties, are more vulnerable to developing PTSD after experiencing
a trauma later on in life.26 These past experiences may create a
vulnerability that causes the normal state of distress after a trauma to
progress to more severe and lasting symptoms. However, the mechanism
whereby prior psychological difficulties or previous traumas increase
one’s risk of PTSD are still unclear. In addition to past adversities, it is
also apparent that current life stress places trauma survivors at greater
risk of PTSD,27 a noteworthy finding given the multiple life stressors
experienced by South Africans living in conditions of poverty.
Finally, it appears that a lack of available support networks and
a perceived negative response from others in the days and weeks
following a trauma may increase the risk of developing PTSD.28 While
we know that there is a relationship between PTSD and poor social
support, it is still unclear whether a lack of social support influences the
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Posttraumatic Stress Disorder And Other Trauma Syndromes

development of PTSD, or whether PTSD symptoms (such as a wish to
avoid speaking about the trauma) restrict the seeking of social support.
More research on the precise relationship between social support and
PTSD is therefore needed.29
Although much is known about the factors that create a risk or
vulnerability for PTSD, less is known about the factors that protect
against PTSD. This may be due to a bias in trauma research towards
focusing on those trauma survivors who have developed PTSD rather
than on those who have not. Research with people who recover from
trauma may yield important information about the reasons for their
recovery. At present there is some evidence to suggest that, while a lack
of social support may increase risk for PTSD, good social support may
be a strong protective factor. Some studies have shown that people who
are able to talk to supportive friends and family about their memories
of the traumatic event and their feelings of distress and anxiety appear
to be less likely to develop ongoing PTSD symptoms than those who
do not have a support network.30 A South African study into the
experiences of over a hundred victims of pre-election political violence
on the East Rand found evidence confirming the centrality of social
support in minimising symptom development.31
It is possible that social support is protective because it provides a
means for the trauma survivor to cognitively process their memory of
the event and the meaning that they assign to the event.32 However, the
role of social support as a protective factor is complex. Even people
who receive a great deal of support after a trauma may go on to develop
PTSD, suggesting that social support is only one of many factors that
determine the long-term outcome of a trauma experience. Further,
many traumatised people do not feel able to use their emotional
support networks even when these are available, due to the need to
avoid talking about the trauma or a fear that others will judge or blame
them for responding inadequately during the trauma.33
There has also been some research into personality features that may
counteract the impact of traumatic events. These include an internal or
external locus of control (that is, a sense that control over one’s life
comes from within or outside of oneself, respectively),34 hardiness (or
resilience to stress)35 and sense of coherence (that is, having a sense
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Traumatic Stress in South Africa

that life is meaningful, predictable and manageable).36 Research into
such personality features and coping styles has been extended from the
general stress field into the traumatic stress field with some indications
that these dimensions may assist in preventing trauma symptoms in
specific populations. However, research into these and other possible
protective factors in the context of trauma is ongoing. The possibility of
finding strength and positive psychological growth through traumatic
experiences will be discussed in more detail in the next chapter.
Many people with PTSD tend to blame themselves for being ‘ill’,
and feel that their symptoms are a sign of personal weakness and
incompetence.37 However, given all the above evidence, it is likely
that whether or not a trauma survivor develops PTSD is dependent
upon a complex combination of different factors that we are only
just beginning to understand. These include factors that pre-date the
trauma (such as gender, genetic vulnerability, personality features and
our cognitive schemas about the world), factors inherent in the trauma
itself (such as the type of traumatic event) and post-trauma variables
(such as social support and additional life stress). Overall, it appears that
factors operating during and after the trauma are more likely to result
in PTSD than pre-existing factors.38 However, the complex interplay of
genetic and environmental interactions in creating a vulnerability for
depression amongst abused children has been demonstrated,39 and it
is likely that similar gene-environment interactions are involved in the
development of PTSD.
The politics of PTSD
What are the implications of classifying PTSD as a psychiatric
disorder? On the one hand, this classification is important because it
acknowledges the severe impact of trauma and indicates that some form
of intervention may be required in order to assist the trauma survivor to
recover. This gives trauma survivors, often from disempowered groups
in society (such as women, children and impoverished communities),
access to proper psychiatric and psychological care.40 On the other
hand, some authors have argued that people with PTSD should not be
pathologised as having a mental disorder.
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Posttraumatic Stress Disorder And Other Trauma Syndromes

Young41 and Summerfield42 have traced the cultural, historical
and political factors that gave impetus to the development of PTSD
as a diagnostic category, highlighting the shifting nature of our
understandings of ‘traumatic stress’ and the ways in which, over the
past century, it has come to be socially constructed as an ‘illness’ rather
than as a normal and appropriate response to abnormal experiences.
Summerfield argues that since the majority of trauma victims tend to
be politically oppressed and/or economically impoverished, trauma
and its effects are symptoms of power imbalances in society, not of
individual disorder.43 He strongly disputes the inclusion of such social
suffering within the domain of biological psychiatry, arguing that
‘distress or suffering is not psychopathology’.44 This medicalisation
of suffering, while offering a form of acknowledgement to victims,
has potentially conservative ideological implications, for it offers an
apolitical and de-contextualised understanding of trauma. This may
serve to de-legitimise experiences of oppression and exploitation, to
marginalise survivors’ feelings of outrage and injustice and to relegate
responsibility for trauma recovery to the individual and those offering
individually oriented interventions, rather than to broader societal
structures.45 In this way, constructing PTSD as an individual mental
disorder ultimately leads to the maintenance of social inequalities.
From a bio-medical perspective, the argument that PTSD is not
a form of individual psychopathology is not well supported by the
available evidence. The research findings that PTSD affects only a
minority of trauma survivors and that the neurobiological functioning
of survivors with PTSD is qualitatively different from those without
PTSD suggest that PTSD constitutes a disruption of, or deviation
from, the normal stress response. This does not imply that the trauma
survivor is somehow to blame for their symptoms, but it does imply
that some form of individual intervention may be required to help the
survivor to regain their best possible functioning in the world.
The current polarisation between the psychiatric and social
perspectives on PTSD is important for stimulating debate and further
research on trauma responses, but often tends to reduce an extremely
complex issue to an either/or dichotomy. The phenomenon of PTSD
clearly has both bio-medical and social aspects, and an integrated
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understanding of both is necessary in order to do justice to the needs
of trauma survivors.46 The cultural dominance of any one particular
discourse or perspective on PTSD needs to be carefully interrogated
by researchers and clinicians, who ultimately produce the published
knowledge base about trauma.

Other Disorders Associated with Ptsd
Responses to trauma are highly complex, and posttraumatic symptoms
may not be restricted to those characterised by PTSD. Research in
the United States indicates that the majority (some studies suggest as
much as 80–90 per cent) of trauma survivors who develop PTSD also
have other psychiatric disorders.47 The psychiatric disorders that are
commonly comorbid with PTSD (in other words, that occur together
with PTSD), and that are commonly found amongst trauma survivors
who do not develop PTSD, include mood disorders, phobias and
substance abuse.
Mood disorders that often occur together with PTSD include
depression and dysthymia. Almost half of the trauma survivors who
have PTSD also have depression.48 In addition, many survivors who do
not develop PTSD after a traumatic experience do go on to develop
depression.49 The clinical picture of depression consists of low mood
and/or loss of interest or pleasure in regular activities, together with
appetite and sleep disturbances, restlessness or agitation, fatigue or
low energy, feelings of worthlessness or guilt, loss of concentration,
and possibly suicidal thoughts. These symptoms must be present most
of the day, nearly every day, for at least two weeks, and must result
in significant distress or noticeable impairment in the person’s daily
functioning.50 Dysthymia refers to a milder but more chronic form of
depression that lasts for at least two years.51
Phobias that commonly occur after trauma include a phobia of
specific objects or places (which may be associated with the trauma
experience), social phobia (a fear and avoidance of social situations
because of anxiety about being evaluated and judged negatively by
others) and agoraphobia (fear of being in spaces from which one could
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Posttraumatic Stress Disorder And Other Trauma Syndromes

not easily escape in the event of having panic-like symptoms, which
often leads to an avoidance of leaving home alone for any reason).
In North American studies, between 65–80 per cent of patients
seeking treatment for PTSD also have a substance abuse disorder.52
Substance abuse disorders may include the abuse of alcohol,
prescription medication or other drugs, to a degree that results
in significant distress or impairment in functioning (for example,
difficulty fulfilling work or home obligations, or engaging in dangerous
behaviours while intoxicated).53 It is possible that people with PTSD
or other posttraumatic symptoms may use substances to try to manage
their distress and anxiety, a pattern known as self-medication.
There are still some unanswered questions regarding the exact
nature of the relationship between PTSD and other disorders that are
commonly found amongst trauma survivors. For example, we do not
yet know for certain whether pre-existing mood, anxiety and substance
abuse disorders create a vulnerability that increases the likelihood of
developing PTSD after a trauma, whether the distressing experience of
having PTSD itself results in depressed mood, phobias and substance
abuse, or whether PTSD and its comorbid disorders develop separately
from each other after a trauma. However, the available information
suggests that mood disorders and substance abuse tend to develop
after PTSD, while phobias and other anxiety disorders sometimes (but
not always) pre-date PTSD and may create a vulnerability for PTSD
after trauma exposure.54 Another issue is that there is a large amount
of overlap between the symptoms of PTSD and the symptoms of
depression, dysthymia and phobias. For example, social withdrawal is
one of the avoidance symptoms of PTSD, but also a primary symptom
of depression, dysthymia, social phobia and agoraphobia. Similarly,
concentration and sleep difficulties are symptoms of PTSD but also
of depression and dysthymia. It is therefore difficult to establish
whether depression, phobias and substance abuse are distinct and
separate disorders from PTSD, or are all part of a broad posttraumatic
syndrome. Nevertheless, it is apparent that posttraumatic symptoms
often extend beyond those captured by the PTSD diagnosis, creating
multiple difficulties and challenges for many trauma survivors.
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The Effects of Prolonged Trauma Exposure or Abuse
Since PTSD first entered the psychiatric classification system in 1980,
it has become increasingly apparent to researchers and clinicians that
the psychological effects of being in a situation of chronic, repeated
trauma at the hands of another person over a long period of time (such
as childhood physical or sexual abuse, abuse by an intimate partner,
or war captivity) are different to the effects of a single trauma such as
a violent crime or serious car accident. Researchers in economically
developed countries such as the United States of America and the
United Kingdom have reported that many survivors of chronic trauma
or abuse perpetrated by a loved and trusted person (such as a parent
figure or an intimate partner) present with patterns of difficulties
that do not fit with the classic PTSD symptoms.55 The syndromes of
‘complex PTSD’,56 ‘disorders of extreme stress not otherwise specified’
(DESNOS)57 and ‘enduring personality changes after catastrophic
experience’58 have been proposed and elaborated by North American,
British and European researchers to describe the impact of prolonged
traumatisation. These syndromes describe the way that survivors of
chronic trauma feel about themselves, their characteristic patterns of
managing difficult feelings and their relationship styles.
Survivors of early or chronic abuse often experience a disturbed
sense of personal identity, ranging from feelings of fragmentation (for
example, experiencing their feelings as being foreign, uncontrollable
and frightening), feeling completely detached from themselves, or even
feeling that they do not really exist. In addition, the survivor might
have experiences of alterations in consciousness, including periods of
dissociation   –  that is, ‘blanking out’ and not being aware afterwards
of what he or she said or did while in this state. Dissociative Identity
Disorder,59 which used to be known as Multiple Personality Disorder, is
a rare and extreme form of dissociation in which distinct personalities
develop in the person’s psyche, and it is usually a consequence of
chronic and severe early child abuse. Experiences of detachment and
dissociation initially develop as protective internal coping mechanisms
to enable the person to psychologically ‘remove’ themselves from

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chronically traumatic experiences that they cannot physically escape,
but these mechanisms create ongoing difficulties in the long term.
Survivors of prolonged trauma, especially at the hands of a controlling
abuser, may also carry feelings of helplessness and passivity, of not
being able to take initiative in acting on the environment. In addition,
survivors of abuse (especially abuse perpetrated in close relationships)
often blame themselves rather than the perpetrator for what took place.
It is much easier to believe that they are bad and deserving of abuse
than to believe that a loved one has chosen to hurt them.60 This may
result in powerful feelings of guilt, shame and unworthiness, and the
survivor may view himself or herself as unlovable, despicable and weak,
and possibly as evil or contaminated.
Survivors of chronic trauma also display a marked difficulty with
regulating or controlling strong feelings, such as sadness or anger,
resulting in unpredictable emotional outbursts. They often have an
inability to soothe themselves, and may even struggle to derive comfort
from supportive others. This results in potentially harmful strategies for
managing feelings of distress or anger, such as substance abuse, eating
disorders, secretly cutting oneself in order to release emotional tension,
and attempting suicide. For survivors of abuse, emotional distress may
often manifest itself bodily in somatic symptoms   –  that is, in physical
complaints that have no medical basis. For example, many survivors of
childhood sexual abuse experience chronic pelvic pain, gastrointestinal
discomfort and numbing or paralysis in different parts of their body
with no medical explanation.61 These symptoms are understood to be
the result of a conversion of emotional distress into bodily pain.
The relationship patterns that develop as a result of prolonged
traumatisation at the hands of another person tend to further
exacerbate the trauma survivor’s difficulties in living. Survivors of
abuse may have extreme difficulty with trusting others, resulting in
social isolation and withdrawal. Alternatively, out of a need for love
and acceptance, the survivor may trust other people indiscriminately,
or become excessively accommodating of other people’s needs in order
to prevent abandonment by them. Together with their chronic feelings
of unworthiness, self-blame and inherent badness, this can result in the
survivor being repeatedly emotionally or physically abused by others.
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Traumatic Stress in South Africa

Indeed, research has found that women who were sexually abused
in childhood are more than twice as likely to be sexually abused in
adulthood than women who experienced no childhood sexual abuse.62
Why do many survivors of early childhood abuse develop what has
been called ‘complex PTSD’ (although given the substantial differences
from classic PTSD, these symptoms could perhaps more accurately
be called ‘complex traumatic stress reactions’)? Neurobiological and
developmental research has begun to map the ways in which early
childhood trauma shapes the development of the emerging brain.63
Repeated traumatic experiences in childhood ‘train’ the brain to focus
on responding to danger and threat rather than to focus on learning and
exploration. Those neural pathways that govern defensive responses
to danger or threat therefore become overdeveloped, while those that
are responsible for other tasks (including the capacity for trust, the
expression of emotions through language, and flexible adaptation
to change or stress in the environment) remain underdeveloped.
In particular, traumatised children often do not develop the neural
networks that assist with the capacity for secure attachment and for
identifying and thinking about their needs and feelings without simply
acting on them. As a result, patterns of response to the early traumatic
situation become entrenched and continue into adulthood, even when
the abusive situation may longer be ongoing. Without the capacity
for secure and trusting attachments, or for reflective self-awareness,
survivors of childhood abuse are often at risk of re-creating abusive
relationships in adulthood.
Because the psychological effects of early or prolonged abuse are
extremely complex, and can differ substantially from more classic
PTSD symptoms, clinicians and counsellors often find it difficult to
accurately diagnose those survivors of abuse who present themselves
for help. This is exacerbated by the fact that many such survivors, due
to deep feelings of shame or distrust, do not actually disclose their
experiences of abuse to those who are treating them. As a result, such
patients are often diagnosed with a mixed bag of different disorders,
in order to account for their many and varied symptoms, or with a
personality disorder such as Borderline Personality Disorder.64 Such
patients often return again and again for help, but may repeatedly fail to
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Posttraumatic Stress Disorder And Other Trauma Syndromes

be correctly identified as trauma survivors by the mental health system.
That is why the recent concepts of ‘complex PTSD’ and ‘disorders of
extreme stress not otherwise specified’ are extremely useful clinical
tools for understanding the needs of survivors of abuse. See Box 3.3
below for an illustrative case study of complex PTSD.
Box 3.3 Case study of complex PTSD
Joy is a 24-year-old woman living with a female flatmate in Johannesburg. She was
admitted to a psychiatric hospital after a suicide attempt. During the interview with
the clinician it emerged that, as a child, Joy was sexually abused by her stepfather
from the age of 7 years old (when he first moved into the house with her and her
mother) until the age of 15 years, when Joy went to live with her biological father
in another city. At the time, Joy told no one about the abuse, including her mother
who she felt was very emotionally fragile and would not be able to cope with the
situation. Since childhood, Joy has struggled with feelings of worthlessness and not
being good enough. Although she has attempted to study several different courses
at university and has had a number of different casual jobs to earn money, she
always feels that she is not doing well enough and is incapable of being a success
at anything, and gives up after a few months. Her social life is also very unstable,
as she tends to make friends very quickly with people but then soon finds herself
feeling let down and rejected by them, becomes angry with them, and withdraws
herself from the relationship. In order to cope with her feelings of emptiness,
rejection and worthlessness, she drinks several glasses of wine every evening and
also smokes marijuana several times a week. She has had several brief romantic
relationships with men who are much older than herself, but in each case she has
felt ‘treated like an object’ by them – she feels that they use her for their own needs
but are not really interested in her needs. However, she is never the one to end these
relationships – rather ‘they just dump me when they’d had enough’. On several
occasions when she has felt very distressed, such as when she was fired from a
casual job due to repeated absences, or when a man she had been dating broke up
with her without explanation, she has cut herself on her legs with a piece of broken
glass from a mirror ‘just to give myself some relief from my feelings’. Recently she
has been having a relationship with a married man. During an argument with him
last week, Joy says she became so angry she ‘blanked out’, and when she became
aware of herself again she found herself physically attacking him. He then told Joy
she was ‘crazy’ and he didn’t want to see her ever again. That night Joy took an
overdose of sleeping tablets. Her flatmate found her shortly thereafter and called
an ambulance.

47

Traumatic Stress in South Africa

The Effects of Community Violence: A Continuous Traumatic
Stress Syndrome?

The development of the concepts of ‘complex PTSD’ or ‘disorders of
extreme stress’ represents a significant advance in our knowledge about
the effects of trauma, and addresses some of the diagnostic confusion
that has existed with regard to survivors of early or prolonged trauma
and abuse. These concepts capture the complex psychological impact of
being abused repeatedly, in a predictable but uncontrollable way, by the
same perpetrator over a period of time, and provide some understanding
of why many survivors of childhood abuse find themselves in similarly
abusive relationship patterns in adulthood.
However, these concepts also have some limitations. Situations
of prolonged abuse at the hands of another person need to be
distinguished from another type of prolonged traumatisation which
is characteristic of many economically disadvantaged communities in
South Africa and other countries. This involves repeated exposure to
community violence on a daily basis, including gang violence and gun
warfare in one’s neighbourhood, school violence, and opportunistic
criminal assaults and sexual assaults. As we have seen in the previous
chapter, for many South Africans this continuous community violence
is exacerbated by physical, emotional or sexual abuse occurring in the
home, with the victims being primarily women and children.
A vast number of South Africans therefore do not enjoy a sense of
physical safety and security either at home or outside the home, and
often have been victimised by multiple perpetrators of violence, some
of whom may be familiar (such as a spouse or neighbour) and some of
whom may be total strangers. The occurrence of violence is therefore
common yet unpredictable with regard to where it may happen, what
form it might take and who the perpetrator might be. A person living in a
highly violent community must not only deal with their own experiences
of direct traumatisation, but also with the indirect trauma of hearing
gunshots and seeing weapons in the neighbourhood, witnessing others
being assaulted, and hearing about the violence experienced by family
members, neighbours and friends. This is further exacerbated by the
constant anxiety of worrying about the safety of themselves and their
loved ones. Finally, for many South Africans, the stress of living in
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Posttraumatic Stress Disorder And Other Trauma Syndromes

conditions of continuous traumatisation is compounded by the chronic
uncertainty and anxiety wrought by severe economic deprivation.
It could therefore be argued that many South Africans do not have
a ‘post’-trauma period in which to process, or attempt to adapt to,
their recent trauma experiences, before the next traumatic experience
(whether it is direct or indirect) occurs. The psychological effects
of this form of cumulative and continuous trauma, as distinct from
repeated abuse at the hands of someone known to the victim, are not
well documented in the international literature. In the 1980s, a group
of South African therapists working with anti-apartheid activists
suffering ongoing state repression, often in hiding or on the run, and
facing detention without trial, interrogation or worse, coined the term
‘continuous traumatic stress’ to represent the fact that for these clients
danger was not past (or ‘post’) and that they faced ongoing risk of
further traumatisation.65 Although this context of political activism and
state repression has passed, this term still has enormous relevance to
the many communities in South Africa where trauma exposure is an
inescapable part of daily life. However, the characteristics of continuous
traumatic stress have never really been fully investigated and described
and, as we shall see in the next section, South African research has yet
to tackle the question of how the psychological impact of continuous
community trauma differs from the impact of single traumas or of an
ongoing abusive relationship.

South African Research On The Psychiatric Effects Of Trauma

A wealth of knowledge about the impact of trauma has emerged in
South Africa over the past few decades. At the same time, there are some
aspects that remain poorly understood and require further attention.
Studies conducted with South African adults will be considered here,
while studies of the impact of trauma on South African children and
adolescents will be discussed in Chapter 6.
South African research on the effects of trauma emerged during
the 1980s within the context of political violence under apartheid.
However, given the scope and scale of political violence in South
Africa during this time (see Chapter 2), and the range of interventions

49

Traumatic Stress in South Africa

that were being offered to survivors of political violence by those
counsellors committed to social activism, surprisingly little research on
the psychological impact of state-sponsored violence was published.
This was likely due not only to the conservative ideological and
political stance of mainstream organised psychology in South Africa
during the apartheid years,66 but also to the very challenging conditions
under which those trauma counsellors who were treating survivors of
political violence had to work. For example, raids of counselling centres
by police or political vigilantes were common in the 1980s.67 Working
in a perpetual crisis mode left little space for politically progressive
psychologists to conduct and write up systematic research on the effects
of political violence, although some of the experiences of working with
detainees and other victims of state repression were documented in the
South Africa-based journal Psychology in Society. Published research
on the effects of state-sponsored violence during the 1980s and early
1990s focused mainly on children and youth (see Chapter 6), while very
little research on work with adult survivors was published. As noted in
Chapter 1, much of the rich knowledge base that developed during this
time was shared and documented in other, less formal ways.
Perhaps the largest and most systematic study of the psychological
impact of organised state violence on South African adults was
completed by Foster and his colleagues in 1987.68 They conducted
semi-structured interviews with 176 political prisoners in detention,
of whom 83 per cent reported that they had been physically tortured.
While the diagnosis of PTSD was not assessed in this sample, these
prisoners commonly reported symptoms of anxiety, depression,
impaired cognitive functioning, somatisation and emotional numbing.
Another study of ninety-five participants who had been displaced as
the result of political violence in KwaZulu Natal in 1990 found that 87
per cent reported symptoms of PTSD, and that such symptoms were
highest amongst those who witnessed a friend or family member being
killed.69
More recently, several studies have assessed the long-term impact of
political violence by assessing the psychological well-being of survivors
in the post-apartheid era. In general, these studies have reported high
rates of psychiatric disorders. For example, in 1998 a DSM-IV-based
50

Posttraumatic Stress Disorder And Other Trauma Syndromes

psychiatric interview (a structured interview assessing a variety of
psychiatric disorders using the diagnostic criteria that are specified in
the American Psychiatric Association’s Diagnostic and Statistical Manual
of Mental Disorders, Fourth Edition [DSM-IV; APA, 2000]) was used to
assess fourteen South African torture survivors presenting at an anxiety
disorders clinic. The study found that all of the participants had PTSD
and panic disorder, while 57 per cent met the diagnostic criteria for
depression.70 Another study with 147 survivors of human rights abuses
presenting for psychological services in KwaZulu-Natal utilised a
semi-structured screening questionnaire for psychological disorders,
as well as a PTSD symptom checklist.71 Rates of PTSD varied across
geographical areas but were generally high (ranging from 25–56 per
cent), while anxiety disorders, depression, substance abuse and somatic
complaints were also common. A Cape Town study recruited 134
volunteer participants from community settings who had experienced
human rights abuses.72 Using a structured psychiatric interview, the
study found that 55 per cent of the participants had depression, 42
per cent had PTSD, 27 per cent had another anxiety disorder, and
54 per cent had more than one psychiatric diagnosis. Furthermore,
somatic complaints such as bodily pains with no medical basis were
also common in this sample.73 Another study with twenty ex-detainees
used a semi-structured qualitative interview to elicit participants’ own
reports about their current concerns.74 The study found that the most
pressing concerns for these survivors of political violence were, in order
of importance, somatic complaints, economic stressors, dissatisfaction
with the political dispensation in South Africa, and symptoms of
posttraumatic stress that were not always severe enough to warrant a
diagnosis of PTSD. Research with ex-combatants from a number of
different military structures found that the majority of interviewees
reported experiencing a range of PTSD symptoms, such as flashbacks
and nightmares. In addition, many of them reported related difficulties
such as substance abuse and aggressive outbursts.75
On the whole, these clinic and community-based studies indicate
that survivors of political violence in South Africa continue to have
many unmet mental health needs. However, it could be argued that the
strength of these findings is limited by some methodological issues. It
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Traumatic Stress in South Africa

is not possible from these studies to conclusively show that experiences
of political violence have been the direct cause of psychiatric disorders
like PTSD and depression, since many other factors (such as other
traumas or life stressors) may have played a causal role. In addition,
these studies utilised samples that may not be very representative of all
survivors of political violence. For example, some of the participants in
these studies were patients attending clinics for treatment. Others had
volunteered to participate in the study in response to advertisements
or word-of-mouth requests, but may have had specific motivations
for volunteering. The SASH survey allowed for a somewhat more
systematic investigation of the link between political violence and
psychiatric disorder. In this large nationally representative sample,
it was found that, among men, experiences of detention and torture
carried the highest risk for PTSD compared with a range of other
forms of violence.76 This finding confirms that political violence does
indeed have a strong link with PTSD, although it does not exclude the
possibility that other factors may also play a role.
We have seen in Chapter 2 that many South Africans have been
and continue to be exposed to criminal violence, either directly or
indirectly. Despite this, there is surprisingly little South African research
on the effects of criminal violence on mental health. One study with
a sample of adult victims of violent crime (including sexual assaults,
armed robberies and attempted murders) in Pietersburg used two
different PTSD symptom self-report scales to assess the rate of PTSD
symptoms.77 The percentage of participants who were at high risk for
having PTSD was 25 per cent on the one scale and 42 per cent on
the other scale. Another study using interviews to qualitatively explore
the effects of hijackings on four victims also reported some PTSD
symptoms.78 These two studies suggest that many victims of violent
crime might experience symptoms of posttraumatic stress but, since
neither study used standardised psychiatric interviews, they could not
establish how many participants actually met the full diagnostic criteria
for PTSD. In the SASH survey,79 which used a psychiatric interview to
establish whether the full diagnosis of PTSD was met, criminal violence
had a low association with PTSD amongst men, compared with many
other kinds of violence (such as torture or childhood physical abuse).
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Posttraumatic Stress Disorder And Other Trauma Syndromes

But for women, non-sexual criminal violence was more than twice as
likely to be associated with PTSD as it was for men.
The psychiatric impact of gender-based violence has very seldom
been systematically researched in South Africa, despite the scale and
severity of gender-based violence in this country. In one study of
1,050 female patients visiting general practitioners, assessment with
self-report questionnaires found that 35 per cent of those who had
experienced domestic violence were at high risk of having a diagnosis
of PTSD, compared with only 3 per cent of those who had not
experienced domestic violence.80 Rates of depressive symptoms were
also substantially higher among those women who were survivors of
domestic violence. Another study with 250 rape survivors reported
moderate levels of re-experiencing, avoidance and hyperarousal
symptoms, with hyperarousal predominating slightly. The participants
also reported behavioural changes such as social withdrawal and
avoidant styles of coping.81 Consistent with findings in other countries,
the SASH national survey found that rape carries the highest risk
for PTSD amongst women, followed by intimate partner violence.82
Given the prevalence and the high degree of toxicity of gender-based
violence, more research is urgently needed in order to fully understand
the mental health needs of the many women and girls in South Africa
who have experienced sexual and physical violence.
With the high prevalence of HIV/AIDS in South Africa,83 it is
important to understand the mental health impact of receiving this
diagnosis. While psychiatric disorders are only one aspect of the
multiple psychological challenges presented by living with HIV/AIDS,
they cannot be neglected since psychiatric disorders like depression
may affect the course of HIV infection84 and may also reduce the
HIV-positive person’s adherence to a treatment regimen.85 One study
followed up a group of fifty-one HIV-positive women in Cape Town
over a six-month period, and found that depression and PTSD were
the most common psychiatric disorders, both at the first interview
(34.9 per cent for depression and 14.8 per cent for PTSD) and six
months later at the second (26 per cent for depression and 20 per cent
for PTSD).86 While there was a substantial increase in the number of
participants meeting criteria for PTSD over this period, this study
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Traumatic Stress in South Africa

could not directly establish a link between receiving an HIV-positive
diagnosis and the development of subsequent PTSD. A study with
465 participants receiving treatment for HIV/AIDS in Cape Town
reported that 14 per cent of the sample met criteria for depression,
5 per cent met criteria for PTSD and 7 per cent met criteria for
substance abuse.87 Again, the study could not establish whether there
was a causal relationship between receiving a diagnosis of HIV/AIDS
and the development of these psychiatric disorders. However, another
study of recently diagnosed HIV-positive patients in the Western Cape
found that 40 per cent of the sample had PTSD specifically linked to
receiving an HIV diagnosis or to being HIV-positive.88 This suggests
a more direct casual relationship between hearing about one’s HIVpositive status and the development of PTSD.
Although rates of traffic injuries are high in South Africa, as discussed
in the previous chapter, there is a lack of research documenting the
psychiatric impact of such accidental trauma. Using self-report
instruments, one study reported that people involved in traffic accidents
as drivers or as passengers experience a significant decrease in their
general health and quality of life after the accident, and also experience
a high rate of post-traumatic symptoms like avoidance and intrusive
recollections.89 But other studies of psychiatric symptoms among South
Africans who have been involved in traffic injuries are scarce. Given
that claims for compensation for road accident injuries are often made
on the basis of a resulting psychiatric disorder, some prevalence data
on the psychiatric impact of traffic accidents in our population would
be valuable.
Some research has been conducted with samples that are routinely
exposed to trauma as part of their occupations. For example, using a
psychiatric interview and self-report questionnaires with 198 members
of the South African National Defence Force, one study found that 25
per cent currently met the criteria for PTSD and 17 per cent were at
high risk for receiving a diagnosis of depression.90 Several studies with
members of the South African Police have similarly found a high rate
of symptoms typical of PTSD,91 although the use of self-report scales
rather than psychiatric interviews limited the degree to which rates of
full-blown PTSD could be ascertained. Research on the mental health
54

Posttraumatic Stress Disorder And Other Trauma Syndromes

needs of people working in occupations with a high risk of exposure
to life-threatening events is important in order to motivate for them to
have better access to mental health resources.
A few studies have examined posttraumatic symptoms among
patients presenting at primary health care clinics in South Africa. One
study used a psychiatric interview to assess 201 patients at an urban
township clinic in Cape Town, and found that 19.9 per cent had a
current diagnosis of PTSD, but that depression and somatisation
disorder were also very common and were frequently comorbid with
PTSD.92 Using a self-report questionnaire, a study with clinic patients
in a rural area of South Africa found that 12.4 per cent were at high risk
of having PTSD, but other diagnoses were not assessed.93
To date, the SASH survey is the only South African study to
examine the prevalence of PTSD in the South African population as a
whole, using a DSM-IV-based standardised psychiatric interview (the
Composite International Diagnostic Interview Version 3.0 or CIDI).94
Interestingly, this survey found a very low rate of PTSD nationally
compared with that reported in many other countries. In the SASH
sample, the lifetime prevalence rate of PTSD (that is, the percentage
of the sample that had ever had a diagnosis of PTSD in their lifetime)
was 2.3 per cent,95 compared with around 8–9 per cent in the American
population96 and 11.2 per cent in the Mexican population,97 both of
which have rates of trauma exposure that are similar to those found
in South Africa. However, it would be premature to conclude from
this that South Africans are not severely affected by trauma. Firstly, the
SASH finding of a low rate of PTSD in the South African population
may be the result of issues in the translation of the standardised
diagnostic interview into six different South African languages, possibly
affecting the way in which questions about symptoms were understood
by respondents. Secondly, the effects of trauma in the South African
population may be different to those that have been documented in
countries such as the United States, where the DSM-IV was developed.
The SASH study also assessed levels of general distress in the sample
(for example, feeling nervous, irritable, depressed and fatigued), as
opposed to specific psychiatric disorders, and found that levels of
distress increased dramatically with more exposure to trauma: those
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Traumatic Stress in South Africa

South Africans who had experienced six or more traumas were five times
more likely to have high distress than individuals who had experienced
no traumas.98 This suggests a cumulative negative emotional effect of
trauma exposure among South Africans, lending support to the notion
of a continuous traumatic stress response that may not necessarily be
manifested as PTSD.
In sum, studies with South African trauma survivors have tended
to focus on establishing the presence of symptoms of PTSD and,
sometimes, depression, in keeping with international research which
has demonstrated that these disorders are commonly found amongst
trauma survivors. Local studies have consistently found very high levels
of PTSD and depressive symptomatology across various groups of
trauma survivors, suggesting that these are very common responses to
trauma exposure in our population, and that substantial mental health
resources need to be allocated to address these issues. However, we
must still remain somewhat cautious about drawing this conclusion.
In many cases, studies have relied on self-report questionnaires which
do not indicate whether symptoms are of sufficient duration and
severity to warrant a clinical diagnosis, and can, in fact, overestimate
the prevalence of disorder.99 More time-consuming and costly research
using structured psychiatric interviews is needed in order to better
understand the mental health needs of trauma survivors. The nationally
representative SASH survey, which used a psychiatric interview to
assess the presence of PTSD, indicated that rates of full-blown PTSD
(that is, PTSD symptoms that are enduring, cause substantial distress,
and significantly reduce the person’s ability to function) may, in fact,
be quite low amongst trauma survivors in South Africa. However,
not all structured psychiatric interviews are necessarily useful in the
local context. There is some interesting preliminary evidence from a
six-month follow-up study of rape survivors in Cape Town that, even
when participants are assessed in their first language, their response
to questions about PTSD symptoms varies substantially depending on
how exactly the questions are phrased.100 Given our many indigenous
languages, we still have some way to go in establishing exactly which
instruments are most valid and reliable for assessing posttraumatic
symptoms in our population.
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Posttraumatic Stress Disorder And Other Trauma Syndromes

Another limitation of the existing research is that it tends to be
cross-sectional (assessing a sample at one specific point in time), which
makes it difficult to conclusively establish a causal link between a past
trauma and current symptoms. Although the SASH study established
that certain types of trauma (specifically, torture for men and rape
for women) have a stronger association with PTSD, the prevalence
of multiple trauma exposure in our population makes it difficult to
causally link one particular kind of past trauma with current PTSD
symptoms. It is also possible that current symptoms of depression
frequently reported by South African trauma survivors may in fact
pre-date exposure to a trauma. Longitudinal research that follows up
a group of participants over a period of time would help to clarify the
causal relationships between different types of trauma exposure and
different psychiatric symptoms.
Since increased trauma exposure amongst South Africans is strongly
related to an increase in levels of general distress, it is likely that many
trauma survivors in South Africa experience psychiatric symptoms that
are, in fact, sub-clinical, or below the threshold for diagnosis. These subclinical symptoms may nonetheless reduce the quality of life of trauma
survivors in numerous ways. It also seems possible that responses to
trauma in the South African population may fit more closely with other
types of diagnoses, besides PTSD and depression. For example, it is
interesting to note that when South African researchers have attempted
to explore the psychiatric effects of trauma more broadly, somatic
symptoms appear to be commonly reported. This is consistent with
findings from a study with traumatised Sudanese refugees in Uganda
and torture survivors in Malawi,101 and suggests that the impact of
trauma amongst South Africans and those living in other countries in
Africa may be more extensive than what emerges from a narrow focus
on PTSD or depression.
There are still many aspects of the effects of trauma in South Africa
that need to be better understood. For example, despite South Africa’s
high rates of child sexual and physical abuse and intimate partner
abuse, we still know very little about the psychiatric effects of prolonged
abuse in our population. Although the SASH survey established that
exposure to multiple traumas is associated with more severe levels
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Traumatic Stress in South Africa

of general distress, the specific psychiatric consequences of multiple
traumatisation and continuous community violence still remain unclear.
Finally, South African studies have seldom explored whether the
psychiatric consequences of trauma are associated with socio-economic
status. The particular ways in which conditions of poverty may impact
upon coping after trauma need further exploration, if we are to provide
effective support to trauma survivors who may be disempowered at a
number of levels.

Conclusion

Many trauma survivors are able to return to their normal functioning
within a few days or weeks after a traumatic event. However, as a result
of the interaction of a number of factors, some survivors develop a more
long-lasting set of symptoms that may fit the diagnostic picture of PTSD.
While PTSD has received a lot of attention in the media and popular
culture, depression, phobias and substance abuse are also common
psychiatric consequences of trauma. In the South African context, most
research with trauma survivors has focused quite narrowly on assessing
symptoms of PTSD and, to a lesser extent, depression. However, some
emerging evidence suggests that other types of symptoms may be quite
prevalent amongst South African trauma survivors, particularly somatic
symptoms.
In international research, it is increasingly apparent that survivors
of early and prolonged abuse often develop difficulties that are not
consistent with PTSD or other diagnoses commonly associated with
single traumatic events. But the effects of prolonged abuse in South
Africa have not yet been well documented and require further
exploration. In addition, the psychological impact of living in a highly
violent community is not yet well understood. This is an important
avenue for research in South Africa, where many people live in contexts
of continuous community violence, and there is an opportunity for
South African researchers to make a valuable contribution to the
international literature in this area.
Psychiatric diagnoses are a useful tool because they alert us to the
common and universal aspects of experiences of distress. For example,
the diagnosis of PTSD or the more recent syndrome of complex PTSD
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Posttraumatic Stress Disorder And Other Trauma Syndromes

both highlight symptoms that are shared by many trauma survivors, and
thereby serve to normalise and validate their feelings and experiences.
But regardless of whether a survivor’s response objectively ‘fits’ a
particular posttraumatic diagnosis, the subjective process of trying to
adapt to a traumatic experience is unique for each trauma survivor.
For example, no two rape survivors with PTSD have exactly the same
internal experience of trying to adapt to what has happened to them.
The danger of psychiatric diagnoses is that they tend to disguise or
silence variations in the subjective experience of distress. In the next
chapter, we move beyond a focus on post-trauma psychiatric disorders
to explore the ways in which trauma can impact upon our personal
systems of meaning, elaborating some of the more clearly psychological
theory about the impact of trauma exposure.

59

Chapter 4

TRAUMA AS A CRISIS
OF MEANING

W

hile much of the psychological literature on the effects of trauma
has focused on specific psychiatric symptoms such as PTSD,
there has also been increasing recognition that trauma presents an
enormous challenge to our belief and meaning systems, even in the
absence of PTSD or other symptoms. Survivors of trauma often struggle
to develop an understanding of why the trauma happened, and of why
they were singled out to be a victim. They may wrestle with how to
reconcile the trauma experience with their fundamental expectations
and beliefs about themselves, other people, and the world, leaving them
feeling vulnerable, distrustful and uncertain. Faced with this existential
crisis, trauma survivors try to develop explanations for the traumatic
event and to generate meanings that will allow them to make sense of
the world in future. Sometimes the explanations and meanings that are
generated enable the survivor to re-establish a sense of trust, control
and purpose, while in other cases the explanations and meanings that
are formed serve to maintain or even exacerbate the survivor’s feelings
of distrust, lack of control and despair. This chapter will explore
what we currently understand about the ‘meaning’ dimension of the
psychological impact of trauma.

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Trauma As A Crisis Of Meaning

Shattered Assumptions and the Search for Comprehensibility

In the previous chapter, we saw that PTSD symptoms of re-experiencing
the trauma may occur because traumatic events cannot be categorised
and integrated within the beliefs (or schemas) about ourselves, others
and the world that we held before the trauma   –  they simply cannot be
located within our existing cognitive map of the world.1 Janoff-Bulman
has identified several core beliefs or assumptions that people hold
regarding themselves, others and the world, that are shattered by a
traumatic experience.2 She argues that we all carry implicit assumptions
that we take for granted and which we are not always consciously aware
of   –  they are an invisible but vital part of our internal cognitive model
of the world and underpin a sense of basic well-being. These include
the assumption that we are invulnerable (for example, believing that ‘it
can’t happen to me’), that we are good and worthy people, that other
people are fundamentally good, and that the world is governed by
just and orderly social laws (for example, ‘if I am cautious, I can avoid
misfortune’, or ‘if I am good, nothing bad will happen to me’).
Even if we are intellectually aware that our safety and security
are not guaranteed, that other people often have hostile intentions
and that sometimes bad things happen to good people out of sheer
random chance, we still hold the above assumptions at a less conscious
level, for these beliefs help us to maintain some sense of predictability
and control in a world that would otherwise feel utterly random
and unpredictable. Often we are not even aware that we hold such
assumptions, until an experience of trauma suddenly makes us realise
that we have taken these beliefs for granted and that we now need
to profoundly re-examine them.3 For example, intense feelings of
powerlessness during and after a trauma may shatter the survivor’s
basic trust in their own capacity to control events and themselves. The
shattering of assumptions of personal competence and control, and of
one’s basic trust in the inherent justness, order and benevolence of the
universe, creates enormous distress, vulnerability and uncertainty for
many trauma survivors.
Other researchers have argued that not all people implicitly
hold positive assumptions about themselves, other people and the
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Traumatic Stress in South Africa

world   –  rather, people who have had a history of early trauma or of
severe psychological difficulties are more likely to quite rigidly perceive
the world as being dangerous, others as untrustworthy and themselves
as incompetent and unworthy.4 For these people, a new experience of
trauma serves to confirm, rather than shatter, their pre-existing negative
assumptions. Researchers suggest that it is those people whose pretrauma assumptions are very rigid or extreme, whether in a positive or
a negative direction, who most struggle to process a trauma experience
in a meaningful way. For those who hold very positive assumptions,
an experience of trauma violates their existing understandings of the
world, leaving a meaning ‘vacuum’, while for those who hold very
negative assumptions, a trauma experience may reinforce their belief
that the world is dangerous and unpredictable and that they themselves
are unworthy and incompetent. In both cases, the trauma survivor is
left with a heightened sense of vulnerability and lack of control.
In their struggle to deal with feelings of uncertainty and vulnerability
in the aftermath of trauma, many survivors wrestle with questions
such as ‘why does this sort of thing happen in the world?’, ‘how can
people do this sort of thing to other people?’ and ‘why did this happen
to me?’.5 These are not simply rhetorical questions arising out of a
sense of despair and disillusionment. Rather, they are active attempts
to make the trauma experience more intelligible, and the search for
comprehensibility entails an exploration and evaluation of different
causal explanations. However, the search for an explanation is not just
an intellectual exercise, but also a deeply emotional process that may
take trauma survivors through a range of different feelings at different
points in time.6 Searching for meaning is also not always a conscious
strategy; survivors do not explicitly tell themselves that they need to
rebuild their fundamental assumptions and find an explanation for the
trauma. Rather, the process of trying to make sense of the trauma is
part of the natural process of seeking to re-establish equilibrium after
a crisis.7
Why do so many trauma survivors seek an explanation for the
trauma? The establishment of causal linkages between events is a
central component of any well-formed story,8 but causal accounts are
particularly important for making sense of extraordinary events.9 The
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stories we tell each other about our ordinary, everyday experiences often
tend to just be descriptive (telling what happened) and to not include
explanatory accounts (telling why it happened). Everyday experiences,
fitting as they do with our existing cultural beliefs and expectations,
are simply taken for granted. However, in response to extraordinary
experiences, such as life traumas, we may be more likely to try to
develop not just descriptive but also explanatory stories, in an attempt
to formulate a meaningful and comprehensible account of things that
deviate substantially from established cultural norms and expectations.
While the process of exploring meaningful explanations for a trauma
experience is a highly personal process that may take trauma survivors
in many different directions, some common explanatory strategies
employed by trauma survivors have been documented (see Box 4.1
for a summary). These strategies are attempts to construct models or
theories about the world, themselves and other people that enable
survivors to make sense of the trauma experience.
How the world works: ‘stuff happens’ versus ‘a greater plan’
In response to being the victim of a traumatic experience such as a
criminal assault, a rape, a car accident, a natural disaster, or the diagnosis
of a life-threatening illness, trauma survivors often try to develop a
theory about how the world or the universe works that adequately
explains their being singled out for victimisation.10 They try to assess
whether there are any cause-and-effect laws governing the universe that
can explain why they were ‘chosen’ as a victim and that can guide them
as they go forward into the future. Often, the conclusions reached by
trauma survivors regarding how the world works fall into one of two
opposing positions or philosophies. The first philosophy is that ‘stuff
happens’. Here the survivor comes to accept that there are no knowable
laws and rules that govern how the universe works, that events occur
fairly randomly, and that the survivor happened to be the victim of a
particular traumatic event due largely to chance, bad luck, or being
in the wrong place at the wrong time. For example, in an exploratory
study conducted with a group of ten survivors of violent criminal
assault who presented to a police station trauma room in Cape Town,
half of the survivors believed that chance and bad luck played a major
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Box 4.1
Examples of explanatory strategies commonly used by trauma survivors
A. Beliefs about the world:
(1) The trauma was due to random chance or bad luck.
(2) The trauma was part of God’s plan.
(3) The trauma was caused by other people using witchcraft.
(4) The trauma was caused by the ancestors because of something I did or did
not do.
B. Beliefs about the perpetrator:
(1) The perpetrator did it because s/he is ill or disturbed.
(2) The perpetrator did it because of their social or economic circumstances.
C. Behavioural self-blame:
(1) I was chosen as the victim because I was not careful or vigilant enough.
(2) I was victimised because I did not fight back hard enough.
D. Characterological self-blame:
(1) I was chosen as the victim because I deserve to be punished.
(2) I was chosen as the victim because I am too trusting.
E. Redefining the event and its impact
(1) It could have been worse.
(2) I was lucky compared to some people.
(3) I am coping better than most people would.

role in their victimisation.11 For some trauma survivors, this conclusion
may be comforting because it suggests that they were not specifically
singled out by fate for victimisation and did not do anything to deserve
suffering or punishment. It therefore preserves a sense of the world as
being a fairly benevolent place, most of the time. However, for other
trauma survivors, the conclusion that bad things happen randomly and
that one can be victimised by chance may exacerbate their sense of
unpredictability and vulnerability, as they may feel they have no control
over events in their lives.12
The second philosophy about how the world works that can be
used to explain a traumatic experience is that the trauma was part of
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Trauma As A Crisis Of Meaning

some greater plan which cannot be fully known by the survivor.13 This
approach is often informed by religious, spiritual and/or traditional
cultural beliefs that the survivor may have held before the trauma, or
which they begin to develop after surviving a trauma. Survivors may
explain the trauma by drawing on conceptions of God, ancestors in
the spirit world, fate, karma or destiny. Within these frameworks, the
trauma is often conceived of as a deliberate test or task which has
been placed in the survivor’s path to challenge their belief system,
to teach them something or give them insight, or to punish them for
some wrongdoing and put them back on the right path.14 For example,
when asked retrospectively how they understood the event and its
impact on their lives, 79 per cent of a sample of survivors of the 1993
St. James Church massacre in Cape Town (in which armed members of
a political grouping entered the church during a service, killing several
congregants and injuring many more) stated that they believed the event
was part of God’s plan and that He meant them to learn something from
the experience.15 This is perhaps expectable in a sample of churchgoing participants, but even trauma survivors who are not particularly
religious may draw on a spiritual framework to make sense of their
experience. For example, 40 per cent of a small sample of South African
mothers who had lost a child to cancer, when asked how they have
made sense of why such bereavements happen, described a belief in a
‘greater scheme’ or ‘bigger picture’ whereby everybody’s time to die is
pre-determined.16 Although this did not mean that they felt a sense of
acceptance regarding their loss, it was important for them to be able
to understand their suffering as being part of a broader, if mysterious,
system that had some logic and coherence to it. On the other hand, the
experience of trauma can result in a profound shattering of long-held
faith and belief systems, and trauma survivors may begin to question
the existence of the God, gods or spiritual forces that they previously
believed in, resulting in a ‘crisis of faith’ that is not resolved.17
The Hindu concept of karma is based on the belief that events
may occur in order to balance out one’s past actions and experiences
(including those that happened in a previous life or incarnation),
and that current experiences will be balanced out in a future life or
incarnation. Within this belief framework, a traumatic experience
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Traumatic Stress in South Africa

may be viewed in two ways, both explanations based on notions of
cause-and-effect: either as being the outcome of previous actions and
experiences or as something negative that will be balanced out by
something more positive in the future.18 This belief system provides
an explanation for why the person has been ‘chosen’ to experience
something extremely adverse and difficult. Similarly, many people in
Africa, including many South Africans, believe in a fluid interaction
between the natural world and the supernatural world where deceased
ancestors reside and from which they continue to exert influence over
the living. Within this belief system, traumatic events can be caused by
ancestors in the spirit world. A person may be chosen by the ancestors
to suffer adversity because that person is in a state of spiritual pollution
(related, for example, to certain reproductive activities and cycles, as
well as to being in a state of bereavement) and has failed to observe the
necessary taboos and rituals to protect him or herself and others from
the effects of this19 or has failed to perform the abeyances expected by
ancestors more generally. Furthermore, this cosmology encompasses
a belief that witchcraft can be intentionally employed by people to
cause distress and suffering for others; traumatic events may therefore
also be the outcome of deliberate magical causation by others in one’s
community.20
While the nature of cultural or religious belief systems about how
the world works may differ, they all offer a framework of causes and
consequences that people can draw on to make sense of events in
their lives, including trauma. However, the extent to which individual
trauma survivors choose to draw on available cultural and religious
belief systems to make meaning out of their experience depends on the
survivor’s own personality characteristics and prior life experiences.
Furthermore, when survivors are familiar with both traditional African
cosmologies and Westernised belief systems, as is often the case in South
Africa, they may draw on a blend of belief systems while grappling
with the meaning of a traumatic experience.21 Clearly not all trauma
survivors from the same religious or ethnic group will develop the same
kind of meanings out of their trauma experiences   –  again, post-trauma
meaning-making is a deeply personal process.
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Making sense of why other people are violent
When trauma involves some kind of interpersonal violence, rather than
an accident or natural disaster, a central struggle for the survivor is
the need to understand why another person would intentionally inflict
harm on him or her.22 Consequently, the survivor’s search for causal
explanations may often focus on the intentional state of the perpetrator,
in order to find a comprehensible reason for the perpetrator’s actions.
For example, a Canadian study with survivors of incest found
that many participants attempted to make sense of their experience
by understanding the parental dynamics that had caused the abuse to
occur (for example, marital difficulties or their fathers’ characterological
defects), and that those who had developed such explanatory accounts
demonstrated less psychological distress and better social adjustment
than those who did not.23 Similarly, a study with ten female rape survivors
attending a rape counselling centre in Cape Town found that most of
the participants had managed to develop an explanatory account for
the rapist’s actions.24 For example, they viewed the rapist as disturbed
or ill, as having a problem with sex, as having a hatred of women, or
as having a need for power and control. However, these participants
had received some post-rape counselling, which had provided them
with a space to explore and develop these explanatory accounts, an
opportunity that many trauma survivors do not have.
The need to understand the motivations of the perpetrator is also a
concern for survivors of human rights abuses. A study of survivors of
human rights violations in South Africa found ‘a strong yearning for
contact with the people who had caused their suffering’ in order to
better understand the behaviour of the perpetrators.25 Similarly, many
people who testified before the South African TRC stated a desire to
meet with the perpetrators who had harmed them or killed their family
members, in order to understand why they had acted as they did.26
The study of crime survivors in Cape Town cited earlier in this
chapter found that most of these survivors had managed to generate
explanations for why people rob and steal from others (for example,
due to poverty, oppression, to support a drug habit, as part of gang
culture and so on) but that they struggled to develop an explanation
for the perpetrator’s use of violence and aggression during the criminal
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assault.27 They viewed the perpetrator’s use of violence as gratuitous and
unnecessary in the context of the assault because there was no real threat
to the perpetrator   –  in every case the crime victim had complied with
the perpetrator’s instructions. Failure to understand the perpetrator’s
use of violence was a source of ongoing emotional distress for these
survivors and led them to question whether they should stay in South
Africa, a dilemma that was particularly painful for those participants
who had played an active role in the struggle to end apartheid.

Self-Blame

Explanations for why a trauma happened often need to address not
only the reasons that the perpetrator did what they did, but also why
the survivor was ‘selected’ to be a victim. The need to understand
‘why me?’ is important even for survivors of traumas that do not
involve interpersonal violence, such as survivors of natural disasters
and accidents and those who have a life-threatening illness such as
cancer or HIV/AIDS. In trying to make sense of why a traumatic event
happened to them, survivors may come to believe that it occurred
because of something they did or something that they failed to do.
Because assumptions about being competent and in control of things
may be deeply challenged by the experience of trauma, survivors often
feel ashamed by their failure to prevent the trauma from happening, or
even that they are somehow to blame for the trauma.28 This tendency
towards self-blame in order to make sense of why the trauma happened
is sometimes exacerbated by blaming reactions from other people, who
may find it more comfortable to blame the victim (for example, by
telling a crime survivor ‘you shouldn’t have been walking alone at night’
or telling someone with HIV ‘you should have been more careful’) than
to have their own illusions of safety and security challenged.29
Janoff-Bulman has identified two forms of self-blame that trauma
survivors may use when trying to develop an explanation for why the
trauma happened.30 Behavioural self-blame refers to the survivor’s
tendency to attribute the trauma to certain behaviours that he or she
engaged in or failed to engage in. For example, rape survivors often
retrospectively blame themselves for behaviours such as going back to
the rapist’s apartment or getting into his car, question whether they
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unwittingly gave the rapist some signal of sexual attraction or wonder
whether the rape could have been avoided if they had fought back hard
enough. These self-blame attributions among rape survivors are often
influenced by myths about rape that are commonly held in society,
which tend to blame rape victims for being assaulted.31 One comparative
study found that South Africans are more likely than Australians to
blame rape survivors.32 Such attitudes are likely to be an important
influence in the development of self-blame beliefs among South African
rape survivors. However, survivors of other kinds of trauma also often
blame themselves when trying to find an explanation for the trauma.
People who have been the victim of a violent crime sometimes feel that
the assault would not have happened if they had done certain things
differently, such as taking more precautions and protective measures
(for example, avoiding certain areas, not driving alone, locking their car
doors or being more vigilant and aware of what was going on around
them).33 People who have received a cancer diagnosis may attribute the
illness to past eating behaviours or other lifestyle factors.34 Behavioural
self-blame allows the survivor to regain some sense of personal control
over events, because they identify behaviours that could be changed in
order to minimise the chances of experiencing a similar trauma in the
future.35 This maintains a belief in a controllable world, where specific
behaviours result in specific outcomes.
Another type of self-blame used by trauma survivors to explain
why the trauma happened to them is characterological self-blame.36
Here the survivor focuses blame on their own character or personal
qualities   –  they come to believe that ‘the trauma happened to me because
of who I am’ not ‘because of what I did or did not do’. For example,
someone who has been the victim of a violent crime might believe that
‘the criminal chose me because he can see I’m weak’ or ‘this happened
because I attract disaster’, while a rape survivor may believe that the
rape happened because ‘I’m too trusting’ or ‘I’m such a poor judge of
character’. The tendency towards characterological self-blame after a
trauma is influenced by the person’s schemas or beliefs about themselves
prior to the trauma, which are in turn influenced by early relationships
(such as with parents) that impact on self-esteem and self-worth, and
by previous experiences of trauma. Thus, people who have survived
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early childhood abuse at the hands of a parent or other caretaker may
be particularly likely to engage in characterological self-blame, as they
struggle to make sense of why someone who is supposed to love and
care for them would hurt them.37 Sometimes, the only way to make
sense of this is for the child to believe that he or she somehow deserved
the abuse, for example because ‘I am a bad person and deserve to be
punished’, or ‘there is something wrong with me as a person’. Children
are particularly prone to self-blame because, developmentally, they are
egocentric in their understanding of the world; but these feelings of
innate badness and shame, related to a sense that they somehow invited
or deserved the abuse, often persist into adulthood.
Earlier research suggested that trauma survivors tend to engage
in either one or the other form of self-blame after a trauma, and that
behavioural self-blame is related to better adjustment after trauma than
characterological self-blame, as the former is associated with a sense
of future control over events (our behaviour can usually be changed),
while the latter creates a sense of being a chronic or perpetual victim.38
However, more recent research with rape survivors39 and with women
newly diagnosed with breast cancer40 found that participants engaged
in both types of self-blame simultaneously and that both types were
associated with high distress levels after trauma. While behavioural
self-blame can increase one’s sense of control over the world, it can
also increase feelings of distress and incompetence after a trauma.
Clinicians working with rape survivors in the United States have found
that behavioural self-blame, such as berating oneself for freezing
during the rape or for not fighting back hard enough, reinforce feelings
of incompetence and shame.41 More locally, clinicians working with
the mothers of children who have sustained serious burn injuries in
informal dwellings in Cape Town have found that these parents struggle
with feelings of self-blame for not preventing the accident, or for not
treating the burn injury properly. This results in extreme distress and
powerful feelings of guilt, especially if others in the family or community
also blame the parent’s behaviour for the child’s injury.42 As with rape
survivors, societal attitudes of blame seem to powerfully influence the
explanatory strategies that these parents develop in order to make
meaning of the trauma of a child’s burn injury. In general it seems that
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self-recrimination or self-blame of whatever kind is counterproductive
to trauma recovery and is often associated with elevated depressive
symptoms and lower self-esteem.
Redefining the event and its impact
Another way in which trauma survivors try to make sense of the event
and its impact is by redefining the event to minimise the degree to which
it disrupts the survivor’s existing assumptive framework.43 One common
way of doing this is by minimising the perceived impact of the event
by comparing oneself with others who have had a worse experience (a
process called ‘downward comparison’). Often after a trauma such as a
hijacking or an armed assault, other people will tell the survivor ‘you’re
so lucky it wasn’t worse; you could have been killed!’. Sometimes, this
response from others can feel very invalidating and judgmental for the
survivor, who feels that they are not supposed to feel so distressed in
response to a relatively ‘minor’ assault. However, many survivors of
trauma may themselves use such comparison processes as a means of
retaining a sense of a benevolent world that has in some way protected
them from a worse outcome. For example, survivors of interpersonal
assaults or accidents may compare themselves with others who have
had a similar experience but who have suffered greater physical injury,
and survivors of a natural disaster who have lost many of their material
possessions may compare themselves with others who have lost even
more.44 The study conducted with crime survivors in Cape Town found
that several participants felt themselves lucky after making comparisons
to hypothetical worse outcomes (such as being killed or being threatened
with a gun instead of with a knife), and that this helped to rebuild their
assumptions about the benevolence of the world and to reassure them
with regard to their needs for safety and control.45
Another form of comparison that survivors may use to redefine the
impact of the event is to compare their coping with that of others.46 Thus
survivors might come to believe that they are coping well compared to
how others might cope under the same circumstances. Although we
have seen in the previous chapter that most trauma survivors actually
return to normal functioning fairly quickly, comparison to others who
would be coping less well can help the survivor to feel competent
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and capable in the aftermath of a trauma. On the other hand, some
survivors compare themselves unfavourably with the perceived norm,
feeling that they are coping worse than other people would after a
similar experience. This may leave the survivor feeling increasingly
incompetent, vulnerable and ashamed of their inability to ‘rise above’
the trauma.

Beyond Comprehensibility: The Search For Significance

Trauma can have an impact on our belief and meaning systems that
goes beyond trying to develop an explanation for why the trauma
happened. For some survivors, meaning-making after trauma may
also involve a consideration of the possible lessons and benefits of
having survived an extremely stressful event. Research indicates that
many, although by no means all, trauma survivors spontaneously (that
is, without the assistance of counselling or therapy) identify positive
outcomes from their trauma experience. Interestingly, it appears that
this process often occurs in parallel with the negative psychological
impact of trauma   –  that is, trauma survivors can experience PTSD
and other psychiatric symptoms after trauma while also experiencing
some positive outcomes from the experience. Research findings on the
positive outcomes of trauma, and on their relationship with the negative
outcomes, will be discussed in this section.
Finding value and purpose in adversity
Although writings about the struggle to find value in suffering have
historically been the domain of philosophy and theology, in more recent
times this concept has been explored in the psychological literature on
trauma. The psychiatrist Viktor Frankl’s47 account of his concentration
camp experiences, and his theory of logotherapy (from the Greek
word for both meaning and spirit), is perhaps the earliest psychological
text that specifically explores the question of finding value in deeply
traumatic experiences. He argued that the search for meaning in life is a
primary motivational force for human beings, and that, even when one
is trapped in a situation of unavoidable suffering, small but meaningful
goals can be developed   –  such as finding ways to engage in ethical or
‘right’ conduct when other people are not. Much more recently, several
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research studies have documented a range of meaningful outcomes
that survivors of many different kinds of trauma have identified as a
result of their experience of adversity. The identification of meaningful
outcomes is usually a long-term process   –  it can seldom be achieved in
the immediate aftermath of a trauma and is more likely to emerge after
many months or even years of internal processing and reflection.48
The first possible type of meaningful outcome that may be
experienced after a trauma is positive changes in perceptions of the
self.49 This generally entails an enhanced sense of personal strength
and competence as a result of having survived something very difficult.
Survivors are often surprised by the resilience and reserves of strength
that they are able to draw on from deep inside themselves in order to
cope with a trauma. But positive perceptions of the self after trauma
can also involve developing a greater respect for one’s vulnerabilities.
Survivors of many different types of trauma have reported that the
trauma experience was so emotionally devastating that it forced them
to change longstanding coping patterns of denying their feelings of
vulnerability or distress and of avoiding asking other people for help.
While this was difficult and even shameful to do at the time, ultimately
it allowed them to gain more knowledge and acceptance of their
vulnerabilities and of the value of being able to depend on others for
support in times of distress.
A second area of meaningful outcomes commonly reported by
trauma survivors is improvements in relationships with others.50
Firstly, survivors have reported that, as a result of having to depend
on others for emotional support in order to cope with the trauma, they
have developed a greater capacity for emotional expressiveness and
for disclosing their feelings and fears to others. This has resulted in a
deeper sense of trust and greater interpersonal intimacy with important
people in their lives. Secondly, trauma survivors often emerge from the
experience with increased compassion and empathy for others. While
survivors may have previously been able to intellectually understand
and sympathise with the suffering of others, their personal experience
of trauma allows for a richer emotional insight into the pain and
distress of other people, and the emergence of a deeper capacity for
compassion towards others. Finally, improved relationships with
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others after the trauma often evolve through the survivor becoming
involved in altruistic social causes that provide them with a feeling of
connection to others and with a greater sense of value and purpose
through making a contribution to others. For example, many survivors
report becoming involved in activities that feel constructive for them,
such as fundraising for a trauma organisation, training to be a trauma
counsellor or volunteering as a police reservist.
Another area of meaning that can arise after a trauma is a changed
philosophy of life.51 This includes a greater appreciation of small
things that were previously taken for granted   –  for example, loving
moments with one’s family, a beautiful sunset, the kindness of other
people. Whether a traumatic experience involves a deliberate assault
by another person, actual or near physical injury due to an accident
or natural disaster or the diagnosis of a life-threatening illness, being
faced with one’s own mortality and with the threat of losing everything
can sometimes serve to highlight the joy and beauty that is inherent in
the simplest of things. A changed philosophy of life after a trauma can
therefore also result in a re-ordering of priorities, including decisions to
spend less time and emotional energy on work and more on family and
other relationships, and to devote time and energy to helping others
rather than to achieving one’s own goals. Finally, a changed philosophy
of life can also entail the development of new or stronger spiritual or
existential beliefs that add a richer dimension of meaning and purpose
to the survivor’s life.
The majority of the research on the positive outcomes of trauma
has been conducted in socio-economically developed countries such
as the United States and Canada. However, in some exploratory
studies South African survivors of different forms of trauma have also
identified a number of post-trauma benefits. Using the Post Traumatic
Growth Inventory (PTGI), a study of sixty-seven parents who had
experienced the loss of a child found evidence that both mothers and
fathers perceived some benefits from their experiences of loss, and that
the perception of benefits increased with the passing of time since the
bereavement.52 A set of semi-structured interviews with small groups
of violent crime survivors, rape survivors and mothers who had lost
a child to cancer explored whether these three groups perceived any
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benefit or value emerging from their traumatic experiences, without
suggesting to participants what these benefits might be. The interviews
were conducted several months or years after the participants had
experienced the trauma about which they were being interviewed, in
order to allow time for post-trauma meaning-making to occur. The
participants were from a range of different language and cultural
groups. Although not all survivors identified post-trauma benefits, the
majority of them did. The interviews yielded remarkably similar themes
of positive meaning-making after trauma across these groups, and these
themes replicated those reported in international studies.53 See Table 4.1
for a summary of the post-trauma benefits reported across these three
groups. In a larger-scale study comparing scores on the PTGI across
135 survivors of various types of trauma (including chronic illness,
traumatic bereavement, crime, and accident or injury), 76 per cent
of the sample reported moderate or high posttraumatic growth, with
survivors of a traumatic bereavement reporting the greatest amount of
growth and survivors of crime reporting the lowest.54 These findings
suggest that South Africans who have survived a variety of potentially
traumatic events are often, though by no means always, able to identify
some value or benefit arising from their experience.
The findings of international and local research therefore seem to
indicate that many trauma survivors use the trauma as an opportunity
to re-evaluate their lives in a more positive way, and that positive
transformation after trauma represents not simply a return to normal
or baseline functioning, but rather may entail the achievement of a
higher level of fulfilment than existed before the trauma.55 Positive
outcomes after trauma have thus often been termed ‘posttraumatic
growth’.56 But how can growth occur in response to extreme adversity?
As discussed above, a severe trauma, and the threatened losses that
accompany it, throws into stark contrast previously unrecognised or
unappreciated aspects of the survivor’s daily life, allowing these to
be ‘seen’ and appreciated for the first time. In addition, in order to
cope with the trauma, the survivor often has to draw on internal and
external resources that they have simply not had to access previously.
These resources also become ‘seen’ and appreciated for the first time.
Finally, since the trauma often does not seem to fit with the existing
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Table 4.1
Post-trauma benefits reported by participants in a study comparing three
groups of South African trauma survivors

Survivors of
violent crime
(n = 10)

Rape survivors
(n = 10)
Greater
compassion for
others

*

More
meaningful
relationships
with others

*

Engaging
in altruistic
activities to help
others

*

*

*

*

*

Greater
appreciation of
‘little things’ in
life
Feeling
emotionally
stronger

Mothers who
have lost a child
to cancer
(n = 10)

*

*

*

*

*

Source: Kaminer, Booley, Lipshitz & Thacker, 2009

beliefs and expectations held by the trauma survivor, these beliefs and
expectations need to be re-examined. A traumatic event can therefore
be conceptualised as a turning point, watershed, crossroad or choicepoint in the survivor’s life in which previous values, priorities and
ways of being can be re-considered, and a change in the ‘plot’ of the
survivor’s life-narrative towards a more purposeful and significant one
becomes possible.57 Some authors have suggested that, in this way, the
trauma can be ‘honoured’ as an opportunity for growth, at the same
time as recognising the losses that the trauma has brought.58
A danger of this literature on the potential benefits of trauma is that
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trauma survivors who are not able to identify any benefits from their
trauma experience may feel that they are somehow deficient. Especially
when our popular culture emphasises the importance of using positive
thinking to overcome adversity, it is all too easy to conclude that trauma
survivors should be able to find some value in their suffering. However,
while many survivors do identify some positive outcomes of their
trauma experience as time goes on, many other survivors do not. They
continue to struggle with a sense of emptiness and meaningless. The
search for meaning after trauma is a deeply personal process and there
is no ‘right’ way to engage in, or resolve, this difficult and often painful
journey. Furthermore, the development of posttraumatic growth implies
some sort of post-traumatic space or phase during which the survivor
can reflect on the meaning of the trauma experience. In a context of
continuous traumatisation, such as living in a situation of ongoing
community and/or domestic violence, the survivor may never have
such a space. They may feel perpetually in fear of danger, or may shut
themselves down emotionally in order to cope   –  emotional states that do
not allow for internal reflection. Studies of benefit-finding have not yet
been conducted with South Africans living in conditions of continuous
violence and trauma. An additional caution, as we shall see in the next
section, is that there is no clear and direct relationship between finding
positive outcomes after trauma and actual psychological recovery from
trauma.
The relationship between positive and negative outcomes of trauma
It seems logical that being able to find positive outcomes in the
aftermath of a traumatic experience would assist a trauma survivor
to recover from their experience and regain a state of psychological
wellness. However, this does not necessarily appear to be the case.
Within the research on the psychological outcomes of trauma, there
is no consistent trend in the relationship between posttraumatic
growth (that is, finding benefit or value in a trauma experience) and
psychological well-being.59 Many studies have found that posttraumatic
growth is related to lower levels of psychological distress   –  that is,
trauma survivors who report posttraumatic growth also report less
psychological distress than survivors who do not report posttraumatic
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growth. However, it is not clear whether finding benefits in the trauma
experience results in a decrease in psychological distress, whether a
decrease in psychological distress makes it possible to begin identifying
value in the trauma experience or whether there is no direct causal
relationship between the two dimensions of experience. A few studies
have reported no relationship at all between posttraumatic growth
and psychological distress, while some other studies have found that
identifying benefits of a trauma experience is, in fact, associated with
an increase in psychological distress, an increase in intrusive and
avoidance symptoms of PTSD, and worse subjective physical health   –  in
other words, people who report posttraumatic growth also sometimes
report worse psychological outcomes than people who do not report
posttraumatic growth.60
While some of the variation in research findings may be the result of
different methodologies used across studies (for example, posttraumatic
growth has been conceptualised and measured in different ways by
different researchers, and the populations of trauma survivors that
have been sampled in these studies differ along a number of variables),
several other explanations have been suggested for the finding
that posttraumatic growth is not always associated with improved
psychological well-being. Firstly, it is possible that posttraumatic
distress and posttraumatic growth are separate, but parallel, processes
or dimensions61   –  that is, in the aftermath of trauma, psychological
growth experiences do not put an end to distress. They simply occur in
parallel with distress. Secondly, it is possible that psychological distress
is necessary in order for meaning-making to occur.62 Struggling with
intrusive reminders of the trauma and experiencing some degree of
subjective emotional pain may provide the impetus for ruminating
about the meaning of the trauma, for trying to make sense of it.
Psychological growth occurs in the aftermath of emotional upheaval,
precipitated by a psychologically seismic event;63 if a trauma has little
emotional impact, there is no need to try to understand the meaning of
the trauma. Interestingly, some studies have found that posttraumatic
growth is more likely to occur when there are moderate levels of PTSD,
rather than mild or severe symptoms64   –  mild symptoms may not create
enough impetus to engage in meaning-making strategies such as benefit78

Trauma As A Crisis Of Meaning

finding, while severe symptoms may prevent any reflective processing
of the traumatic event. Thirdly, it has been argued that there may be a
self-deceptive, illusory aspect to posttraumatic growth.65 When faced
with feelings of vulnerability after a trauma, survivors may respond with
positive but slightly distorted beliefs about themselves and the future.
This is a form of cognitive avoidance or denial of the difficulties that
the trauma represents, which may occur temporarily as a short-term
coping strategy in the immediate aftermath of the trauma and which
may be replaced by more authentic posttraumatic growth (or not) over
the long term. Together, these theories may account for the apparently
contradictory findings across studies regarding the relationship between
negative and positive outcomes of trauma.

Conclusion

An important psychological consequence of trauma is a struggle
to make meaning of the event. After an experience of trauma, the
survivor’s world can never be quite the same again. Previous beliefs
and assumptions may be profoundly challenged and the survivor must
search for new beliefs and assumptions that can enable him or her to
make sense of what has taken place and to go forward into the future.
For some survivors, the trauma may leave behind an ongoing sense of
meaninglessness, raising troubling questions about themselves, others
and the world for which no satisfactory answer can be found. Others
may develop a new appreciation for themselves, other people and life
in general. Yet others may experience a combination of feelings   –  it
seems that the outcomes of trauma are not purely negative or positive,
but often a complex mix of the two. Regardless of the outcome, the
process of struggling to answer the question ‘why?’ is an important part
of trying to adapt to a traumatic experience.

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Chapter 5

TRAUMA INTERVENTIONS FOR
INDIVIDUALS, GROUPS AND
COMMUNITIES

H

aving spent considerable time exploring the prevalence of trauma
in society in general and in South Africa in particular, as well
as the impact of trauma in terms of both symptoms and alterations
to meaning, it is important to look at what can be done to address
these effects. The discussion of interventions will include a focus on
psychotherapeutic and alternative, community-based interventions
as well as a brief section on pharmacotherapy or drug treatment. The
chapter will also address interventions as they are formulated to assist
individuals, groups and communities.
Dealing with the impact of traumatic events has long been the
focus of psychotherapists, with Freud’s early work in the 1800s as a
prime example. However, with the formalisation and refinement of the
diagnosis of Acute Stress Disorder(ASD) and PTSD, over the last ten to
twenty years there has been renewed interest in treatment approaches
for trauma, and a move to more research-based practice. There is a large
array of therapeutic approaches to dealing with traumatic stress with
considerable debate about the merits and demerits of various models
of intervention. In addition to the more conventional ‘talking-based’
types of therapy and counselling, there are also more creative and
body-oriented interventions. It is also not uncommon for psychotropic
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medication to be prescribed for trauma clients alongside psychotherapy.
As will be discussed further in Chapter 6, play therapy is also commonly
used to assist traumatised children to process traumatic events.
Over and above professional counselling and psychotherapeutic
treatments that might be individual- or group-focused, the impact
of traumatic events has also been recognised as significant by social
and community groups. In many instances members of a particular
geographical or value-based community have been known to
spontaneously generate rituals and practices to mark and heal the
impact of trauma, recognising that in addition to having individual
effects, trauma damages interpersonal bonds and tests community
cohesion. In some cases members of society, previously unknown to
each other, who have undergone a similar traumatic experience have
also developed mechanisms for sharing and support that transcend
group psychotherapy. Such kinds of community-based initiatives have
been particularly important in South Africa where professional services
are not always easily available and accessible and where communal
aspects of identity have been strongly inculcated in traditional African
culture and belief systems.
This chapter will first discuss more individually oriented and
formally based interventions before addressing more communityfocused interventions.

Individual Psychotherapy and Counselling
The context
In a seminal work in the traumatic stress field, Judith Herman1 suggests
that there are three crucial aspects to all treatment of traumatic stress.
Firstly, it is necessary to establish a sense of safety for the individual;
secondly, it is important to process and integrate the trauma in some
way, and thirdly, it is important for some kind of re-engagement with the
larger community to be facilitated. She asserts that if the first of these
elements is not in place it is virtually impossible for the other aspects
of trauma work to be initiated and to be successful. It makes sense
that a person who feels unsafe in reality in the present is unlikely to be
able to engage in a therapy process that involves processing traumatic
material, since this inevitably evokes strong anxiety. In a situation of
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experienced danger it would be irresponsible to add to current anxiety
and to possibly tamper with the psychological defences a person has
in place in order to deal with ongoing threats. This may be the case
for people living in the conditions of ‘continuous traumatic stress’
described in Chapter 3. This issue will be returned to further, but at
this point it is important to emphasise that, as far as possible, trauma
therapy assumes that a client’s safety has been secured prior to other
aspects of intervention.
A further dimension influencing choices about intervention is the
immediacy of the traumatising event and the severity of the diagnostic
symptom picture. A person who comes for therapy twenty-four hours
after a rape will present differently from someone who decides to seek
therapy three years after the rape event. Until recently it was assumed
that trauma counselling should be offered as soon as possible after the
trauma, within seventy-two hours if at all possible. However, based
on mixed reports and some critical research findings that will be
discussed under the section on debriefing, it is now generally thought
that early support is important but that optimal therapeutic work may
only be possible some time after the trauma, once the initial shock and
disorganisation has passed.2 Although people may sometimes need to
be encouraged to seek counselling, given a tendency to want to avoid
trauma associations, it is very important that they feel a sense of choice
in engaging in counselling. This is significant in light of the fact that
trauma involves loss of control and helplessness. There are also different
treatment implications depending upon whether a person is diagnosable
as suffering from ASD, or Acute, Chronic or Delayed-onset forms of
PTSD. Generally the longer a person has been symptomatic, the deeper
and longer therapy will need to be, although there are exceptions to
this. Chronic forms of PTSD are particularly difficult to treat and may
require multiple forms of intervention including medication, individual,
couple and family therapy, as well as social support.
A useful way of thinking about trauma counselling is to divide it into
three different sub-fields: acute interventions or debriefing, short-term
counselling, and long-term counselling or psychotherapy. Generally
ASD is treated by means of debriefing or short-term counselling, whereas
PTSD is treated by means of short-term or long-term psychotherapy.
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At Camden Trauma Clinic in London a useful distinction has been
made between what staff broadly term ‘simple’ and complex’ forms
of trauma, the latter involving some sort of deliberate degradation or
humiliation of the victim. Their Cognitive Behavioural Therapy (CBT)based treatment protocol entails an eight-session intervention for
‘simple’ trauma cases and a twenty-session intervention for ‘complex’
cases.
Trauma practitioners usually select one of the three therapeutic
forms available (acute, short-term or long-term) based on a number
of different situational and organisational criteria. In South Africa, a
significant element in determining intervention, beyond severity of
traumatisation and length of time elapsed since the event, is whether
survivors can easily access services. Working-class clients, such as
security guards and domestic workers, may find it difficult to take time
off work and services may be geographically distant and transport
too expensive. Thus although longer-term work might be desirable in
some cases, brief-term work is often all that is feasible and therapeutic
modalities need to be tailored to this limitation. However, before looking
further at contextually specific South African issues in treatment, it
is important to discuss what each of the three broad treatment types
encompasses.
Acute or ‘frontline’ interventions
Acute interventions are often subsumed under the term ‘trauma
debriefing’ but include more extensive approaches than this. Raphael
and Dobson3 include emergency interventions, psychological first
aid, military interventions and crisis intervention, together with
debriefing, as all constituting ‘acute’ interventions. They argue that
while acute trauma interventions have been defined in terms of their
almost immediate use after damaging events, ‘the provision of trauma
counselling may take place in the early days or even weeks and can still
be considered acute’,4 in part based on the fact that full-blown PTSD
has not developed.
The term ‘debriefing’ was originally associated with military and
paramilitary procedures and in this context referred to the sharing of
information after a particular exercise or manoeuvre in an attempt to
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resolve issues for participants. The use of the term within the trauma
field became popular in the 1970s and ‘debriefing’ has become part of
everyday discourse concerning trauma treatment. It is also within the
military that the emphasis on intervention soon after an incident has
been emphasised. For example, the acronym for trauma intervention
that is used in the Israeli military, which influenced previous South
African National Defence Force (SANDF) thinking, is PIE, standing
for Proximity, Immediacy and Expectancy. The idea behind this
approach is that troops in action should be treated close to the battle
front, as quickly as possible, with the expectation that they return to
active combat within a relatively short period of time. This intervention
was designed to assist the military institution but it was also hoped that
it would ameliorate the development of more serious combat trauma.
While the approach seems to have been successful in getting soldiers
to return to active combat, the long-term effects have not been well
researched and it is not clear that this prevented the later development
of PTSD. In fact, it is possible that the intervention led to increased
vulnerability to pathology later: ‘whether keeping people functional but
in so doing keeping them in a situation where they may be traumatised
again (and again) is ultimately helpful to outcomes is a critical question
for future research’.5 This question still has bearing in broader terms for
various groups in contemporary society; for example, for men working
in the South African security industry, many of whom are ex-soldiers.
Those involved in the cash transportation business, for instance, face
daily danger and witness colleagues injured and murdered. Debriefing
for such personnel has to take account of the fact that many of these
men have no choice but to return to the same working conditions within
days of life-threatening incidents.
Historically it is interesting to observe that while some psychological
debriefing along the lines discussed was used in the South African
Defence Force (SADF) in the later stages of the war fought in Angola and
Namibia, traumatic stress in war veterans within the country amongst
both SADF and liberation fighters has generally gone untreated in the
period following demobilisation and return to civilian life. Although
there are a number of organisations dealing with the current difficulties
of ex-combatants, trauma treatment is still often scanty and difficult to
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implement because of the lapse of time since combat-related trauma
exposure and the preoccupation with pressing current social problems,
such as unemployment. In this respect, trauma treatment facilities for
South African veterans have been under-developed relative to those
offered to veterans in the United States, the population who, in many
respects, put posttraumatic stress disorder and its treatment on the
world map. One local intervention with ex-combatants from both formal
and informal military structures has been what is generally termed
‘Wilderness Therapy’ and will be discussed later under the section on
group intervention, since it is not an acute form of intervention.
Returning to the discussion of debriefing, the approach to
intervention known as debriefing is generally synonymous with what
more accurately is called Critical Incident Stress Debriefing (CISD).
CISD was initially developed by Mitchell6 to address the psychological
effects of work stress in emergency service workers, such as paramedics
and fire fighters. It was designed as a group intervention to be used
within seventy-two hours of a particular incident and was intended to
allow for discharge of distress or the dilution of the possible ‘toxic’
effects of intervening in traumatic situations, aimed in turn at the
prevention of later PTSD. For example, debriefing was used with
fire fighters who were involved in removing children’s bodies from
the scene of the Oklahoma bombing with the expectation that this
would reduce later psychological distress. Dyregov’s7 group model of
intervention known as Psychological Debriefing (PD), also designed
for use with ‘helpers’, is the other prominent debriefing model and is
sometimes used in conjunction with the Mitchell model. Neither CISD
nor PD appear to be used routinely with emergency service workers in
South Africa, but debriefing may be employed in organisations after
particularly horrific incidents, and involve both group and individual
debriefing.
CISD involves seven set steps of intervention and may be conducted
in groups as large as ten to twenty people.8 The seven components
are: introduction, expectations and facts, thoughts and impressions,
emotional reactions, normalisation, future planning and coping,
and disengagement.9 The model involves reflecting back upon and
recounting various aspects of the traumatic incident in a deliberately
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structured manner, for example, separating out thoughts about the
event in one re-telling from a re-telling focused on the more emotional
aspects. It is possible that this allows for manageable engagement with
difficult content, or what Horowitz10 refers to as ‘optimal dosing’. In
addition the intervention has a strong psychoeducational component.
Dyregov’s PD11 has many similar elements but deals with the trauma
story in a less tightly compartmentalised way and places more weight
on stimulating group processes, such as the provision of peer support.
A summary of the common elements of most debriefings is as follows:
During a PD, participants are encouraged to provide a full
narrative account of the trauma that encompasses facts, cognitions,
and feelings. In addition, emotional reactions to the trauma are
considered in some detail with the emphasis on normalisation.
Individuals are reassured that they are responding normally to an
abnormal event, are prepared for later emotional reactions and
told how to deal with them and where to find further support if
necessary.12
Following the introduction of PD into the trauma field in the 1980s
this kind of intervention became used in increasingly wider settings.
PD became the treatment of choice not only for groups, but also for
individuals, and for both direct and indirect victims of traumatic events.
For example, PD has been used after natural disasters, motor vehicle
accidents (MVAs) and violent crime incidents, amongst others. In South
Africa, PD and CISD have been widely used in the banking and retail
industry to assist staff after armed robberies and work-place incidents
(such as suicides), and have been provided mostly by Employee
Assistance (EA) personnel. Psychologists are also commonly called
in to debrief families who have been through trauma or members of
organisations in which traumatic incidents have taken place, including
schools. For example, following the suicide of a work colleague or
fellow pupil, debriefers may be called in to address the fall-out in an
organisation or school, often attempting to assess the likelihood of
later symptom development amongst members of the group as part of
their task. More recently there has been increasing concern amongst
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trauma specialists that debriefing has become over-used, sometimes
in contexts that are inappropriate and sometimes by inexperienced
practitioners. This is in part because it has become a fairly lucrative
practice, particularly for counsellors servicing large organisations.
While the moral imperative to help people who have been traumatised
in their workplace is understandable, the use of debriefing is sometimes
rather formulaic and other interventions, such as improving working
conditions or advising management about how best to offer support to
their staff, might be more appropriate. Despite the fact that assessment
of risk for the development of pathology is usually intrinsic in debriefing,
organisations are not always willing to fund recommended follow-up
services. The popularity of debriefing as a trauma intervention is not
peculiar to South Africa and in the late 1990s researchers from the
United Kingdom began to review the widespread use of debriefing and
to question its efficacy.
In their meta-theoretical study of the results of a range of research
studies into the efficacy of trauma debriefing, Rose and Bisson13
established that the grounds for the continued use of CISD and
other forms of debriefing were rather shaky. Of the six reasonably
controlled studies of treatment that they were able to identify and
review, there was evidence of minor improvement in two studies, of no
improvement in another two studies and, in the remaining two studies,
some suggestion that debriefing might even be detrimental in terms of
creating a vulnerability to later pathology. It is possible that debriefing
offered too early may ‘re-traumatise’ individuals in that it exposes them
to emotionally arousing subject matter at a point at which it might be
more beneficial for natural defences to operate to allow for more gradual
habituation to the material. It has also been suggested that group
debriefing may expose members to new traumatic material as details
of different people’s experience during the trauma are recounted, also
possibly leading to increased traumatisation. Despite the lack of clear
evidence for the efficacy of psychological debriefing it is worth noting
that where participant evaluations of their experiences of the debriefing
were sought, in the vast majority of cases survivors themselves perceived
the intervention as beneficial.14 It is now generally accepted that, while
some sort of frontline support is useful to individuals immediately
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following a trauma because it provides some emotional containment
and structure (what some have called ‘tea and sympathy’), any thorough
processing of the event may be better introduced some time after the
event when people are less disorientated, disorganised and vulnerable.
However, the importance of perceived support should not be underestimated and it may be that intervention of a supportive kind soon
after the occurrence of a trauma is particularly important in helping
to counteract people’s experience of other people as harmful and in
making people aware of the fact that further assistance can be sought.
It seems that debriefing might have its place if introduced thoughtfully
in a considered, rather than automatic ‘one size fits all’ kind of way.
Practitioners have begun to look at the merits of ‘Emergency Support’
or ‘Psychological First Aid’ rather than necessarily offering debriefing
in the form associated with CISD.
Short- and medium-term counselling
The most common and widely used forms of intervention in the trauma
field would fall into the category of brief- to medium-term intervention,
with therapy lasting anything from two sessions to several months.
Structured approaches may, for example, involve a set of either four to
six, or alternatively eight to twelve sessions. Such counselling is aimed
at those suffering from ASD, PTSD or other related trauma conditions.
There are a range of different types or models of what is generally
referred to as ‘short-term’ counselling interventions, including models
based in mainstream paradigms of psychotherapy, such as cognitive
behaviour therapy (CBT) and psychodynamic therapy, as well as Eye
Movement Desensitisation and Reprocessing (EMDR) and other
approaches that are sometimes collectively referred to as the ‘power’
or ‘neoteric’ or new therapies. The use of pharmacotherapy will be
discussed somewhat later as it straddles both short- and long-term
trauma intervention.
Mainstream approaches
The more mainstream approaches to short-term treatment of
traumatic stress include cognitive behaviour therapy, narrative therapy,
psychodynamic therapy and integrative therapeutic approaches.
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Cognitive Behaviour Therapy
Cognitive behavioural treatments for traumatic stress share in common
that they are based on an understanding of symptoms as stemming
from maladaptive learning and conditioning that takes place in
response to traumatic stimuli. There are many different treatment
protocols and types that fall under the umbrella of CBT treatment,
including Foa and colleagues’ Prolonged Exposure (PE),15 Resick and
Schnicke’s Cognitive Processing Therapy (CPT),16 Meichenbaum’s
Stress Inoculation Training (SIT)17 and Ehler’s and Clark’s Cognitive
Therapy (CT).18 These types of CBT treatment are usually prescriptive,
detailed well into manuals and take between nine to sixteen sessions
to implement. Different aspects may be used in combination at times.
Generally, at least three different principles are involved in CBT
treatment of trauma, namely repeated exposure to traumatic memories
and traumatic reminders in order to reduce the anxiety associated with
these and habituate the client to such material; developing strategies to
manage anxiety, such as relaxation training or thought-stopping; and
cognitive restructuring in order to modify any maladaptive beliefs that
may have developed in relation to the trauma (such as those already
discussed in Chapter 4).
Foa and colleagues’ approach requires not only that the client
recount the trauma repeatedly in therapy, but that the sessions are
recorded and then played back to the client between consultations.19
The therapy is based within a classical conditioning framework which
holds that the process of traumatisation entails the association of
previously neutral stimuli with anxiety and fear and that this pairing
is followed by consequent avoidance of reminders of the event. For
example, a woman who had been raped by a man wearing a green overall
became agitated whenever she encountered a man wearing green and
would move as far away from him as possible. The avoidance of feared
objects, situations and people means that new learning cannot take
place and the cycle of association is reinforced. Exposure to traumatic
material in the supportive context of the therapeutic relationship is
designed to reduce the connection between trauma memories and
high levels of fear and arousal, while gradual exposure to realistically
unthreatening traumatic reminders outside of the therapy room aims
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to modify the survivor’s cycle of avoidance. This approach appears to
have considerable benefit if the survivor can tolerate the treatment,
which entails willingness to manage high levels of anxiety. Resick and
Schicke’s CPT also involves exposure elements, including the writing
of a personal account of what happened, but places greater weight
on working with the maladaptive thoughts that are generated by the
trauma.20 For example, over-generalisation, self-recrimination and
negativity about the future would all be tackled using forms of cognitive
restructuring. Meichenbaum’s SIT is designed to look at managing
future anxiety, amongst other aspects, and helps the person to imagine
approaching feared situations and coping with these.21 Role-plays
with the therapist and strategies for gradually approaching feared, but
realistically safe, situations may be used to help the survivor to regain
control. For example, someone who fears driving after an accident
might be encouraged just to sit in a car initially, then to be a passenger,
then to drive a short distance in a safe setting, then to drive further and
so on. In addition to most of the aspects of treatment already described,
Ehlers et al’s CT requires that the client specifically revisit what they
refer to as the ‘hotspots’ (or the most distressing and anxiety-provoking
aspects) within the trauma experience so as to examine the associations
to these emotionally charged elements and detoxify them.22 There is
also attention to modifying excessively negative appraisals of the event
and its consequences.
CBT approaches generally employ a strong psychoeducational
component and the client is usually informed about the impact of
traumatic stressors and the reasoning behind treatment. Although there
are some differences among CBT approaches, in general CBT has the
clearest proven efficacy in treating trauma and is probably the treatment
of choice of most practitioners.23 However, it is important to point out
that protocol-based CBT therapy is often difficult to implement in South
Africa, in part because of a lack of trained professionals and in part
because clients may find it difficult to attend structured counselling for
the requisite number of sessions. Language and other resource barriers
also preclude the easy replication of international models and it is often
the case that aspects of CBT-based approaches are used rather than
entire protocols. From a research perspective, perhaps because the
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procedures used in CBT are easier to replicate, since they are based
in many instances on set protocols, CBT approaches have tended to
be more concertedly researched than psychodynamic, narrative and
integrative approaches.
Narrative therapy
Although not as widely documented and used in the treatment of
trauma as either CBT or psychodynamic approaches, narrative therapy
has also been employed to assist traumatised clients. Since narrative
therapy is focused on re-authoring people’s life stories and altering
meaning in a way that benefits the client and increases his/her sense
of personal agency or potency, it makes sense that this is an approach
that has been used to deal with trauma. The narrative therapy literature
proposes that adverse or traumatic experiences can become the basis
for stories of resilience and survival and that these aspects of the story
can be thickened and enriched.24 In narrative therapy, ‘the stories
can be separated from the survivor. Rather than emphasising that the
client has been the victim of a traumatic event, the client can almost
immediately be seen as a survivor who wants to move forward from the
traumatic experience. In addition, the therapy encourages that power
be collaborative rather than enforced over the client, a basic rule in
trauma treatment’.25 Narrative therapy has been successfully used
with African and Asian refugee populations with the suggestion that
such an approach may be compatible with traditional oral story telling
practices.26 In addition, in his more recent writings Meichenbaum has
incorporated aspects of narrative theory into his trauma treatment
approach, referring to it as ‘narrative constructivist’.27 Meichenbaum
encourages therapists to work collaboratively with the client to
reconstruct the traumatic event/s in such a way that the survivor is able
to integrate and live with his or her interpretation and version of what
happened. This aspect of therapeutic work resonates with the second
central element of trauma work outlined by Herman as discussed at the
outset of this chapter.
The narrative approach also underpins a more politically oriented
approach to trauma treatment known as testimony therapy.28 In
testimony therapy, the client is assisted to tell and document the story
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of their traumatisation or tribulation in such a way that the telling
represents a formal record of the event. This record or testimony may
be explicitly intended to become part of the public record with the
aim of influencing policy or providing a basis for lobbying, prosecution
or restitution. This approach has been used primarily with victims
of political repression, torture or violence.29 In addition to serving a
personal function, the telling and detailed documentation of the story
may serve an empowering function in providing the survivor with some
validation and potential agency. Since most repression and torture
takes place in hidden and intimidating circumstances, there is an
element of defiance or resistance in testimony therapy. Clearly clients
exercise choice in how material is documented and where their stories
are stored and appear. Currently, for example, a number of torture
survivors from a neighbouring African country have provided accounts
of their experiences as part of their treatment in order to contribute
to a dossier of evidence on torture that may be used to exert political
pressure on those employing such methods of control. Other refugee
groups in South Africa have also extended narrative aspects of their
therapy into ‘testimony’ in order to expose atrocities committed in
their countries of origin and to appeal to the collective South African
conscience in terms of their experiences of being treated as illegitimate
in the country. The idea that giving public testimony at the Truth and
Reconciliation Commission of South Africa would be beneficial (or
even therapeutic) to victims and their families, also had its origins in
this kind of testimony approach to trauma and therapy. While existing
evidence suggests that there were actually few psychological benefits of
giving testimony to the TRC,30 this is perhaps not surprising since TRC
testimony did not occur within the context of a therapeutic relationship.
Narrative therapy is thus an approach that has been modified for use in
various contexts in South Africa, even if it is not widely documented as
a trauma treatment model internationally.
Brief psychodynamic approaches
Although it is less usual for psychodynamic therapy to be offered on a
short-term basis, there are specific forms of brief-term psychodynamic
therapy. Brief Psychodynamic Psychotherapy (BPP) is a trauma92

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focused form of therapy conducted over twelve to fifteen sessions.31 In
the trauma field short-term psychodynamic approaches to therapy have
been associated primarily with the work of Horowitz32 and Lindy33 and
tend to be located within the Ego-Psychology tradition. Horowitz’s focal
psychodynamic treatment focuses on assisting the client to assimilate the
trauma material, based on an understanding that this ‘information’ has
intruded in an overwhelming way and therefore cannot be processed
according to usual psychic mechanisms. The work is supportive and
strongly cognitive, rather than aimed at character change or emotional
catharsis.34 Clients are categorised in terms of whether they tend to
be using an over-controlled or under-controlled defensive style in
dealing with the trauma, associated respectively with whether they are
manifesting more avoidant or more re-experiencing symptoms. Based
on this, the therapist aims to assist the ‘patient’ to engage with the
information associated with the trauma in a manageable way, by means
of the ‘optimal dosing’ mentioned earlier, that is by helping the patient
to ‘divide the experience into suitably small and therefore potentially
integrated units of information’.35 The relational element of the therapy
is emphasised in psychodynamic therapy for trauma, with the therapist
aiming to provide a ‘good object’ experience that can gradually be
internalised by the patient.
With trauma survivors, what is known in psychodynamic therapy
as ‘working through’ consists of helping the client to make interpretive
links between the trauma experience and other past and present aspects
of their lives. The clinician ‘helps the client understand the meaning
of each unconscious process to achieve a balance between traumatic
memories, external demands, and subjective needs’.36 Or alternatively
working through could be understood as, ‘detailed conceptual,
emotional, object-relations, and self-image implications of the traumatic
stressor are addressed’.37 It is clear that psychodynamic approaches to
traumatic stress place a strong emphasis on the appreciation of the
subjective meaning of the event for the individual and the linking of
this to the person’s ‘internal world’, while at the same time offering a
supportive and containing relationship.
There has been little research into short-term psychodynamic
treatment of trauma. However, one study on BPP established positive
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results in using this insight-oriented approach in the treatment of
rape victims.38 In another study comparing hypnotherapy, traumatic
desensitisation and psychodynamic psychotherapy, the last mentioned
approach proved more effective in reducing avoidance symptoms
whereas the other two approaches were superior in diminishing reexperiencing symptoms.39 In South Africa there is a fairly strong
allegiance to psychodynamic and psychoanalytic psychotherapy
amongst private psychotherapists and many of these practitioners treat
trauma clients within this modality if they do take on trauma cases.
Much of this work is long term rather than short term, however. In
addition, there are some interesting traditions within British group
psychoanalysis that have been applied in community work in South
Africa, including in doing work with traumatised populations. Such
applications tend to be more group focused. Given an interest in
meaning-making amongst many South African trauma practitioners,
perhaps because of the highly politicised nature of much trauma in the
country, both historically and contemporarily, many draw on aspects
of psychodynamic thinking in their work even if they work in more
integrative or eclectic ways.
Integrative approaches
Although there is not a lot of literature on employing a specifically
integrative approach to trauma intervention, in practice there is
considerable evidence of integration within the field. This includes
integration both across theoretical paradigms and across practical
modalities of psychotherapy. For example, Horowitz’s40 informationprocessing approach is located within both a cognitive and a psychodynamic framework, Meichenbaum’s41 trauma approach encompasses
both CBT and narrative approaches, and group and individual therapy
may be used in conjunction in trauma work. Although most structured
interventions are multimodal cognitive-behavioural packages, these are
generally integrative in character since the historical sources of many
specific techniques come from a range of therapy traditions.42 Eagle
has argued that there is a strong case to be made for integration in
trauma work, given the interaction of external events with personality
style and defensive patterns in producing trauma outcomes.43 Thus
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there is a need to address impact at different levels in different ways.
Edwards concurs, arguing in a recent article on evidence-based practice
for traumatic stress conditions, that the field has developed over time
such that purist psychotherapeutic practitioners ‘could be considered
at the least narrow-minded and at most unethical since there is now
abundant evidence that treatment needs to draw on a range of different
interventions’.44
In Johannesburg, one of the commonly used local models of
trauma intervention is known as the ‘Wits Trauma Model’, based on
its development by a team of staff working at the University of the
Witwatersrand (Wits). Drawing on a range of different existing
frameworks and models for trauma intervention, including locally used
rape trauma intervention models, the Wits approach is a short-term
method for optimal use in two to twelve sessions with relatively straightforward forms of trauma. However, it has been adapted for use with
more complex forms of trauma such as traumatic bereavement and
torture. The model is integrative as it draws upon both psychodynamic
and cognitive-behavioural-theoretical underpinnings and consists of
five components that can be used interchangeably in different sessions,
depending on what the client brings to the sessions. In this respect,
it is a flexible approach rather than a protocol-based intervention.
The five components are: telling and retelling the story; normalisation
of symptoms and responses (including fantasy elements, such as the
fantasy of taking violent revenge against the perpetrator); addressing
self-blame or survivor guilt (oriented towards the restoration of selfrespect); enhancing mastery (including the accessing of social support);
and facilitating the creation of meaning (in the context of existing belief
systems). The model has been documented45 and appears to work well
based on practitioner and client reports, but has not been subject to any
control-based or comparative research. It has been informally adopted
by several non-government organisations (NGOs) and welfare bodies
and is one of the main forms of counselling offered at the Trauma Clinic
of the CSVR in Johannesburg, one of the few trauma-focused service
organisations in the country.
There are other authors who have written about the benefits of an
integrated approach to trauma work and have identified ‘common
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ingredients’ that appear to make trauma interventions successful.
In a well-observed paper, Prout and Schwarz,46 having reviewed the
range of trauma intervention approaches available at the time, suggest
that trauma interventions generally embrace the following principles:
supporting adaptive coping skills; normalising trauma-related symptoms
and feelings; decreasing avoidance of traumatic reminders; altering
maladaptive attributions of meaning; and facilitating integration of the
self (bringing together all the memories, feelings and thoughts about the
trauma that the person may have split off from consciousness in order to
defend themselves from the anxiety associated with these). Raphael and
Wilson similarly comment that the benefits of trauma treatment pertain
to ‘helping the individual to confront what has happened; expression
of feeling associated with the event; construction of meaning; and
gaining practical and cognitive mastery’.47 It seems then that there is
considerable agreement about what ‘ingredients’ make good trauma
treatment and that therapists might be well informed by holding these
over-arching guidelines in mind in making decisions about how best to
assist clients.
The neoterics or power therapies
Although not widely used in South Africa and lacking empirical or
practical validation in many instances, the power therapies are worth
mentioning, as these methods of intervention are employed by some
practitioners in the country and are seen to promise fast alleviation
of symptoms. In surveying some several hundred practitioners in the
United States about trauma treatment approaches that they found had
assisted with quick symptom reduction in a short number of sessions,
Figley and Carbonell48 identified four such approaches. These were
Eye Movement Desensitisation and Reprocessing (EMDR), Traumatic
Incident Reduction (TIR), Visual Kinaesthetic Dissociation (VKD)
and Thought Field Therapy (TFT). All four approaches involve
pairing of revisited trauma imagery under structured conditions with
some anxiety-counteracting input, and so could perhaps be broadly
viewed as ‘exposure techniques’, involving desensitisation to traumatic
material. VKD has its origins in Neurolinguistic Programming (NLP)
and TFT in applied kinesiology, but as exposure-based approaches
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they could be viewed as broadly behaviour therapy-oriented. They
are technique-based approaches, which is perhaps both their strength
and limitation. The therapist takes a very active role in directing the
process and the treatment is standard for every client, which is what
is sometimes discomforting for both clients and therapists. In practice
those trained in such techniques in South Africa tend to use them
as part of a broad repertoire of available approaches, preferring to
work in a more relational and case-based way with trauma clients. In
focusing on symptom reduction there is little attention to meaningmaking or integration of the trauma into life experience. EMDR is the
most widely used and best researched of the power therapies and so
will be discussed in more detail. In fact, some clinicians might contest
its inclusion under the category of ‘neoteric’, viewing EMDR as a
mainstream CBT approach or method within its own right.
EMDR49 is a technique-based therapy approach that has become
very popular in the United Kingdom and United States, and has
proponents in South Africa since international practitioners come
out regularly to offer training in the method to professionals at fairly
substantial cost. The method was developed by Francine Shapiro
almost by chance after a link was made between the stimulation of
saccadic or rapid eye movements and the reduction of anxiety. EMDR
has been categorised as a CBT intervention, since it involves elements of
desensitisation and cognitive restructuring, but tends to be viewed as a
distinct treatment based on neurological processing that is not yet fully
understood. Because there has been considerable controversy about
the method, it has been well researched and results have generally been
positive in terms of beneficial outcomes. However, it is not conclusively
established as to what actually produces therapeutic change and the
necessity of rapid eye movement as part of the process has even been
questioned.50 There is a fairly lengthy assessment process that takes
place before treatment is initiated and in many instances considerable
insight occurs in this assessment phase. It is suggested that part of the
success of EMDR might lie in its efficacy as a distraction technique,
requiring the person to simultaneously focus on traumatic material and
the task at hand (visually tracking the hand movement of the therapist).
Despite considerable debate about what makes it work and whether it
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deserves its positive reputation, EMDR continues to be widely used
and is the treatment of choice for many practitioners overseas. In South
Africa many therapists are sceptical of the approach and, as with the
other power therapies, are concerned about its overly technical base
and its indiscriminate application. However, there are also proponents
of EMDR, although it is perhaps not as widely practiced as it might be
were the training not so expensive and, therefore, fairly elitist. Since
the second phase of EMDR training is focused on working with more
serious posttraumatic pathology (such as Dissociative Disorders), the
training is also restricted to people with professional clinical training in
psychology and medicine.
Having covered short term trauma intervention approaches in some
depth the next section deals with longer term approaches.
Long-term approaches
Long term approaches to trauma therapy, that is, therapy of several
months or years duration, tends to be oriented to more complex cases
of trauma, for example early childhood trauma, and to more intractable
cases of PTSD. Two main approaches are referred to here, psychodynamic
or psychoanalytic trauma treatment and multi-dimensional treatment.
Although CBT treatment can clearly be extended into longer-term
intervention, it is generally intended as a short to medium term timelimited intervention. Psychodynamic approaches, on the other hand,
are conventionally long-term oriented with an expectation that clients
(or patients, as they are often referred to) will be in psychotherapy or
analysis for years.
Psychodynamic treatment
As alluded to previously, the early history of psychoanalysis is strongly
associated with the exploration of psychological trauma. Subsequently,
however, the analytic movement’s emphasis on unconscious, intrapsychic functioning and on the role of transference and countertransference in effecting psychotherapeutic change, has meant that
traumatic stress cases have sometimes been viewed as unsuitable for
psychodynamic therapy. Nevertheless, there is a trauma service associated
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dynamic psychotherapy training centres in the world. Caroline Garland,
a key practitioner within this service, has edited a book which provides
a basis for understanding psychodynamic approaches to trauma work,
titled Understanding trauma: a psychoanalytical approach.51
Although there are different perspectives on mechanisms of
traumatisation and related treatment within the psychodynamic
community, some common elements will be outlined. Within this
framework the subjective interpretation of the event by the patient
is strongly emphasised, based on the assumption that the trauma
experience will be shaped by, and mapped onto, prior life experiences,
particularly fearful or disturbing experiences. Thus each individual’s
experience of a traumatic event is understood to be unique and the
meaning of the incident can only be fully appreciated by exploring both
conscious and unconscious associations to the trauma. In addition, the
way in which the traumatic experience is processed will be shaped
by the person’s previous defensive style and intra-psychic dynamics.
For example, a person who has a very harsh superego or internally
judgmental aspect to their personality may struggle much more with
surviving an incident in which a colleague was killed than someone with
a more benign superego. It is also assumed that the manner in which
the person deals with the trauma afterwards will reflect the health of
their internal ‘objects’, which in part represent the kinds of blueprints
for dealing with anxiety and danger that have been laid down by early
experiences with significant caretakers.
Further, it is assumed that the trauma survivor’s relationship with the
therapist will also reflect these kinds of early ‘object’ relationships. For
example, a client who has had the experience of a very fragile mother,
who seemed overwhelmed by any demands made by her child, might
choose to hide some of the worst aspects of the trauma incident in
therapy, assuming that he or she can only be helped if they bring what
is manageable to the therapist (who is unconsciously associated with
the vulnerable mother). Drawing on a related idea, Herman reminds
therapists that they should not always assume that traumatised clients
share the perception of therapy as a benign process and suggests that
for those who have been previously abused the therapist can sometimes
be experienced as helpful, but can also be experienced as an abuser,
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a seducer or an impotent bystander.52 Feelings from the past may
be transferred onto the therapist in the present, and in the case of
trauma, the strength of violations that the patient has experienced may
sometimes mean that aspects of the trauma situation are unconsciously
replayed in therapy.53
As should be evident from this brief discussion of psychoanalytic
perspectives on trauma, the working through of material in therapy
at this level can take considerable time. The early phase of therapy
involves forming a good working relationship so that when the more
in depth trauma-focused work needs to be done the therapeutic bond
or alliance is strong enough to sustain the patient through the difficult
process. It is also suggested that the therapist needs to play a strongly
‘containing’ role in therapy,54 with the word ‘containment’ understood
in a specific sense. It is the therapist’s role (in parallel to that of a mother
with a distressed infant) to be able to tolerate the most difficult and
unmanageable feelings and sensations associated with the trauma, to
be able to reflect upon and make sense of these, and then to be able
to help the patient to symbolise this material and put it into words.
This is perhaps a different way of understanding the benefit that the
client may feel in talking through or narrating the trauma experience
in depth to the therapist. It has also been proposed by psychodynamic
therapists influenced by a ‘Self Psychology’ orientation that early work
in trauma therapy with patients who have been severely abused and
are not very stable, should consist of ego strengthening or assistance in
developing ‘self capacities’.55 For example, a client may need to learn
how to tolerate being alone, or to ask for help when fearful, before any
processing of anxiety-provoking trauma memories can be introduced.
While this might be seen as similar to teaching a client anxiety
management techniques in CBT, self capacities are seen as deeper
aspects of personality rather than as techniques that can be employed
after some training. Again, it is apparent that working with complex
trauma cases in this way might take years rather than weeks.
There is little research that systematically documents the impact of
long-term psychodynamic therapy for trauma compared with other
interventions, perhaps because of the highly individualised nature of
the work with each case. However, there are some very compelling case
studies documented in the psychoanalytic literature (for example in
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Garland’s book, referred to earlier). Much of the work in long-term
psychodynamic treatment of trauma is about meaning-making and
draws upon some of the understandings outlined in Chapter 4.
Multi-dimensional treatment
A second form of long-term therapy for trauma could perhaps best be
termed multi-dimensional, since in some instances of treatment of more
complex or intractable forms of trauma several different approaches
and interventions might be used in combination. An individual may,
for example, be involved in individual therapy, couple counselling (to
deal with the relational impact of their trauma symptoms) and group
therapy (to gain social support for their difficulties). Services for war
veterans in the United States span these kinds of treatment inputs. In
many instances trauma treatment with more marginalised populations
extends beyond conventional forms of psychotherapy into psychosocial
support, such as support in job-seeking.
Treatment for refugee victims of torture in specialist centres in
Europe and England involves input from a multi-disciplinary team,
including psychiatrists, psychologists, physiotherapists, social workers
and others. For example, the Medical Foundation in the United
Kingdom56 and the treatment centres associated with the International
Rehabilitation Council for Torture Victims (IRCT)57 offer such multifaceted intervention. Treatment may involve medication as well as
physical and psychological rehabilitation. A central aspect of treatment
for such populations is often some sort of occupational deployment
or skills training, as it is recognised that trauma recovery is in part
dependent upon the restitution of a sense of self-reliance and selfsufficiency. Long-term psychotherapy is but one aspect of a multidimensional intervention and the focus of the therapy may change over
time to assist the client not only to process the past trauma but also
to deal with its indirect effects in the present, including adjustment
to very changed life circumstances. South Africa is one of five sites at
present involved in piloting a torture treatment programme based on
IRCT protocols.
While treatment facilities for African refugees in South Africa tend
to be much more modest than those just described, there are attempts
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to work in a multi-dimensional way with psychiatrists, social workers,
psychologists and lawyers often collaboratively assisting asylum seekers
and refugees. Therapy with such refugees is often of extended duration
as therapists attempt to support clients to establish some sort of daily
stability and meaningful existence, whilst at the same time assisting
them to process the experiences that led them to flee their country of
origin and to manage more classic trauma symptoms.58
A further example of the employment of such a multi-dimensional
therapy approach was a psychosocial programme aimed at excombatants run jointly by Technikon South Africa and the CSVR. Over
about a six-month period, ex-combatants from the former liberation
movements, who were unemployed at the time, received skills training
in a number of trades and simultaneously attended a structured grouptherapy programme aimed at trauma resolution, psychoeducation,
exploration of identity, self-insight and social skills development. Several
participants also chose to engage in additional individual therapy to
explore issues that had come up in the groups in greater depth. Although
the job placement aspect of the programme was not as successful as
hoped, the evaluations of the psychosocial intervention was generally
very positive.59 It is sometimes important for skills development to
supplement trauma work in order for people in deprived communities
to attach value to psychotherapy. Complementing this perspective is
the idea that highly traumatised and symptomatic individuals need
psychotherapy if they are to be optimally able to make use of training,
service and work opportunities.
It is evident that multi-dimensional long-term therapy for PTSD
and traumatic stress can take both more conventional forms, in the
employment of multiple and complementary psychotherapeutic
interventions, or less traditional, more socially oriented forms, in the
sense of addressing social and community needs as part and parcel
of trauma intervention. In the case of the latter types of intervention
there is a strong overlap or synthesis between psychotherapeutic
and community psychology modes of intervention. However, further
discussion of community-level interventions that do not necessarily
entail traditional psychotherapy is warranted in a subsequent section.
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Pharmacotherapy

Having looked extensively at primarily individual psychotherapeutic
approaches to dealing with traumatic stress it is important to
acknowledge that although psychotherapy is generally recognised as
the treatment of choice for traumatic stress,60 there is also evidence that
pharmacotherapy, usually employed in conjunction with psychotherapy,
can be of benefit to those suffering from PTSD and related conditions.
Psychiatric medication is sometimes employed explicitly to assist the
process of psychotherapy, particularly exposure-oriented therapy,
helping the patient to manage the re-experiencing symptoms and the
associated anxiety that often increase initially in such treatments.61
‘For example, antidepressants can dampen down involuntary reexperiencing symptoms such as flashbacks and nightmares, particularly
when used in conjunction with insight oriented therapy. By modifying
involuntary re-experiencing symptoms that follow intense and painful
memories in psychotherapy, antidepressants allow patients to more freely
experience, work through and master the trauma.’62 Psychotherapy
and pharmacotherapy can thus be used in complementary ways in the
treatment of PTSD
As advances in brain imaging technology allow the neurobiology
of traumatic stress to be increasingly better understood, the use of
medication in treating specific aspects of PTSD is becoming refined.
However, there are some general trends which are briefly summarised
here. ‘With very few exceptions (e.g., sleep disturbances, bipolar
disorder), the experts prefer the selective serotonin reuptake inhibitors
(SSRIs) as the first line of treatment.’63 Thus PTSD is generally treated
with similar medication to that used to treat depressive disorders and
this tends to be the first kind of medication prescribed for people
suffering from PTSD (despite its categorisation as an anxiety disorder
in diagnostic systems). In cases of ASD it is not uncommon for
general practitioners (GPs) to prescribe tranquillisers (or anxiolytic
medications) and sleeping tablets or sedatives. While these medications
may assist with the immediate or short-term control of symptoms, they
need to be carefully managed so as not to create dependence and also
so as not to suppress the processing of traumatic material required
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for longer-term adjustment. Suppression of traumatic symptoms or
memories is not desirable, medical support should rather be designed
to assist with optimal processing of trauma experiences. It should also
be recognised that the conditions that are commonly comorbid with
PTSD, such as depression or substance dependence, may also require
pharmacologic treatment.
A somewhat more differentiated discussion of drug treatments
for PTSD suggests the following in terms of symptom management.
‘Medications most often prescribed include antidepressant, andrenergic blockers, benzodiazepines and anticonvulsants  ...  Among antidepressants, serotonergic antidepressants have demonstrated efficacy in
treating core PTSD symptoms when prescribed at higher doses for 5-8
weeks  ...  Tricyclic antidepressants have alleviated intrusive symptoms,
sleep disturbances, anxiety and depression, but have not reliably reduced
avoidance.’64 In further summarising the results of several clinical trials,
Tucker and Trautman also indicate that adrenergic blockers may be
used to treat strong arousal symptoms, lithium or mood stabilisers to
treat impulsivity and labile mood, anticonvulsants to reduce constant
hyperarousal, and benzodiazepines to treat severe anxiety and panic
attacks.
It is apparent that medication is part of the repertoire of interventions
available to treat ASD and PTSD and that the prescription of drugs
in such cases is becoming increasingly refined. It seems most useful
for medical and psychological practitioners to work collaboratively in
planning optimal treatment for clients. Writing from a psychotherapeutic
point of view, Southwick and Yehuda65 provide an interesting critical
reflection about how the prescription of medication may play a role
in the therapeutic relationship and what meaning clients may attach
to this. They stress that therapists need to be both open to the use of
medication and mindful of the impact of the introduction of medication
into an existing therapeutic partnership or treatment regime.
In South Africa it seems that the majority of trauma cases, particularly
ASD cases, are treated by psychotherapists or counsellors, including
professionals and volunteers. It is primarily in cases of chronic or
severe PTSD that psychiatric intervention is introduced (or takes
primacy) or in cases where serious comorbid psychiatric conditions are
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present. Few pure PTSD cases are treated as in-patients and in most
cases medication is managed on an out-patient basis. Psychotherapists
tend to refer clients for psychiatric assessment when symptoms appear
intractable and particularly when anxiety or depressive symptoms
become debilitating. In rare instances, clients being treated for PTSD
may manifest psychotic symptoms and require hospitalisation. For
example, a Rwandan refugee woman who had witnessed the killing
of family members and had been raped in a refugee camp prior to
coming to South Africa, began to describe ‘hearing voices’ and to
demonstrate bizarre behaviour, following an assault in this country,
and required psychiatric referral and hospitalisation. Given the large
numbers of people affected by traumatic incidents in the country, it
is the minority who see psychiatrists, and it is not uncommon for GPs
and traditional healers to be the practitioners who prescribe medical
and physical treatments. In general, there is reasonable collaboration
between medical and psychosocial practitioners with cross-referral
taking place, although there is still some ignorance concerning the fact
that both psychotherapy and pharmacotherapy can be of benefit and
that treatment for traumatic stress generally requires some form of
counselling or psychotherapy.

Group Psychotherapy

There are three main forms of widely used group psychotherapy for
trauma: psychodynamic, cognitive behavioural and supportive.66
Groups are usually offered to people suffering from the same kind of
trauma, for example, rape, combat stress or a terminal illness diagnosis.
One of the difficulties in forming such groups is that individuals may be
at very different stages in the processing of their experiences, but group
treatment is economical and has particular merits. The main benefits
of group psychotherapy lie in the support that such groups can offer
(beyond that of the therapist and existing networks) and the degree to
which they aid in the reduction of stigma by facilitating the sharing of
common experiences and reactions. Normalisation of trauma reactions
is very powerful in group therapy, since members find that they can
identify with others’ accounts. In some cases relational networks are
created that are sustained outside of therapy. In a group conducted
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for asylum seekers traumatised by the 9/11 attacks in New York City.
participants reported that the building of social bonds with others in
a similar predicament was one of the most beneficial aspects of group
attendance.67
While each of the three approaches differs in focus, ‘the ultimate
goal for both psychodynamic and cognitive behavioural group therapy
is for group members to gain “authority” over traumatic material so
that it no longer becomes a dominant factor in their lives’. 68 In contrast,
supportive group therapy is generally present-centred and aimed at
management of everyday issues as well as social and interpersonal skills
development. Research has indicated that all three forms of group
psychotherapy are associated with improvements, with CBT approaches
again demonstrating the most conclusive benefits.69
Alongside these more conventional forms of group psychotherapy
there are a range of other approaches, some of which appear to wax
and wane in terms of popularity. One alternative form of group
psychotherapy that has been offered for several years in South Africa,
initially under the auspices of the National Peace Accord Trust (NPAT),
is what is known as ‘Wilderness Therapy’.70 Originally developed by
two psychologists in conjunction with an ex-member of one of the
township paramilitary structures, Wilderness Therapy for traumatised
groups adapted the principles of eco-psychological, Jungian-oriented,
wilderness therapy to meet the needs of local groups. Selected groups
of trauma survivors are taken into natural areas, such as the Cedarberg
or the Drakensberg, to take part in a ritualised process of self and
group discovery over several days. Amongst other benefits there was
the development of self-reliance and mastery through negotiation of
physically and emotionally challenging tasks; the development of trust
through sharing and team-building processes; and the development of
self-reflection, introspection and meaning-making in the face of time
spent in isolation and against a vast natural backdrop. The physicality
of the therapy is seen as important in that trauma experiences are
understood as being ‘locked in the body’ as well as the mind. ‘The
physical obstacles, challenges, failures and achievements are understood
as impacting directly on, and involving completely, their psychological
equivalents.’71 The programme also draws on notions of the collective
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unconscious and Jungian archetypes and brings all these aspects to
bear in the facilitation of trauma processing. Initially it was primarily
men who had taken part in military and paramilitary structures
during the anti-apartheid struggle (sometimes from opposing political
structures) who took part in the trails. Subsequently the programme
was broadened to cater for adolescents at risk, sex workers and other
marginalised populations, losing some of its narrower traumatic stress
focus.72 Anecdotal reports indicate that there is considerable benefit
for both individuals and communities ensuing from such programmes.
In some respects this more ritualised form of healing parallels reports
of the use of American Indian Sweat Lodge practices in the treatment
of Vietnam War veterans. It is argued that traditional practices geared
towards taking community members through rites of passage can
be adapted to take traumatised groups through some sort of trauma
cleansing, healing and transcendence process.
Other alternative forms of group psychotherapy draw on creative
and active participation models. For example, there is a form of
psychodrama specifically oriented to trauma work offered by the Spiral
Therapy group that involves using trained team support in the group
enactment of trauma. Some Spiral Therapy trainers visited South Africa
a few years ago to demonstrate and train NGO members in the method,
but the approach does not seem to have taken off widely, despite the
fact that enactment of trauma seems to be a natural form of facilitating
catharsis and working through. There are also trauma healing groups
involving collective creative activities, such as the production of art
work or the workshopping of short plays for performance. South
African counsellors and community members have shown considerable
innovation in this regard, in part out of necessity and in part out of
recognition of the richness of local cultural resources. Many of these
innovative approaches are not widely documented and one of the tasks
of the National Network of Trauma Service Providers set up in the
late 1990s, known as Themba Lesizwe,73 was to gather and document
the range of treatment approaches being used in the country and to
establish guidelines for best practice. Unfortunately the network has
been terminated due to lack of funding but the capacity for creative
intervention development continues. This is seen, for example, in
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the range of group psychotherapeutic interventions that have been
developed to work with issues associated with HIV and AIDS.
In addition to the formally constituted groups (both conventional
and alternative) facilitated usually by at least one or two professional
therapists, there are forms of trauma therapy that make use of peer
support and networks. One such organisation in South Africa is
‘Compassionate Friends’, a group set up to support people suffering
from bereavement related to the loss of a child, usually under traumatic circumstances. The network is made up of similarly bereaved
people who hold group meetings and also offer one-on-one support.
The organisation’s underlying philosophy is that people with similar
experiences who have had time to work through their trauma and
bereavement may be well placed to assist those who are newly
traumatised. There is a similar support network for women recently
diagnosed with breast cancer, also staffed by breast cancer survivors.
Self-help or peer support groups have also been established by excombatants in South Africa and by survivors of human rights violations
in the form of the organisation known as Khulumani.74 Friedman75
observes that because of its non-professional roots, peer counselling has
not been well researched, but comments that ongoing involvement in
such structures and initiatives suggests that those that flourish must have
benefit for participants. Given the constraints to offering professional
assistance to the South African population as a whole, self-help
initiatives for trauma survivors are a welcome addition to overstretched
state and NGO services, provided they are ethically managed. Many of
these peer support groups make use of professional input on an ad-hoc
basis or are supported free of charge by professionals as a social service
to the community.

Common Mechanisms and Best Practice

The discussion of individual and group therapy for traumatic stress has
covered considerable ground. At this point it might be helpful to offer
a short discussion on what aspects of psychotherapy have generally
been found to be beneficial or form part of what has become known as
‘evidence-based practice’ or ‘best practice’.
There is generally consensus amongst trauma treatment service
providers that the establishment of a strong, trustworthy therapeutic
relationship is crucial to the success of therapy. In addition:
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Regardless of the type of psychotherapy used, certain elements
of psychotherapy are especially important in engaging and
maintaining patients in treatment of PTSD, such as establishing
a strong therapeutic rapport, confronting denial, setting limits
for behaviours such as substance abuse and self-injurious acts,
and emphasizing the ‘here and now’ as well as processing the
trauma.76
This quotation summarises some of the important elements in creating
what could be termed the ‘frame’ or context within which effective
psychotherapy can take place. Assuming the establishment of a good,
containing, hope-instilling therapeutic relationship, research into
different modalities has established that some aspects of therapy
appear to be particularly beneficial in terms of specific symptoms.
‘Overall the most highly recommended psychotherapy techniques
are anxiety management, cognitive therapy, exposure therapy and
psychoeducation. Play therapy is recommended for children. The
experts reported three preferences for treating specific PTSD symptoms:
Exposure therapy for intrusive thoughts, flashbacks, trauma-related
fears, and avoidance; cognitive therapy for guilt and shame symptoms;
and anxiety management for hyperarousal and sleep disturbances.’77
Psychoeducation is an important supplementary therapeutic mechanism
but is generally not viewed as a sufficient treatment in and of itself.78
In general it is also well established that psychotherapy is beneficial
in the treatment of psychological trauma and PTSD. ‘A meta-analysis
of controlled clinical trials of psychotherapeutic treatment for PTSD,
including cognitive behavioural and psychodynamic modalities, in
both group and individual settings, demonstrated significant reduction
of symptoms with no decay in effects on follow-up (Sherman, 1998).’79
Tucker and Trautman80 also go on to summarise the findings of a study
conducted into the progress of 459 people with PTSD, indicating
that psychotherapeutic treatment significantly reduced the duration
of PTSD in this group. It is generally widely accepted then that
traumatic stress conditions are amenable to psychotherapy and that
a range of interventions offer established benefit. This having been
said, it is important to raise some further contextually relevant issues
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that influence the practice and provision of trauma treatment in South
Africa. These considerations reflect both caveats to accepted wisdoms
about trauma intervention and special contributions that South African
practitioners have made to the trauma field, spurred on by fairly unique
contextual demands.

Treatment of Multiple and Continuous Traumatic Stress

An element that characterises much trauma work in South Africa is the
fact that large numbers of clients suffer multiple traumatisation, being
subject to a range of different traumatic events in their lives.81 Alongside
this is the fact that the recovery environment is often perceived as still
dangerous and in reality may well be so. At the outset of the chapter it
was emphasised that the creation of safety is almost a precondition for
the introduction of trauma-focused psychotherapy. The provision of
containment and stabilisation as essential for therapeutic benefit was
reiterated in a number of subsequent sections, for example in relation
to debriefing and self-psychology models of intervention. In South
Africa, the establishment of this kind of safe, holding environment
is sometimes not feasible, since, as noted in Chapter 3, many South
Africans live in situations of continuous trauma exposure. Thus, many
trauma survivors who present for treatment face the real prospect
of future victimisation and cannot easily escape dangerous living
circumstances. This is in part because of generally very high levels of
violence in particular communities, but also because of inefficiencies,
corruption, lack of capacity and lack of resources in the criminal justice
system. To describe a case in point, a woman in her early twenties who
had reported her rape by a taxi driver to the local police station found
that initially her case report went missing. After making a second report
her family home was visited by three associates of the taxi driver who
threatened to assault family members if she did not withdraw the case.
At the time of coming for counselling she had relocated to live with
a friend in town but was afraid of being followed from her place of
work and particularly concerned about the safety of her grandmother
who reported a man loitering across the street from the family home.
Such reports are not uncommon. During ongoing taxi route and drug
dealing territory disputes there may be several assaults and murders,
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attacks on property and on family members, with those indirectly and
directly involved feeling little sense of safety. Asylum seekers from other
African countries are particularly vulnerable to continuous traumatic
stress, with the prospect of xenophobic attacks, muggings and police
raids on places of accommodation. One refugee client has reported
three rapes or sexual assaults since coming to South Africa, in part,
because of living a precarious existence on the streets of a major city. It
is also not infrequent for clients to bring new traumatic experiences that
have taken place during the course of psychotherapy to counselling, in
one case a mugging that had just taken place on the way to therapy.
Such accounts and client circumstances can be rather overwhelming
for counsellors who may question whether there is any benefit in
offering services in such circumstances, given the cardinal issue of
safety in treatment. However, such clients also often desperately need
support and look to counselling to help sustain them through such
difficult experiences. See Box 5.1 for the findings of a recent study82
into observations concerning the counselling of refugee clients in South
Africa, many of whom could be viewed as continuous traumatic stress
cases.
Straker and the Sanctuaries Counselling Team,83 who developed the
concept of ‘continuous traumatic stress’ in the context of their work
with political activists, recognised that they had an important role
to play for the traumatised activists who sought out their assistance,
but also realised that their therapeutic input needed to be tailored to
take account of their particular circumstances. Many of the principles
informing their intervention still have bearing for working generally
with clients in non-containing or risky environments. Although it is not
possible to do justice to the full content of Straker et al.’s84 article on
continuous traumatic stress, some important features are highlighted.
Recognising that clients in this kind of circumstance might not be
predictable in their attendance of therapy it is proposed that every
session be treated as a potentially stand-alone intervention. Trust may
need to be rebuilt at each new appointment and sessions should be
terminated or ‘closed’ with particular care, ensuring as far as possible
that the client feels adequately contained and able to operate in the
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Box 5.1
Therapeutic issues in working with African ‘refugee’ clients in South Africa
Grootenhuis (2006) conducted a qualitative research study83 into counselling
services for refugees by interviewing four refugee clients and four therapists
who had worked with refugees at the CSVR about their experiences. The
focus was on what had been found to be beneficial, where difficulties had
been encountered and what particular dilemmas psychotherapists faced in such
work. The following dilemmas were commonly reported by the therapists:
Therapist dilemmas
(1) Therapists had difficulty in straddling supportive and exploratory
therapeutic objectives and interventions given the unstable living
conditions of asylum seeking clients.
(2) Therapists found existing trauma therapy models either inadequate or
overly rigid for work with such clients.
(3) In diagnosing clients, therapists experienced difficulty in distinguishing
between personality and situational dimensions, particularly with respect
to anxious, depressed and paranoid presentations.
(4) Therapists experienced role conflict with respect to potentially
contaminating the therapeutic alliance in feeling compelled to offer
clients practical and social support.
(5) Role conflict contributed to a lack of team cohesion and feelings of
inadequacy.
(6) The powerfully dependent transference of refugees was experienced as
burdensome.
(7) The truthfulness of clients’ accounts was sometimes in question given
refugee perceptions of therapists’ capacity to influence decisions about
their status and potential resettlement, creating some difficulties in
terms of relational congruence.
(8) Therapists had strong counter-transference feelings about the
victimisation and lack of institutional support faced by refugees in South
Africa, including feelings of guilt, anger, frustration, despondency,
anxiety and shame by association.
(9) Therapists found such work physically tiring.
(10) Therapists found reward in being of some assistance and in witnessing
the resilience of refugee clients.

context they return to. The therapist may also allow for the extension
of the time of sessions beyond the conventional hour.85
Straker et al. argue that therapists need to recognise that, in general,
the client’s defences should not be tampered with as they are necessary
for ongoing survival. At the same time it may well still be important to
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assist the client to process traumatic experiences by talking about them.
This discussion of events should as far as possible be restricted to factual
and cognitive aspects, consciously steering away from emotional, sensory
and physical associations. A strong focus of the therapy should be on
coping resources and the mechanisms that clients can employ to manage
their fears and the real threats in their environment. The therapist may
help the client to distinguish as far as possible between real and imagined
threat, as opposed to potential risk (in other words, the enhancement of
discriminating capacities). Realistic fear and distress is not minimised
and survival strategies are explicitly explored. The therapist attempts
to hold realistic hope for the client. At the CSVR, therapists talk about
helping the client to find ‘islands of safety’, representing mental spaces
that feel uncontaminated by daily stressors. Such mental spaces may
be achieved through training in relaxation techniques, guided fantasy,
prayer or taking part in particular activities (such as playing sport or
attending a religious ceremony). In CBT terms, it could be argued that
much greater weight is placed on anxiety management, as opposed
to exposure techniques, with cognitive restructuring work oriented
towards realistic appraisal and acknowledgement of what internal and
external resources are available for coping with potential threats. Such
psychotherapy might also be subsumed under the label of ‘supportive
psychotherapy’. However working with continuous traumatic stress
may call for some engagement with traumatic material as discussed
above, as opposed to restricting work to everyday issues. The aim of
such interventions may well be modest, such as the emotional ‘holding’
of the person in the situation and the prevention of the development of
serious pathology, such as major depression, dissociative conditions or
psychotic breakdown.
In addition to their therapeutic role, therapists may find themselves
taking on advocacy roles, becoming involved in assisting clients
to relocate or to better access the criminal justice system and other
formal systems of protection. This has implications for the therapeutic
relationship and therapist capacity that need to be carefully thought
through, but the adoption of advocacy roles may feel more congruent
for therapists in such contexts.86 With such explicit understandings in
mind, therapists may be able to continue to intervene without feeling
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completely de-skilled or helpless. While such demands have been
strongly characteristic of much trauma intervention in South Africa, it
is apparent that most contexts of civil conflict, war, political repression
and endemic community violence, throw up similar challenges and
have produced similar observations about how to promote resilience
in such circumstances.

Traditional / Indigenous Practices

A further interesting and somewhat unique aspect of trauma
intervention in South Africa is the fact that traditional African healers
play a significant role as traumatic stress practitioners. We have seen in
Chapter 4 that individuals seek to make meaning of traumatic events
and that such meaning is often socially and culturally located. For
example, we noted that in traditional African belief systems misfortune
is generally viewed as caused by some agent or set of events, rather
than as purely accidental. At the risk of over-generalisation, traumatic
events are often understood to stem from either human or ancestral
agency, particularly when multiple misfortunes have occurred, and
two common explanations offered for misfortune are bewitchment
and displeasure on the part of ancestors.87 If such cultural attributions
for traumatic events are dominant for an individual, they are likely to
seek the assistance of a traditional practitioner who may help identify
the source of the troubles and prescribe certain medicines, practices
or rituals to overcome the adversity. For example, in the case that
misfortune is attributed to disrespect of ancestors it is very common
for clients to be instructed to perform some kind of ritual slaughter of
an animal. It is often suggested that the trauma will remain unresolved
and further misfortune follow, in the absence of such rituals. Given the
powerful impact of trauma, it is not unusual for westernised African
people to entertain more traditional beliefs when they attempt to
make sense of such events. It is therefore important that therapists
take account of such belief systems and are open to the fact that
many African people not only consult traditional practitioners as their
healer of choice, but also that some clients may use ‘westernised’ and
traditional services concurrently. In many instances such treatment is
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complementary but psychotherapists may sometimes be called upon to
negotiate tensions between different explanatory frameworks.88 It is also
worth reiterating that traditional healers represent a significant group
of trauma interventionists in South Africa, albeit that their treatment
appears to differ quite strongly from western therapeutic approaches
and has not been subject to scientific validation.89

Social Alienation as a Product of Traumatisation

One of the other features that many trauma practitioners have observed
in South Africa is that traumatised individuals often tend to become
increasingly prejudiced, alienated and critical of government and
society in general. Victims of crime, in particular, perceive a lack of
capacity or even a lack of will on the part of the criminal justice system
to protect them, to curb crime and to apprehend and punish offenders.
This perception in turn appears to contribute to disillusionment,
hopelessness and depression that extend beyond conventional trauma
symptomology, as well as to retributive acts and vigilantism. In some
instances, disinvestment leads to emigration or relocation. A very
common response amongst trauma survivors is an increase in racism
or inter-group prejudice.90 Following counsellor observations about
the difficulty of engaging with the extremity of racism and prejudice
that commonly emerges in trauma counselling in South Africa, Benn91
undertook research with victims of violent attacks who volunteered to
be interviewed about self-observed alterations to their race or groupbased attitudes, including the entertainment of xenophobia, anti-black
and anti-ethnic sentiments. A number of these interviewees (both
‘black’ and ‘white’) volunteered that they had experienced extreme
feelings of anxiety, fear, anger, hatred, suspicion and mistrust towards
groups of people who they associated with their attackers, consequent
on their traumatisation. They had also found themselves entertaining
increasingly negative stereotypes about such groups of people,
including ideas that they were inherently violent, cruel, inhumane,
primitive, animal-like and dangerous. For victims who had previously
held liberal or anti-racist positions such alterations to their schemas
were very uncomfortable. These ideas and sentiments often surface in
psychotherapy and present ethical, technical and counter-transferential
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dilemmas for psychotherapists.92 Counsellors and therapists struggle
to know how to engage with such content. Given the extremity of
traumatisation and frequently regressed presentation of traumatised
clients, it may feel uncontaining and counter-therapeutic to explore
and challenge such material. Therapists are trained to respect client
autonomy, including the respect of a client’s value system and may see
such intervention as a form of consciousness-raising exceeding their
brief as psychotherapists. Nevertheless it is possible to understand such
alterations to attitudes as a pathological response to trauma, either in
terms of stimulus over-generalisation or more complicated unconscious
defensive processes of splitting, projection and displacement, and
therefore to understand it to be a therapeutic imperative to intervene to
change such responses if possible. In two related studies investigating
how non-professional trauma debriefers93 and psychodynamicallyoriented clinical psychologists94 work with negative racial sentiments in
traumatised clients in practice, both groups volunteered that they felt
some personal discomfort not only in listening to such material but also
in knowing how to separate out their own feeling or countertransference
responses in order to appreciate how and when to intervene. Working
with such prejudice and the disillusionment, social alienation and
negativity described earlier, places considerable pressure on local
psychotherapists. Such responses to trauma are clearly contextually
informed and reflect responses to a transforming society in which
social institutions and the nature of government have changed rapidly
and dramatically over the past decade against a backdrop of a prior,
shameful history of racial oppression. However, it could be argued that
the world is rapidly transforming and there is clearly evidence of this
kind of group prejudice occurring in response to violence in other parts
of the world, such as the anti-Arab prejudice that has developed in
response to the 9/11 attacks in America and the bombings in England
in 2007. Contemporary trauma therapists are required to be reflective
about their own values and sometimes to interrogate accepted wisdoms
in responding to this ‘politicised’ element of trauma intervention. South
Africa therapists may be well placed to lead the way in thinking through
how to engage with such trauma responses.
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Box 5.2
Negative racial sentiments amongst traumatised clients: observations and
therapeutic implications
Case Example
In a study conducted by Benn in 2007, a woman who had been robbed and
threatened, and whose husband had been shot and killed by a group of house
breakers reported that her attitudes had altered in the following way:
I have always been very trusting and very comfortable, you know, I do not
think that I would have behaved any different in a crowd situation with black
people or white people. I would expect a white kid to pickpocket me just as
readily as I would expect a black person to grab my handbag. I avoid them
now, the idea of any physicality with them is like ‘yuck’, disgust … and I do
have a different perception of common everyday people I might encounter.
I see the potential now for black men to be ruthless, callous and definitely
not to live by the same human rules as I am and the abiding mass of people
are. Okay. One change for me is that I now see the potential for damage and
harm and danger in every black man I see.
Recognising the complexity of such a presentation in a context such as South Africa,
it is nevertheless possible to see how the regression and traumatisation associated
with violent attack or threat of attack leads to the employment of defences such as
othering, distantiation, displacement, projection and splitting. There is clearly also
evidence of over-generalisation and the surfacing of categoric and stereotypical
ways of thinking. It is apparent that this victim of trauma remains imprisoned in
a fearful world in which it is difficult to distinguish the good people from the bad
people, and crude markers (such as skin colour) then become salient. Despite having
received some trauma counselling it appears that her anxiety levels associated with
the presence of black men are still very high and that the changes to her belief
system or schemas are somewhat enduring. This poses questions as to how to work
therapeutically with such material.
Therapists’ Reflections
Therapists and counsellors indicated that they frequently encountered such kinds
of sentiments in traumatised clients, often expressed with considerable intensity
in early sessions in counselling. In Fletcher’s 2007 study, it appears that therapists
make informal assessments concerning, for example, how regressed the client is and
whether they are still in the impact phase or have moved beyond this, whether the
sentiments appear to be ego-syntonic or ego-dystonic in terms of client discomfort,
whether there is an alteration to or a solidification of prior attitudes, whether the
client has adequate support outside of therapy and how strong the therapeutic
alliance is. This informs the decision as to whether it is appropriate to use a more
challenging as opposed to a more reflective intervention (with concern in the latter
case not to appear to legitimate prejudice).

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I generally don’t address racist material in therapy with a client who has been
through a trauma. Often in the first week or two or three that will come with
a lot of racism; a lot of anger is expressed in racism, the injustice of trauma is
expressed in racism, but often that abates as part of the process of working
through the trauma. I don’t find that one necessarily has to address it directly.
(Therapist 2)
When they decide to intervene in more challenging ways, therapists then generally
chose one of two approaches. They may locate the prejudice at the level of a symptom
and employ psychoeducation to reduce polarisation and over-generalisation.
On a level it is part of the desensitization process. Not everybody is a
criminal. Not everybody of that race is worse than someone of another race.
(Therapist 5)
Alternatively, psychodynamic therapists in particular might work more interpretively,
linking such virulent content to underlying feelings of helplessness, rage and
impotence.
If I am working with a client long term, it is all about the internal world, how
do I relate? What their object relations are like, whether they have punitive
objects because then often those prejudices are a way of making the self feel
better in the world. Inevitably if you take them there, there is a very helpless,
powerless, insecure child that you are dealing with. They were raised in a
world where someone had to be the baddy. If I don’t look like that then at
least I have some good, at least I have some value. (Therapist 1)
Therapists recognised their own ambivalences in engaging with such material and
the fact that, if left untreated, such elements of trauma impact may have not only
personal but also societal consequences.
A person who is using primitive defences can actually be horrible to other
people whether it is racist or whether it is just that they have got these bad
objects and they hate them. If you look at a whole society doing that, the
cost of it is huge, there is war. (Therapist 6)
It thus seems that careful attention to such material in therapy is important in the
prevention of further spirals of violence, racism and prejudice and that therapists
have moral as well as technical obligations and choices to make in this regard.

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Community Interventions, Rituals And Memorials

A chapter covering traumatic stress treatment and intervention in South
Africa would not be complete without some discussion of communitylevel interventions. While the subject of community interventions could
comprise a chapter on its own, this sub-section provides some orientation
to this level of input. Some aspects of community-level interventions
have been discussed in the earlier section on group interventions,
particularly the psychosocial aspects of such intervention. Wilderness
therapy aimed at selected participants from communities in conflict
could also be understood as a community intervention in some respects.
However, it is important to recognise that some trauma interventions
are targeted at large groups of people forming communities of various
kinds, rather than at individually traumatised people within such
groups. The indirect effects of traumatisation on the social networks
of direct victims have been recognised, as has the fact that traumatic
events often tear apart the social fabric of communities. Interventions
are usually designed to collectively mark and mourn what has been lost
and to recreate some sense of social cohesion.
Meintjes95 describes such a community intervention project aimed
at healing the trauma of communities affected by the extreme political
violence that took place between African National Congress (ANC)
and Inkatha Freedom Party (IFP) supporters in the period leading up
to the first democratic elections in 1994. She documents the difficulties
encountered in entering and gaining credibility in such communities in
the face of very high levels of mistrust. She also describes the necessarily
multi-faceted nature of such intervention, including occupational skills
development, inter-group mediation, and psychoeducation, in addition
to holding groups that were overtly therapeutic in orientation. It is
apparent that a range of community practice skills is necessary for
effective trauma intervention in such situations.
In addition to its other objectives, the South African TRC was
intended partly as a trauma healing intervention at the level of
communities and the nation as a whole. ‘Despite its shortcomings,
the process served as a public acknowledgement of the political and
social nature of the context in which atrocities were committed and
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individuals traumatised, and an impetus to create a new future in which
racial conflicts would no longer result in tragic and needless conflict.
The significance of the TRC as a social process towards healing has
been widely acknowledged.’96 At a social level, in keeping with aspects
of individual trauma therapy, it was hoped that the surfacing of difficult,
painful and horrific material would allow for collective catharsis and
avoidance of suppression and repression of historical atrocities. This
idea was complemented by an expectation of public and collective
censure and apology as grounds for potential reconciliation. There
have been numerous evaluations of aspects of the TRC with mixed
findings about its ostensible strengths and weaknesses.97 Nevertheless,
as a model for reconciliation in previously conflict ridden societies, it
has been drawn upon to inform similar processes in countries such as
Northern Ireland, Rwanda and Sierra Leone. The TRC epitomises a
societal level trauma intervention.
One of the outcomes of the TRC was restitution of both a material
and symbolic nature. At a symbolic level, monuments have been erected
to struggle heroes, and streets and geographical areas have been named
after such individuals. Such initiatives represent further collective
approaches to heal trauma through remembrance and homage. Such
social symbols or markers have existed since time immemorial around
the world, such as the tomb of the ‘unknown soldier’ and the many
monuments and gardens of remembrance commemorating war victims.
The declaration of 16 June as a public holiday in South Africa, recognising
the tragic sacrifices made by Soweto school children in foregrounding
the struggle against apartheid, is a further example of such social
memorialisation. Public rituals on such days of remembrance serve to
pay respect to those who suffered traumatisation and to emphasise the
need to prevent future such tragedies through community solidarity and
mindfulness of the implications of conflict. While trauma practitioners
may not be directly involved in initiating healing at these kinds of metasocial levels, they may play a part in the discursive construction of such
events and in optimising social healing.
It should be evident that there are many interlinking tiers of
intervention for traumatised individuals, families, groups, communities
and populations, and that individual healing often needs to be complemented by broader interventions and vice versa.
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Conclusion

In concluding this chapter on trauma interventions, it is perhaps worth
making mention of one more aspect and that is to note the impact
of trauma work on practitioners. It is widely accepted that traumatic
stress counselling is emotionally taxing for psychotherapists, evoking
strong feelings and resulting sometimes in vicarious traumatisation,
compassion fatigue and powerful countertransferences.98 Volunteer
counsellors may be at even more risk than professionals, given a lack
of awareness of warning signs and potentially toxic effects. Self-care
strategies, regular supervision, group support, time for debriefing and
collective reflection are all useful in managing responses to such work.
It has also been suggested that therapists might experience what could
be called ‘vicarious resilience’ in doing trauma work as they bear witness
to how traumatised people manage to survive and even transcend such
life shattering experiences.
Despite some poverty in professional resources, South Africa has
a strong trauma intervention history with evidence of considerable
innovation and creativity. Given the importance of trauma treatment
in trauma recovery, it is essential that services are maintained and
expanded where possible. In agreement with Edwards,99 it is also
important that therapists research and document their practices so that
ever more credible bases for intervention are consolidated.

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Chapter 6

TRAUMA AND CHILDREN

A

ny book on traumatic stress in South Africa would be incomplete
without attention to the traumatisation of children. Exposure to
traumatic events is not restricted to adults who operate in the world
outside of the family or home and it is common cause that children
(ranging from infants to adolescents) are vulnerable to trauma stemming
from exposure to a broad spectrum of events. Children in many instances
are both direct and indirect victims of trauma and are frequently
witnesses to violence enacted between adults in their environment.
While children may have a range of coping capacities to deal with
extreme stressors, the fact that aspects of their bodies, minds and brains
are not fully developed means that they are often particularly vulnerable
to the impact of trauma. In addition, they need to invest psychological
resources in mastering normative developmental tasks and attempts
to manage traumatic events may impede such development and lead
to considerable strain. Many studies have shown that the impact of
trauma at early stages of development can have a long-lasting impact on
personality formation, behaviour and mental health. For example, it is
now well established that adult abusers more frequently report having
suffered abuse in their own childhoods than non-abusers.1 A South
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African-based study found that, along with several other conditions,
exposure to traumatic life events and childhood PTSD were associated
with the increased likelihood that the individual would not complete
high school education.2 Trauma in childhood may thus have both more
immediate as well as long-term effects.
While children present with trauma responses that in many respects
parallel those of adults, their response to traumatic incidents is strongly
determined by their developmental stage and capacities. Thus anyone
assessing or intervening with traumatised children needs to have a good
understanding of normal developmental patterns.

Prevalence of Trauma and Posttraumatic Stress in Children

It is difficult to establish what percentage of children are exposed to
traumatic events and just how many become disturbed as a consequence
of this, given some of the problems in assessing exposure and levels
of distress across situations and countries. Trauma exposure, for preschool children, for example, is unlikely to come to the attention of
outside authorities unless parents or caregivers report such exposure
on behalf of the child. It is clear that the more violent and conflicted
any society, the more children will be exposed to extraordinary life
stressors. Given the history of strife in South Africa and the elevated
crime and accident levels discussed in Chapter 2, it is to be anticipated
that trauma exposure levels for South African children are high. Indeed,
several studies of school-age children in South Africa have indicated
that exposure to what might generally be considered extraordinary
traumatising events, is actually normative in certain contexts. In a study
comparing levels of exposure to traumatic events amongst South African
and Kenyan youth, it was found that 80 per cent of these adolescents
had been exposed to severe trauma at some point in their lives, either
as direct victims or as witnesses.3 A South African study conducted in
Cape Town found that fifty-seven of the sixty children assessed (thirty
school children from a violent area and thirty from a children’s home
in Khayelitsha) had witnessed violence and thirty-four had experienced
violence themselves.4 Another survey of 185 children at five township
schools in Cape Town also found an extremely high rate of exposure
to violence: 73 per cent of the children had witnessed someone being
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beaten up, 57 per cent had seen someone being attacked with a sharp
weapon, 45 per cent had witnessed someone being threatened with
a gun and 35 per cent had witnessed someone being killed in their
neighbourhood.5 Even in a survey of youth at private schools in Cape
Town, trauma exposure levels were high, with 30 per cent reporting that
they had been violently assaulted by a stranger and 48 per cent reporting
an assault by someone known to them.6 A further study conducted in
a ‘high-violence’ area in Cape Town found that amongst the Grade 6
children assessed across five schools, well over half (68.44 per cent)
reported exposure to violence either as victim and/or as witness.7
And it is not only children in urban settings who are exposed to high
levels of violence: a study of 148 children in a rural community in the
Northern Province found that 67 per cent had experienced a traumatic
event, either directly or as a witness.8 These studies collectively suggest
that by adolescence easily half the population of children in South
Africa may have been exposed to a traumatic event either as a witness
or direct victim. It is thus important to understand what the impact of
such exposure might be and what scope there is for both preventive
and secondary intervention.
While there are no groups of children who are necessarily exempt
from trauma exposure, levels of exposure do appear to differ in relation
to demographic features such as gender, race and class, and in relation
to socio-political and historical circumstances. For example, ‘minority’
male youth in America seem to be exposed to more violent crime than
their counterparts9 and in the previously cited study comparing South
African and Kenyan adolescents,10 the Kenyan youth interestingly
reported significantly higher levels of exposure to witnessing violence
and physical and sexual assault, suggesting context-related differences
in life circumstances. Some historical events clearly place large numbers
of children at risk, such as wars, civil conflicts, genocides and mass
displacement of people.11 In countries at war, children become both
direct victims of violence, as in the much publicised case of the child
burn victim in Iraq, or indirect victims, in the sense of witnessing
combat and conflict related atrocities. Children’s lives are often further
disrupted by family instability and the breakdown of health and
educational structures. Children may also become orphaned, displaced
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or separated from families in the aftermath of major conflicts and there
are large numbers of refugee children living in camps in many parts of
Africa, some of these unaccompanied minors. Thus traumatic events may
have effects beyond immediate shock and traumatisation, powerfully
affecting the subsequent context within which a child continues to
develop, and in this respect it is difficult to do justice to the full impact
of traumatic events within the kinds of diagnostic systems available.
For example, two little girls who had witnessed their abusive father
beat and stab their mother to death were sent to live with relatives,
having to then cope with traumatic bereavement, the incarceration
of their father, and the adjustment of living in a new household with
relatives who were traumatised themselves and felt over-burdened by
the responsibility of taking care of them.
As discussed in Chapter 3, in relation to adult populations, children
exposed to traumatic stressors may not always present with difficulties
that can be categorised within the framework of ASD or PTSD. As
will be discussed further later, children may show their distress in
the form of physical symptoms, depression, anxiety, school problems
and developmental difficulties, amongst others. When the impact of
trauma is compounded by ongoing related difficulties, for example, the
adjustment to living with relatives as in the case just mentioned, it may
become difficult to separate out where the effects of a trauma begin
and end for a particular child.
Bearing this difficulty of categorisation in mind it is still useful to look
at some figures for those children who do meet diagnostic criteria for
PTSD or other psychiatric disorders. Studies of different populations
of traumatised children have found varying prevalence rates, some of
these of considerable concern. In a fairly recent study looking at the
impact of military violence on Palestinian children aged from six to
sixteen years it was found that 54 per cent of the children appeared to
be suffering from severe PTSD and 33.5 per cent from mild PTSD.12
Thus, in this context of ongoing conflict, the majority of children were
symptomatic. On the other hand, in examining the impact of a natural
disaster, in the form of a hurricane, on a population of school-going
children in America, the number of children meeting PTSD diagnostic
criteria was just over 5 per cent.13 A study conducted in Australia on
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children admitted to hospital after a traumatic injury found ASD in 10
per cent and PTSD in 13 per cent of these children14 It is apparent that
different stressors are more or less likely to cause significant levels of
symptomatology amongst different groups of children. It seems that one
factor may be the issue of whether events are accidental or deliberately
inflicted and, as with adults, it appears that human-inflicted trauma
may be more likely to produce disturbance in children and adolescents
than traumas of natural or non-human origin.15
In South Africa, several studies have documented levels of distress
in traumatised children. In the late 1980s and early 1990s, most of this
research focused on assessing the consequences of political violence
and civil unrest in the last years of apartheid. These studies relied largely
on indirect means of assessing traumatic distress among children, such
as parent or teacher observations of PTSD symptoms or the content
of the drawings of very young children,16 or else drew on in-depth
interviews and case studies.17 Findings from these studies indicated that
a high percentage of younger children experienced various symptoms
of posttraumatic stress, while older youth exposed to chronic political
violence frequently presented with difficulties related to substance
abuse and aggression.
Although political violence is no longer prevalent, we have seen in
Chapter 2 and earlier in this chapter that many South African children
continue to live in conditions of both domestic and community violence
With the increasing availability of standardised measures for PTSD and
other disorders in children in the past decade, more recent South African
studies have been able to document the psychiatric impact of childhood
trauma more precisely. In the 1997 study conducted in Khayelitsha,
which utilised a structured PTSD questionnaire, a psychiatric diagnostic
interview and a semi-structured clinical interview, it was established
that 40 per cent of the sixty children assessed manifested symptoms
consistent with some kind of DSM diagnosis and 21.7 per cent met
the criteria for PTSD.18 In the comparative study between Kenyan and
South African adolescents referred to earlier, a standardised self-report
measure of PTSD found that 22 per cent of the South African sample
were at high risk for meeting the criteria for PTSD whereas only 5
per cent of the Kenyan pupils displayed symptoms consistent with the
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diagnosis, despite the fact that Kenyan adolescents reported higher
levels of exposure to violence than their South African counterparts.19
A study assessing psychopathology amongst a group of ninety-seven
adolescents and children who attended a Youth Stress Clinic in South
Africa found that 53 per cent reported sexual abuse and 63.8 per cent
of these abused children presented with PTSD.20 Some other studies
of posttraumatic symptoms among school-age children in South Africa
have yielded lower rates of risk for PTSD (such as 8 per cent in the study
of children in the Northern Province21 and 6 per cent of adolescents in
the study of private schools in Cape Town22). In addition to PTSD,
symptoms of depression, aggression and anxiety have also been found to
be associated with exposure to trauma among South African children.23
An important finding from a longitudinal study with over 600 South
African children is that, for all children regardless of gender or income
level, indirect exposure to violence (through witnessing and hearing
about it) produces effects very similar to those that result from direct
victimisation.24
Although the relationship between AIDS and traumatic stress
is still under considerable debate, the loss of a parent or parents to
AIDS is clearly a serious stressor that is affecting increasing numbers
of South African children under the age of eighteen, with estimates
of 1.15 million maternal orphans by the year 2015. Research into the
psychological well-being of sixty Cape Town-based African children
orphaned by AIDS indicated that ‘73 per cent scored above the cutoff for Post-traumatic Stress Disorder’.25 This same study also cites
research indicating that amongst a group of Congolese AIDS orphans
the PTSD prevalence was 39 per cent.
It is apparent that exposure to traumatic events is a serious problem
for South African children and youth and that some child populations
in the country are at significant risk for the development of PTSD
and other disturbances. While some of the worst effects of apartheidera policies and practices on children (including overt forms of state
repression and separation from migrant parents26) may no longer be
affecting child populations, it is clear that there are other both new and
old forms of trauma exposure that currently play a role in the lives of
South African children. These include exposure to criminal and family
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violence, injury in motor vehicle accidents, high levels of sexual abuse
and child rape, and the impact of AIDS.27 All of these features of South
African society, as discussed previously, create particular patterns of
traumatisation and vulnerability.
Having established that children and adolescents are indeed amongst
the victims of traumatic events in all societies, including in South Africa,
and that varying and often high proportions of such children are at
risk for the development of pathology, it is useful to perhaps make
three further observations concerning prevalence and diagnosis. The
first noteworthy observation is that across a range of research studies
it appears that girl children, like their adult counterparts, appear to
be generally more vulnerable to the development of traumatic stress
symptoms and also that younger children may, similarly, be more at
risk.28 However, developmental issues will be discussed further later
in the chapter. The second issue worth noting is that because of their
limited verbal and reading ability it is difficult to assess the impact of
traumatic events on very young children and researchers are generally
obliged to rely on the observations and reports of caretakers in such
cases. Generally trauma in children is assessed by means of interviews,
self-report measures, caretaker reports and sometimes projective
tests.29 Some of the differences in findings as regards prevalence rates
for PTSD across different populations are a consequence of using
different measures and different cut-off points. School-going children
are easier to access and study than younger children. Thirdly, it is
worth emphasising that children can be exposed to both acute and
chronic traumatic stressors and that, as with adults, these two ‘types’
of traumatisation may produce different outcomes. In addition to the
kinds of traumatic incidents associated with sudden, unexpected or
catastrophic events, children are also exposed to other more chronic
destructive forces. These include most significantly physical and
sexual abuse by parents, family members, family associates, teachers,
care takers or acquaintances. Such abuse is often ongoing or involves
multiple exposures, that is, the same traumatising experiences happen
repetitively. This kind of chronic traumatic exposure is generally
understood to evoke different kinds of responses and symptoms from
once-off traumas. ‘Among the symptoms found in children following
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traumas that are not included in the DSM-IV, PTSD diagnostic criteria
are affect dysregulation, somatisation, loss of beliefs, dissociation,
self-destructive behaviours, loss of faith in authority or adults, and
unrelenting hopelessness.’30 These kinds of symptom patterns are more
common in child victims of prolonged traumas and parallel the kinds
of conditions described as complex PTSD in adults, as discussed in
Chapter 3 and further in the following section of this chapter.
From the discussion of prevalence of trauma exposure and
symptomatology in a range of studies it is clear that children are
vulnerable to PTSD, but this does not necessarily give a full picture
as to how children who are traumatised might show their distress. The
next section offers a more in-depth discussion of the presentation of
traumatic stress in children.

The Impact of Different Forms of Trauma on Children

One of the trauma theorists who has researched and written about
children over a considerable period of time is Lenore Terr. In an
important paper she wrote in 1991 entitled Childhood traumas: an
outline and overview,31 she presents a sensitive and comprehensive
discussion of the impact of trauma on children, based both on research
and her extensive clinical practice. She offers a useful formulation in
proposing that what she calls Type I and Type II Disorders need to be
understood differently, the former representing responses to once-off
or ‘single blow’ traumas and the latter a set of responses to multiple
or long-standing traumas. Being bitten by a dog, for example, might
evoke a Type I Disorder, but being sexually abused over several years
would be more likely to result in a Type II Disorder.
The focus of this book is primarily on trauma as it would be
experienced in Type I conditions, that is, on traumatisation in the face
of unexpected, abnormal, catastrophic, life-threatening and injurious
events. For this reason, the discussion of Type II Disorders is rather
brief since it is difficult to do justice to the complicated factors involved
in longer-term abuse or child exploitation situations. These kinds of
traumas are likely to take place within some kind of system (such as the
family) that then ideally needs to be understood and treated as a whole.
Dealing with this kind of abuse may require structural interventions,
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such as the calling in of welfare, policing and legal services. However,
in her discussion of Type II Disorders in children it is apparent that
Terr32 identifies responses that parallel those characteristic of adults
with complex PTSD. Terr argues that for child victims of prolonged
and repetitive trauma, in addition to dealing with the torment of every
trauma experience, it is the anticipation of injury and traumatisation
(the anticipatory anxiety) that has to be managed. This is often achieved
through the use of numbing and detachment, the use of cutting-off
defences that allow the child not to feel too intensely and to become
almost immune to a pain they cannot escape. In order to survive in
an environment in which they are often dependant on their abusers
for material and psychological care, children may need to be able to
split off the bad experiences from good ones and may be able to hold
quite contradictory positions and ways of relating to the world. The
recurrent employment of such defences early in life can lay down the
tracks for the development of a particular kind of personality style or
type. Without intervention or treatment (and even with these in some
cases), children suffering from Type II Disorders may go on to develop
adult personality disorders such as Dissociative Identity Disorder (or
what was previously referred to as Multiple Personality Disorder) and
Borderline Personality Disorder. Terr33 also acknowledges that there
may be situations in which Type I and II patterns overlap.
In the case of Type I Disorders, children are required to develop
the means to integrate the experience of the trauma and to go forward
in the world despite what has happened. Their energy is primarily
expended in dealing with something that took place in the past,
although their attempts to come to terms with the shock of a trauma
will clearly affect their behaviour in the present. Terr suggests that
four characteristics or symptoms are typical in most cases of childhood
trauma. These include visualised or otherwise repeatedly perceived
memories; repetitive behaviours; trauma-specific fears; and changed
attitudes about people, life and the future.34 It is apparent that some
of these features could be understood as falling within the psychiatric
diagnostic system of DSM IV-TR35 discussed in Chapter 3. For example,
repeatedly perceived memories would clearly fall under the intrusive or
re-experiencing symptom cluster of PTSD and there are also overlaps
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with both avoidance and hyperarousal symptoms. The DSM system
makes allowance for the classification of children within the category
of PTSD, at points indicating that children’s symptoms may present in
a slightly different way, for example in repetitive play or disorganised
behaviour,36 but that they essentially parallel those of adult patients.
In offering a clinically rich, observation-based overview of children’s
responses to trauma, Terr37 paints a more elaborated picture of
childhood trauma responses. She writes in such a way that we get a feel
for what a child may be experiencing. For example, in discussing the
case of a little girl who had undergone several surgeries to heal head
wounds sustained when she was unexpectedly attacked by a circus lion,
she describes how the girl would insist on playing hairdresser with her
friends and how she would often hurt the younger children with the
roughness of her brushing, seemingly trying to get rid of her feelings
of fear and difference and indirectly expressing her anger at what had
happened. Reading such case material brings home the importance of
careful observation of traumatised children in order to understand the
specific impact of the trauma for the child concerned.
In the case of children who have experienced single event traumas,
Terr38 also goes on to describe the fact that they often have very clear
and vivid memories of the event, indeed sometimes better memories
than adults (unlike Type II children whose memories may be vague). In
younger children, as will be discussed in further detail, their difficulty
in clearly distinguishing fantasy from reality and their ‘egocentrism’ or
sense of their central place in their limited worlds, may lead them to seek
explanations for bad events that are self-referenced and faulty in terms
of logic. For example, a little girl of four who witnessed the drive-by
shooting of her mother at a taxi terminus in Soweto on the way to take
her to pre-school, was concerned that she may have caused her mother’s
death by feeling angry towards her following an argument over using
the toilet before they left the house. She had linked her own aggression
towards her mother with the later violence and was struggling to deal
with feelings of guilt as well as fear, shock and loss. Terr39 suggests
that children may experience ‘omens’ or premonitions about events,
have misperceptions that may even take the form of hallucinations on
occasion, and may develop rituals to protect themselves. We see this in
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milder form in anxious children who need to check under their beds or
in a cupboard before they go to sleep. Terr’s work gives a rich picture
of how children are affected by trauma that usefully complements the
DSM formulation.
In some respects, discussing the way in which trauma affects children
as a whole is somewhat misleading, as the term is used to include all
those who might be considered minors or not yet adult in terms of
society, in South Africa all those under the age of sixteen or eighteen
years. In reading about children and trauma it is perhaps important
to remember that adolescents, and more particularly those in late
adolescence, may need to be understood as having characteristics of
both adult and child responses. Another useful angle from which to
discuss how trauma may present or show itself in children is to look at
how children at varying stages of development in terms of the life cycle
are differently affected.40

Developmental Differences in Trauma Presentations

Very young infants can be traumatised, although their ability to
comprehend what has happened and express this is obviously limited.
They may experience trauma primarily as pain when they have been
physically hurt or as anxiety if they pick up distress or agitation in their
caretakers. Children between the ages of zero and two years will tend
to express distress primarily physically, such as through sleeping or
eating difficulties. They may be more easily distressed, more irritable
and more difficult to settle, but their response to trauma will be
strongly dependent on how their caretakers respond to the trauma. A
little girl of 2-years-old who was masturbated over by an uncle was
roughly scrubbed in a very hot bath by her hysterical mother when
she discovered the abuse. The child subsequently refused to eat solid
foods, became aggressive towards her parents and preoccupied with
touching her genital area. When her mother became calmer and was
helped to manage her own distress through some counselling then the
child’s behaviour improved and her distress seemed to ease.
In early childhood, between the ages of about three and six years,
children’s lives are very focused on their homes and families. They
are also at an age when their rational thinking capacity is not yet fully
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developed and they have rich fantasy lives. Children at this age, in
accordance with Erikson’s psychosocial theory of development,41 are
beginning to learn to do things for themselves, such as to dress and feed
themselves. Exposure to trauma may compromise this development of
autonomy, and traumatised young children may become clingy and
dependent, returning to behaviour more in keeping with earlier stages
of development. Their capacity for fantasy may mean that they also
become fearful of imaginary dangers and young children often have
nightmares linked to the trauma. As alluded to previously, their faulty
logic sometimes leads them to hold themselves responsible for what
took place or for what might take place in the future. A little boy of five
who slept through an armed robbery in his home in which his older
brother was injured, began to insist that he would not go to sleep unless
his cricket bat was under his bed in case he needed to defend the family
if the robbers came back again. Children of this age look to caretakers
for reassurance and simple and clear explanations for events. Their
fearfulness and increased dependence need to be accepted, certainly
in the initial period following a trauma, after which they should be
encouraged to gradually develop more confidence and independence
again.
In middle childhood, from about seven to eleven years, a child’s focus
shifts to some extent away from home to the school context. Making
relationships with other children and other adults, such as teachers,
becomes important, as does formal learning. Children who experience
trauma at this stage of development are better able to comprehend what
has happened because of their more sophisticated thinking capacity.
This can be helpful but can also lead to difficulties when it contributes
to reality-based fear and disillusionment at such a young age. What
is also evident is that traumatised children’s concentration is affected
and there is often deterioration in school performance and a tendency
to be easily distracted.42 Although less common, in some cases the
opposite is true, and a child may become perfectionistic and highly
achievement oriented, attempting to establish control and mastery in
the part of their lives where they feel this is possible. Achieving well
academically may be a way of defending against anxious, helpless and
fearful emotions. Children may also struggle interpersonally, feeling
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now different from their peers and somewhat self-conscious. Like
younger children, these junior school-aged children may also become
more dependent and fearful of being left alone. Again it is important for
caretakers to respond as openly as possible to the trauma and to help
their child to talk about their experiences and fears in a sensitive and
non-pressurising way. It may be important for the school to be made
aware of what has happened and to look at how supports can be put in
place without invasion of the child’s privacy. In some instances group
support for pupils may be helpful if the trauma has affected them as
a collective. In a case in which a twelve year-old girl was shot on her
way to school in Johannesburg as a bystander to an armed robbery,
the school organised a peaceful march of pupils and parents and the
collection of funds to assist with better policing. The principal reported
that the children seemed to feel better to be able to do something active
in response to their classmate’s homicide.43
From the age of about twelve until eighteen years children move
into the stage of adolescence, involving large physical, mental and
social changes. The sense of being male or female is strengthened
with body changes and there is an increased interest in sexual and
partner relationships. It is almost a cliché that adolescents become
very focused on and invested in the acceptance of their peer group
and more challenging of their parents’ attitudes and behaviours. With
the development of formal operational thinking comes the capacity
to think symbolically and to become more interested in political,
philosophical and spiritual issues, although this tends to happen in
later adolescence and young adulthood. Traumatisation in adolescence
can take a number of paths. Some adolescents become withdrawn,
uncommunicative and almost ‘shut down’. Others become defiant,
oppositional and even aggressive in their manner. Given the propensity
for experimentation and risk-taking at this age, trauma may precipitate
substance abuse and reckless behaviour. For many adolescents though,
the central difficulty is in making sense of the event and what this means
for their identity and their understanding of life values. Given that this
is a strongly formative stage in terms of these dimensions, it is hoped
that intervention can help an adolescent put the traumatic event into
perspective without it necessarily leading to the setting of a negative
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life outlook. It may also be difficult to persuade adolescents to accept
help or support as this may be viewed as compromising independence
and they are often highly self-conscious in both individual and group
therapy settings. Nevertheless, intervention from a trusted adult can
often assist a teenager to negotiate the trauma in a more thoughtful way
and to prevent the likelihood of a negative developmental trajectory.
At all developmental stages it is important to recognise the resources
of the child, such as the capacity for imagination or the need to begin
to define a personal value system, and to marshal these strengths in
supporting children and adolescents through trauma. It is apparent
that it is important to marry generic understandings of trauma impact
with a developmental perspective in order to do justice to the way in
which children of different ages and developmental stages are likely to
respond. Although the individual developmental attributes of a child
are important in determining how trauma manifests, it has also been
demonstrated in numerous contexts that the environment in which the
child is traumatised (be this family, immediate community or broader
society), plays a significant role in outcomes.

Familial, Social and Community Dimensions

A common finding in trauma research with children, and one that
makes intuitive sense, is that parents or caregivers play a crucial role
in whether exposure to trauma leads to symptomatology or disorder,
or whether the child recovers relatively unscathed from the event.
If caretakers, particularly mothers, are traumatised themselves the
likelihood of children manifesting distress in increased. While it is
common for parents to experience their own distress and even some
posttraumatic symptoms after their child has experienced a trauma,
a very high level of parental distress can impede a parent’s capacity to
create a secure and predictable post-trauma environment for the child
and to provide emotional containment for the child’s fear and anxiety.44
Several South African studies have found that there is a significant
correlation between the presentation of symptoms in children and
level of symptomatology reported by the mother.45 Similarly, in a study
conducted amongst Palestinian children exposed to military violence it
was found that the group ‘most vulnerable to intrusion symptoms were
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younger girls whose mothers showed high levels of PTSD symptoms’46
and that high levels of avoidance symptoms were also strongly associated
with mothers’ PTSD symptoms. A study into the effects of the 9/11
attack in New York on a national sample of adolescents also found
that their levels of posttraumatic stress symptoms were associated
with parental distress, amongst other factors.47 It seems that parental
distress is generally a good predictor of child distress. This finding is
in keeping with some psychoanalytic understandings of the impact of
trauma that suggest that traumas represent attacks on attachment48 and
involve experiences of loss. In object relations terms it is suggested
that the harm sustained during a trauma is experienced as a failure by
good caretaking ‘objects’ (people or representations of people in an
individual’s life) to protect one in the face of danger. If one’s primary
caretaker (usually the object who is most strongly internalised to create
a kind of an internal protective mechanism) is also clearly harmed by
an experience, then there is likely to be increased anxiety on the part of
a child. The sense that the world is a bad place full of harmful ‘objects’
and that good objects (in this case the mother or parents) are helpless
in the face of such badness, is likely to increase distress, fear and
despair. This is most particularly the case with younger children whose
models of the world and relationships are still being developed. Such
ideas would also resonate with those of Janoff-Bulman49 concerning
basic assumptions, discussed in Chapter 4. A child whose parents or
caretakers seem overwhelmed and disorganised by a traumatic event
is likely to be more vulnerable to questioning their beliefs about how
benign and meaningful the world is.
It is important to recognise that family or caretaking systems do not
exist in isolation and that community and societal stability, cohesion,
values, resources and social capital, also play an important role in
childhood trauma. Community psychology perspectives emphasise the
importance of context in understanding both group and individual
problems. To reiterate the premise touched on in the introduction, it is
apparent that community upheaval and disruption, such as what takes
place during both national and international conflicts and wars, not
only places children at risk for victimisation and traumatisation but
also compromises the recovery context. Referring to a UNICEF report
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in a book published in 1997, Rock writes, ‘During the last 10 years
alone, 2 million children have been killed, 4 to 5 million have been
disabled, 12 million left homeless, and 10 million left psychologically
traumatised. More than a million have been orphaned or separated from
their parents’.50 Since then there have been wars in Eastern Europe and
Iraq, and in Africa there has been the war in the Democratic Republic
of the Congo, ongoing conflict in Sudan and political battles in Kenya
and Zimbabwe, amongst other instances of severe social upheaval.
Thousands of children are impacted by these kinds of events. In
addition, although not necessarily categorised as traumatic stressors in
the classic sense, it is also apparent that poverty, political repression,
gender oppression and various forms of discrimination create a climate
for traumatisation. Butchart and colleagues51 point out that amongst
the victims of trauma the poor and oppressed are disproportionably
represented. While recognising that it is impossible to do justice to this
scale of ‘social ills’, two trauma-related sets of difficulties that illustrate
the importance of community-level understandings will be briefly
discussed   –  the issue of youth involvement in protest politics and the
issue of AIDS-related parental bereavement.
Although South Africa has moved on markedly from the era of
apartheid politics and the struggles associated with the implementation
and contestation of a race- and class-based system of oppression, a
large body of trauma work in South Africa was generated in response
to this historical climate. At the time of the 1994 democratic elections
the Goldstone Commission was set up to ‘undertake an inquiry into the
effects of public violence and intimidation on children’.52 The findings
of this commission are well documented in the final report but were
also disseminated in a book entitled Spirals of Suffering.53 Both texts
provide telling accounts of the effects of the apartheid system and state
repression on the lives of children. One group of children that received
particular attention were those who became involved in protest politics
and the armed struggle, the majority of these boys aged from twelve to
eighteen years, but some even younger. These youth were subject to
tear-gassing and arrest, detention without trial, torture, house arrest,
forced re-education camp attendance and in some cases, were killed.
For example, over 15,000 children were detained between the years
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of 1960 and 1994 and between 1984 and 1986 security force violence
claimed the lives of 300 children and 18,000 were arrested on protest
charges.54 There is acknowledgement of the brutalising effect of the
conflict and of the fact that for the youth involved in the struggle, the
young ‘comrades’, the long-term effects of precocious engagement in
violent conflict were difficult to gauge, but potentially harmful to them
and others. Up until the present, children continue to be recruited
into armed forces (in many African countries in particular) and there
is ongoing concern about the identity of ‘child soldiers’ and what this
means for their own and their societies’ futures. Some of the longterm consequences of child and adolescent engagement in township
paramilitary structures in South Africa in the early 1990s appear to
be social alienation, substance use and some rigidity of identity for
many of these boys who are now men.55 When children are victims of
structural violence in the kinds of large numbers suggested here it is
clear that change needs to take place at structural and political levels
and that individual treatment of trauma victims may be unfeasible and
limited in efficacy.
A more contemporary, community-level, trauma-related problem
in South Africa is that of loss of a parent or parents due to AIDS.
While death of a parent due to illness might not always constitute
a traumatic stressor (and, for older adults, is in the normal order of
life), for children such a loss is often experienced as traumatic, even
if anticipated. One of the central concerns arising out of Cluver and
Gardner’s56 study of AIDS orphans cited previously, is that levels of
traumatic stress amongst these children were very high. Although they
are cautious not to over-generalise their findings, in part because of how
levels of traumatic stress were assessed, they nevertheless conclude that
the ‘findings of strikingly high PTSD-type symptoms  ...  indicate that
this should be a key area for research and intervention’.57 They also
propose that a number of aspects of AIDS-related bereavement may
contribute to traumatisation. They write that ‘many children witness
the slow, painful death of a parent in degrading circumstances. The
intermittent nature of the disease, stigma and secrecy around the death,
the move into foster care, into a child-headed household, or onto the
streets, could all potentially contribute to trauma for children’.58 Thus
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there appear to be multiple features that are implicated in AIDS-related
bereavement, including exposure to physically repugnant images (such
as the abjection of a dying parent) and the social isolation stemming
from ongoing shame and stigmatisation. This is clearly a kind of event
that has multiple traumatic elements with both immediate and longterm impacts. Interestingly a recent study of AIDS-orphaned children
in South Africa found strong evidence that perceived social support
played an ameliorating role with regard to the rates of traumatic stress
symptoms observed in a group of 425 children.59 This study reinforces
the idea that the impact of becoming orphaned due to AIDS-related
death of a parent or parents is complex and multi-dimensional. The
fact that social support appears to play a positive role in preventing
the development of traumatic stress conditions suggests that both lack
of stigmatisation and the active involvement of others in one’s future
survival may make a difference to vulnerable children. The study also
points to the importance of social level interventions as will be discussed
later. While this cursory coverage of AIDS-related bereavement cannot
do justice to the complexity of the problem, it is apparent that this is
a traumatic stressor that is affecting and will increasingly affect large
numbers of children in South Africa. The scope of the problem again
suggests that multi-level and multi-faceted intervention is required. In
the same way that the impact of trauma needs to be understood at both
individual and systemic levels, intervention in response to trauma also
needs to be understood as involving many kinds of intervention which
can be used in complementary ways.

Treating Childhood Trauma

Treating trauma in children can take place at a number of levels.
These include: individual treatment for the child; parent or caretaker
support and counselling; group psychotherapy; and community or
organisational interventions, such as school-based projects.60
There is considerable overlap between the types of individual
interventions used for adults and children, child treatment also
encompassing debriefing and both short- and longer-term psychotherapy. Pharmacotherapy or drug treatment may also be used with
children and adolescents but is still somewhat controversial as the
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effects of drug treatment on children have not been well enough
established.61 Psychotherapy approaches include cognitive behavioural
therapy, psychodynamic psychotherapy, narrative and systemic
interventions.62 For children aged between about four and twelve years,
play therapy is the most commonly used intervention, often employing
drawing and creative activities and/or play with objects representing
the trauma. One of the most widely cited brief term approaches is ‘The
child interview’ developed by Pynoos and Eth63 for child witnesses or
victims of violent incidents. Although designed as a brief-term model
for early intervention, it can be used to assist children to work through
Type I traumas more generally. The model involves encouraging and
supporting the child to recount their experiences and associated fears
and then helping them to explore and process what has happened,
giving particular attention to misperceptions, feelings of responsibility
and self-blame and how the child is making sense of the event. The
child client is assisted to ‘work through’ these issues and there is
encouragement to take a future-oriented perspective and to look at
ways of managing bad feelings if they recur. The model facilitates the
processing of trauma using the common principles that guide most
interventions with children: assisting the child to face and process the
event; to gain some sense of understanding of what took place; and
to regain some sense of control, trust and hope. Treatment also often
involves identifying adults who the child can usefully call upon for
assistance and helping the child to access such support so that there is
containment beyond the therapy.
Particularly with very young children, but also with older children,
psychoeducation of parents may be important in helping them to
become more effective in their support.64 Caretakers can offer ongoing
care outside of a therapy setting and may be able to assist their children
in day-to-day circumstances.65 By supporting parents to manage their
own feelings of distress and by giving them helpful input about what to
anticipate and how best to respond to their child’s needs, the therapist
can create a context in which caretakers effectively become auxiliary
counsellors. A case study documenting the use of this kind of approach
in the treatment of a little girl from Alexandra township who had
been raped illustrates how counselling of the mother enabled her to
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explore her child’s experiences and feelings with greater confidence,
and how this in turn helped the child to turn to her mother as a source
of therapeutic support.66 Assisting caretakers to become effective in
helping their children to deal with their distress also restores a sense
of safety and trust for the child and rebuilds or strengthens lasting
relationships. This may sometimes require parallel therapy for parents
and children when they have both been traumatised by events. For
example, a mother and her twelve-year-old daughter who had lost their
husband and father in a car accident seemed distant and conflicted in
their first session together. It proved helpful to see them both separately
for therapy for a period so that the mother could express her fear of
single parent responsibility and the daughter her distress at losing the
person she had perceived as her primary parent. It was only as the
mother became less overwhelmed by grief and panic, having worked
through her anxieties in therapy, that her daughter felt safer and began
to share some of her own grief and adjustment difficulties with her
surviving parent. Individual therapy seemed to create a transitional
space for them to work through important issues in such a way that
they were then able to engage more productively in some co-therapy
before termination. The case study in Box 6.1 provides an account of
both the presentation and treatment of a child trauma case illustrating
many of the issues that have been highlighted thus far.
In some instances group interventions may be helpful. This is
particularly the case when a group of children have all been affected
by the same traumatic event, for example, in a school, club or social
setting. Groups for children who have experienced the same kind of
trauma (even when this occurred in unrelated settings) have also been
found to be helpful, such as groups for refugee or HIV-positive children.
Group interventions may involve creative forms of therapy such as
drama, dance and art-making, as well as more conventional talk-based
psychotherapy. An intervention of the latter kind took place at a girls’
school where pupils away on a camp had been affected by a lightning
strike, causing the death of one child and severe injury to two others. In
addition to giving a talk to the whole school about the impact of trauma
and bereavement, two therapists also ran an eight-session, semistructured, discussion-based group for girls who had been on the camp
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Box 6.1

Case study of an intervention with a traumatised child
Tulani, a little boy of five years, was brought to a trauma clinic in Johannesburg by
his mother. She described how his behaviour had changed following a taxi accident
some months previously. Initially she said he had seemed alright but now he was afraid
to let her out of his sight and refused to travel in any kind of motorised transport.
This created difficulties for her as it meant that she either had to walk to places with
him or leave him behind when she travelled long distances, despite his crying and
clinging to her when she left the house. She was planning to travel to Limpopo over a
forthcoming long weekend and was concerned as to how she would manage Tulani’s
fears as she planned to take him with her to visit his grandmother. She also reported
that his play-school teacher had noticed that he was more withdrawn and that he was
asking for assistance with tasks that he had previously begun to manage on his own.
For example, he asked her to cut up his food for him and would forget where he had
put his school bag. She said that his concentration had also deteriorated and that he
seemed to go into a kind of day-dream at times. Her younger brother who lived with
them had also noticed changes and was trying to spend more time with his nephew.
In further discussion it emerged that Tulani and his mother had both been involved
in the accident together when the taxi in which they were travelling swerved to avoid
a pedestrian and overturned. Tulani sustained minor injuries in the form of a cut to
his hand but his mother, who was thrown out of the vehicle, had hit her head and
been unconscious for about 20 minutes. Together with some other passengers they
had been taken to a hospital where, after examination, they were both discharged.
The mother reported no further symptoms on her part, other than some occasional
headaches. She said that it had been difficult to take taxi transport initially but that
she was now used to this again and that such travel was necessary. She repeated
her observation that Tulani had initially seemed fine and when questioned confirmed
that he had not sustained any head or other injuries beyond the cut to his hand.
She recalled that he had woken up crying on two or three occasions soon after the
accident but that his sleep had then improved. Her main concern was his extreme fear
of going near or travelling in any motor vehicle, a fear that seemed to have grown
stronger with time. Although she was mostly sympathetic, there were times when she
felt exasperated with him. Tulani himself was a shy boy and during the first session that
he and his mother had with the therapist, he spoke very little on his own behalf. He
seemed rather anxious but was also cooperative and endearing in his manner.
Tulani was treated over the course of ten weeks of therapy. It was decided
that he and his mother should be offered separate interventions, with the mother
receiving some personal counselling, psychoeducation and parental guidance, and
Tulani receiving play therapy with a different therapist. It was suggested to the mother
that it was her injury and apparent abandonment of Tulani at the very frightening
time immediately after the accident that had been most difficult for him and with
counselling she was able to better understand his fears. Tulani was initially quite shy
and inhibited in the playroom and would only leave his mother when shown where
he could find her if necessary. Over two sessions, however, he began to trust the

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therapist and seemed eager to go into the playroom. During his play therapy sessions
he initially did some drawing but then concentrated on building roads in the sandpit
and playing with cars that in many instances bumped and overturned. He seemed
quite energised in playing this kind of game over and over. The therapist interpreted
the possible parallels between his play and the trauma incident, focusing on his
concerns about injury and need for reassurance. It appeared that at the time that his
mother was unconscious he had feared that she was dead and had indeed struggled
to comprehend what was happening. He emphasised the noise of the accident often
in his play and it was clear that a sense of danger had become associated with loud
noises. His later play became extended into acting out scenes in which people became
injured and he would sometimes instruct the therapist that she was injured and offer
to bandage parts of her body. He would also pretend to cook her food which they
would share, seemingly indicating that he wanted to restore a sense of harmony in
his life and that he perhaps had seen his mother as being in need of care. Again the
play therapist made links between his fears during the accident and his attempts to
make things better.
About four sessions into the therapy it was decided to add a behavioural
component to the treatment in parallel with the play therapy. It was agreed that in
the company of both the therapist and his mother (in keeping with the principles of
systematic desensitisation) Tulani would be encouraged to begin to get used to motor
cars again. On the first occasion, after some preparation from the therapist, Tulani, his
mother and the play therapist all spent some time looking at and then just sitting in a
car for a part of the session. On the next occasion all three were driven a short distance
around the parking lot and the following week they drove once around the block in
traffic. On each occasion Tulani’s fears were acknowledged and he was reassured by
both his mother and the therapist, being praised for his bravery in tackling something
so difficult for him. He also chose to bring an action figure from the playroom with
him which seemed to represent some courageous part of himself but was also seen as
being protective of him. Although Tulani’s mother wanted to increase the steps that
he was taking after the first week, the importance of a gradual approach, allowing
Tulani to overcome his fears and relax sufficiently at each stage, was explained to her.
However, on their arrival at therapy after the third week of the behavioural treatment
she reported that they had needed to take a taxi to do some shopping and that
Tulani had come willingly with her after she had reassured him that they could get
off the taxi if he became too frightened. They had successfully completed a round
trip to the shopping centre and back and she was very excited. Tulani also seemed
proud to report what he had achieved. After a couple more sessions allowing Tulani
to consolidate his progress and to prepare for termination, the therapist and he had a
farewell session and special tea to end the therapy. While Tulani found it difficult to say
goodbye to the therapist, he and his mother seemed close and happier. The mother’s
involvement in both her own and his therapy indicated her level of commitment to
the process and to her child and suggested that she would continue to support him
after termination. The therapeutic team found the work with Tulani and his evident
improvement very rewarding.

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at the time. The girls were aged between about ten and twelve years so
were able to verbalise their concerns within the group. Group work
allows therapists to meet the needs of several children at a time and
also often helps to de-stigmatise traumatic responses and promote
interpersonal support. The local Wilderness therapy programmes
developed by the National Peace Accord Trust67 and the AIDS story
book project68 are two examples of how group work with children
and youth can be innovative, embracing principles of both group
psychotherapy and community intervention.
The findings of one South African study of the effects of community
violence on children suggest that, while support from families
and schools can moderate the impact of trauma, there is a limit to
what these sources of social support can do to buffer the effects of
community violence.69 Ultimately, finding ways to reduce or prevent
violence and trauma in the first instance is the most effective way to
protect children from distress. Community-based interventions, which
address traumatisation in even broader groups of children, frequently
take the form of preventative rather than curative interventions. There
are numerous school-based programmes that have been designed, for
example, to tackle issues of violence prevention, sexual abuse/coercion
and death and bereavement. Such interventions aim to prepare children
to deal with difficult events as well as to avoid dangers and risks. There
is some evidence that after-school activities played a role in reducing
anxiety amongst early adolescents growing up in a high-violence area in
Cape Town,70 suggesting that even interventions of a more general nature
(such as sporting, creative or social activities) may protect children
against the worst impact of trauma exposure. However, when trauma
has already taken place, community interventions are often helpful in
providing symbolic as well as literal kinds of support to victims, for
example, in the singing of songs, saying of prayers and construction
of symbols of remembrance. The school march described earlier
could be seen as such a kind of community intervention. Community
interventions of this kind are often explicitly geared to create a sense
of community cohesion and common humanity. In this respect they
can assist in rebuilding positive meaning systems for children who have

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been traumatised as well as a sense of belonging to a containing social
group.

Conclusion

Children who have been traumatised represent an important category
of victims or survivors requiring acknowledgement and intervention.
However, it may be useful to sound a word of caution in recognising that
they are also a group of victims whose identity is open to exploitation.
The idea of the innocent ‘child victim’ can be manipulated at times
for political leverage and public recruitment around social agendas.
The victimisation of children almost inevitably sparks particular civil
outrage, as perhaps it should. It is important though, that in highlighting
the plight of children for political ends intervention with the victims
themselves does not take second place. In concluding this chapter on
children and trauma it is perhaps useful to entertain a critical perspective
and to think carefully about how child traumatisation is represented in
the media and popular discourse71 and what this might say about the
perceived agency of children in general and about the legitimacy (or
illegitimacy) of adult trauma survivors. As has been argued, children
are vulnerable to traumatisation of a range of kinds and the impact
of this in the form of psychological distress and psychiatric disorders
has been well-documented. Both more classically psychotherapeutic
and community-based interventions appear to be helpful in addressing
trauma in children. Part of the prevention of future trauma lies in the
treatment of those who are damaged as children since this may operate
to curb ongoing cycles of violence brought about by the re-enactment
of victim and victimiser positions. Child trauma intervention thus has
potential benefits for both the individuals concerned and the broader
society. The resilience and resourcefulness of children in overcoming
trauma also needs to be foregrounded. In South Africa we need to
hold the tension of recognising both the damage sustained and the
extraordinary strengths displayed by children who are traumatised in
multiple ways in this country.

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Chapter 7

CONCLUSION

T

he psychoanalytic view of trauma argues that until traumatic
experiences and their personal meaning are fully recognised,
understood and ‘owned’ by the survivor, these experiences will continue
to manifest themselves in symptoms of distress and unconscious reenactments of the original traumatic situation. Perhaps this also
provides a useful analogy for a traumatised society. Until we have a fuller
understanding of the types of trauma that South Africans are exposed
to, and the full range of the psychological impact of and meaning
attached to such experiences, traumatisation in South African society is
likely to be repeated from one generation to the next. An illustration of
this possible kind of effect is the fact that one of the findings of a series
of panel hearings on violence in Western Cape schools, held by the
South African Human Rights Commission in 2006, was that children
as young as seven frequently engage in games called ‘rape me rape me’
and ‘hit me hit me’ in the playground, demonstrating how endemic
and normalised violence has become for the very young members of
our society.1
Given what we know about the prevalence rates of different forms of
direct and indirect trauma exposure in South African society, it should
be no surprise that trauma is a common, even normal, part of the lives
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Conclusion

of many South Africans of all ages, including young children. But in
order to really understand the psychological impact of this exposure, to
be truly mindful of what it means to live in a context of chronic danger,
the meaning and functions of behaviours such as playground games
about violence need to be carefully explored. A layered psychological
understanding might suggest a range of different possible meanings
and functions of such playground enactments, including that they are
a form of traumatic re-experiencing, an active attempt at mastery over
situations that make children feel anxious, a way of trying to understand
things they commonly see and hear about in their homes and community,
or a form of identification with adults (developmentally parallel to the
more benign games of ‘house house’ or ‘doctor doctor’ that many
young children engage in to ‘practice’ adult roles). Such games may
indeed be considered a symptom of posttraumatic stress; on the other
hand, turning potentially frightening domestic or community events
into a playground game may be an indication of children’s resilience
and capacity for coping in the face of endemic trauma. Without a fuller
exploration of the meaning of such behaviours, we cannot really know
exactly what they might mean for our youth and how best to engage
with them and offer optimal support.
We would like to conclude this book by emphasising the need to
continue to systematically document trauma exposure, impact and
treatment in South African society in order to address important gaps
in our knowledge and to continue to enhance our interventions, so that
a legacy of trauma will not be passed on to future generations of South
Africans. Throughout this book, we have described not only the state of
knowledge about the prevalence, impact and treatment of trauma in the
international literature, but also the many local knowledges that have
emerged to date. In this chapter, we consider those local knowledges
that remain to be documented, and suggest some ways forward.
We have seen in Chapter 2 that several different forms of trauma
are extremely common in South Africa. Over the past fifteen years,
endemic political violence has been replaced by high levels of criminal
violence, intimate partner abuse, and physical and sexual assaults against
women and children. Although South Africa does not necessarily have
higher rates of all forms of violence than other countries, the severity
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of violence in this country does appear to be particularly extreme   –  our
rates of homicide and fatal sexual assaults are amongst the very highest
in the world. In addition, many South Africans are traumatised by
accidental injuries such as traffic accidents and burns. These direct
forms of traumatisation are further compounded by indirect exposure
to trauma, such as witnessing violence or hearing about the violent
death of a loved one. It is therefore not surprising that the majority of
South Africans have experienced not one but multiple traumas in their
lives. Although no South Africans are entirely protected from trauma,
it is apparent that South Africans of all ages who live in conditions of
poverty are most at risk of experiencing many forms of violence and
accidental injury.
In South Africa, as elsewhere, it is difficult to accurately establish
the prevalence of certain forms of trauma, even with anonymous
survey questionnaires. Sexual violence and coercion is probably
under-reported and experiences of child abuse are hard to assess with
younger children. And given that memory disturbances and avoidance
of traumatic material are common psychological consequences of
trauma, it must be assumed that trauma reporting in general is prone
to inaccuracies. While bearing these issues in mind, we now have a
number of prevalence studies, community studies, clinic studies and
other valuable sources of data that contribute to an emerging picture
of the scope and severity of trauma exposure in South Africa. What is
less clear, however, is the psychological impact of trauma exposure in
our society and the best ways in which to ameliorate this.
Compared with economically developed countries, there has been
less published research on the psychological effects of trauma in
economically developing countries. In South Africa too, the amount of
published research on the psychological effects of trauma (as opposed
to patterns of trauma exposure) is surprisingly small given the scope
and scale of trauma exposure in our society and the amount of rich
clinical experience that interventionists working with trauma survivors
in a variety of settings have accumulated. As discussed in Chapter
3, where South African researchers have attempted to explore the
impact of trauma, their approach to doing so has often been framed by
research trends in economically developed countries, in particular the
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Conclusion

use of PTSD symptom scales to assess the impact of trauma exposure.
While it is useful to have information about posttraumatic symptoms
that can be compared across countries, there are some limitations to
exploring the impact of trauma through the use of highly structured
tools developed in contexts other than our own.
PTSD, comorbid disorders like depression, phobias and substance
abuse, and complex PTSD (or Disorders of Extreme Stress) are trauma
consequences that have been identified by clinicians and researchers in
North America, Canada, the United Kingdom and European countries.
Establishing how common they are in other contexts, and particularly
in one that is as diverse with regard to language, culture and socioeconomic circumstances as South Africa, is a complex matter indeed.
In recent years, the relevance of the PTSD diagnostic category to non‘Western’ cultures (that is, cultural contexts outside of the United States,
the United Kingdom and Europe) has been debated.2 This argument
forms part of a broader debate regarding ‘etic’ and ‘emic’ processes
in mental health research.3 The term ‘etic’ refers to the process of
applying a particular (usually ‘Western’) meaning system across all
cultures. Studies that apply the PTSD diagnosis to cultures outside of
the context in which it was developed, for example, by assessing PTSD
symptoms using questionnaires or structured interviews for PTSD
developed in the United States or the United Kingdom, are adopting an
etic perspective on mental illness. By contrast, the term ‘emic’ refers to
the exploration of culturally unique meaning systems. Studies applying
emic principles attempt to understand the subjective meaning of the
illness experience for the sufferer. This subjective experience is always
culturally mediated   –   that is, it is patterned by, or filtered through
the lens of, local cultural meaning systems.4 This subjective ‘insider’
perspective can often best be accessed by asking people to describe in
an open, unstructured way what they are experiencing and how they
understand this, rather than by asking them to endorse an existing list
of symptoms.
Some researchers are tempted to argue in favour of one approach
over the other. For example, those who favour an etic approach could
argue that certain biological and neurobiological processes involved
in trauma responses (such as the body’s fight-or-flight response) are
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Traumatic Stress in South Africa

universal and not culture-specific, or that researchers should use one
standard tool (such as a PTSD questionnaire) to assess the occurrence of
a psychiatric diagnosis in different contexts so that we can meaningfully
compare the results. Those who favour an emic approach could argue
that, by using a questionnaire to ask people whether or not they have
symptoms that have been ‘discovered’ elsewhere, we could miss all
those symptoms or experiences that do not fit neatly into these predefined categories. For example, a study with traumatised Sudanese
refugees in Uganda and torture survivors in Malawi found that PTSD
re-experiencing and hyperarousal symptoms were common in these
samples, but that the classic avoidance symptoms of PTSD were rare.5
Rather, avoidance appeared to be manifested through somatic symptoms
of bodily numbing. As we noted in Chapter 3, a few local studies
have similarly found that somatic symptoms are very common among
South African trauma survivors. This suggests that, even when PTSD
symptoms are present across different cultures, culture- and contextspecific manifestations may be found if they are looked for. These local
expressions of posttraumatic stress may require somewhat different
interventions than those offered by mainstream trauma therapies. It is,
therefore, apparent that both emic and etic approaches have something
of value to offer, and that they should, in fact, supplement each other
in order to develop a full understanding of traumatic stress in South
Africa.
At this stage in the emergence of local knowledges about traumatic
stress in South Africa, we would argue that the use of psychiatric tools
from other countries should be just one of a range of methods for
exploring the impact of trauma on the South African population, and
that more qualitative research is needed to understand those aspects
of trauma response that may be context-specific. However, when
international tools are utilised, it is important that they be applied with
clinical rigour. We saw in Chapter 3 that symptoms of posttraumatic
stress certainly appear to be very common among South African trauma
survivors in a wide variety of settings. However, the trend towards
using self-report symptom scales, which do not allow one to establish
with certainty the duration or impact of symptoms, makes it difficult to
be certain whether these are transitory posttraumatic responses that fall
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Conclusion

within the normal range or whether they reflect the presence of PTSD.
At the same time, we have also noted some emerging evidence to suggest
that many trauma survivors in South Africa may suffer from non-specific
forms of distress rather than from specific psychiatric disorders. Even
when trauma survivors do not meet the clinical threshold for particular
psychiatric diagnoses, it is, therefore, important that we document
those psychological symptoms that do seem to persist in the aftermath
of a trauma.
There are particular populations of trauma survivors in South Africa
that require more careful and thorough understanding. Little has been
documented locally regarding the impact of chronic abuse, either in
childhood or in the context of intimate partner violence, even though
some potentially useful diagnostic guidelines have emerged from other
countries in the concepts of complex PTSD or Disorders of Extreme
Stress. In other developing countries, there have been some attempts
to assess the cross-cultural relevance of these concepts, with mixed
results. While some of the symptoms associated with these syndromes
(for example, difficulty with modulating anger) have been found in
traumatised populations in Ethiopia, Algeria and Gaza, others (such as
low self-esteem) have not.6 But to date there has been little published
research on these complex adaptations to prolonged abuse in South
Africa, despite ample evidence of the high prevalence of both child
abuse and intimate partner abuse in this country.
Survivors of rape, too, are generally surprisingly under-represented
in existing South African studies. Although survivors of gender-based
violence are often difficult to access as research participants, these
methodological difficulties alone cannot account for the scarcity of
systematic research on the psychological effects of rape in South Africa.
Given the prevalence of rape in this country, and the finding that South
African rape survivors are at higher risk for developing PTSD than
survivors of many other forms of violence7, it might be fruitful for
South African researchers to reflect on other possible reasons for these
silences and to begin to address this relatively neglected area more
actively.
Chapter 6 highlighted the ways in which trauma presents differently
in children of different ages and developmental stages. Although there
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have been a number of studies conducted with South African children
and adolescents, these too have focused primarily on assessing symptoms
of PTSD and depression rather than exploring developmentally
specific manifestations of trauma. The findings of the report of the
Human Rights Commission on school violence, noted earlier in this
chapter, highlights the importance of developing local knowledges and
understandings of the impact of trauma on our children and youth.
We saw in Chapter 2 that there is evidence that multiple trauma is
extremely common in South Africa. At present there is little published
research that has specifically explored the psychological consequences
of multiple or continuous trauma in South Africa, or the ways in which
poverty may impact on coping in circumstances of continuous trauma.
Indeed, poverty, HIV/AIDS and chronic trauma exposure present
a multiple burden to many South Africans.8 This includes children
who, as discussed in Chapter 6, must often cope with the loss of their
parents to HIV/AIDS, surviving in conditions of poverty, and ongoing
exposure to many different types of trauma. In a context of continuous
traumatisation, it is possible that specific traumatic events may not
stand out for a person as being particularly stressful or significant,
but may rather be viewed as yet another challenge in the ongoing
struggle for survival.9 In one of the few qualitative studies with South
African trauma survivors conducted to date,10 PTSD symptoms were
found to be present, but other concerns were more pressing, including
somatic complaints and a prevailing sense of economic and political
marginalisation. In other words, events that meet the definition of
trauma provided by the DSM may not necessarily be afforded any more
importance in people’s minds than the stressors associated with meeting
their basic survival needs (such as food, shelter and employment) and
with chronic feelings of disempowerment. Some authors have argued
that, in trying to capture the psychological impact of trauma, we cannot
divorce the impact of specific traumatic events from the impact of
ongoing structural violence in the form of extreme poverty and socioeconomic disempowerment.11
In Chapter 4 we noted that some trauma research in other countries
has extended beyond a focus on psychiatric symptoms to explore the
role of meaning-making in adaptation to trauma. Even when psychiatric
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Conclusion

symptoms are absent, the impact of trauma on our fundamental beliefs
about ourselves, others and the world can create significant and ongoing
distress, anxiety and feelings of vulnerability. Alternatively, trauma can
sometimes be a catalyst for psychological growth. With a few exceptions,
the area of meaning-making has seldom been explored with South
African trauma survivors. Since adaptation to trauma has so often been
defined in the psychological literature as a struggle with meaning, and
since meaning-making is patterned by culture and context, this seems
an important avenue for South African researchers to explore. At the
same time, it is important to recognise that the development of meaning
after trauma requires a post-trauma space in which to reflect on and
evaluate the trauma experience, a privilege that is denied to the many
South Africans who live in contexts of ongoing trauma.
South African researchers are certainly not alone in focusing more
on post-trauma pathology than on resilience   –  this trend is characteristic
of the international trauma literature. However, the unfortunately high
levels of trauma in South African society present us with an opportunity
to better understand resilience and coping in contexts of frequent,
multiple trauma. There is perhaps an opportunity for South Africans to
offer some new insights on trauma resilience and coping among adults
and children, rather than waiting for researchers in other countries to
lead the way in this area.
As reviewed in Chapter 5, there are several intervention approaches
developed in other countries that have been found to be effective for
trauma survivors. In South Africa, those working with trauma survivors
in a variety of settings have drawn on these existing models and adapted
them, where necessary, to local needs and resources. However, trauma
interventionists in this country continue to face many challenges,
including the difficulty with accessing treatment for many people living
in conditions of poverty, ongoing community violence which makes
it difficult to establish the client’s basic safety before proceeding with
an exploration of past traumatic experiences, and the need to remain
constantly aware of, and sensitive to, issues of cultural, racial, linguistic
and class differences between therapists and clients. The development
and evaluation of accessible, short-term, and culturally or contextually
meaningful trauma interventions is an ongoing task. Finally, in
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exploring ways to assist trauma survivors, we need to look beyond
individual treatment to ways of harnessing community support and
resilience, and to re-conceptualise trauma intervention more holistically
as an inter-disciplinary enterprise that involves not only mental health
workers, but also non-governmental organisations in the community
development sector and the state education, security, justice and social
welfare systems, amongst others.
This book has attempted to present a comprehensive picture of the
current state of knowledge about traumatic stress, both internationally
and in South Africa, and to highlight issues that still require fuller
understanding. While a solid local database of the effects of trauma on
South Africans of all ages has begun to emerge, and some contextually
responsive local adaptations of trauma intervention models have been
developed, some important gaps in our knowledge remain. Two issues
bear repeating. Firstly, while we need to be cognisant of international
findings about trauma, we also need to continue to allow local,
contextually-specific understandings and interventions to emerge.
Secondly, the intersection of continuous trauma and the structural
violence of poverty creates a particular challenge for South Africans that
needs to be better understood. While legislated apartheid is a thing of
the past, it is apparent that the burden of trauma and violence in South
Africa is primarily borne by those groups and communities who are
most socio-economically disempowered. We noted in Chapter 1 that
the development of local knowledge about trauma has its early roots
in the activist agenda of the apartheid era, and would like to conclude
this book by emphasising that trauma researchers and practitioners
in South Africa continue to have an important role as social activists.
The careful documentation of emerging understandings about trauma
exposure, impact, intervention and recovery is an important part of this
role. We need to draw on the variety of experiences and resources we
have as a society to join together in reducing trauma causative events,
addressing the multiple needs of trauma survivors and bolstering our
individual and communal resilience.

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ENDNOTES

Chapter 1
1. Wilson, J. P. 1994. ‘The historical evolution of PTSD diagnostic criteria:
from Freud to DSM-IV’. Journal of Traumatic Stress, 7(3): 681–698.
2. Herman, J. 1992. Trauma and recovery: the aftermath of violence from
domestic abuse to political terror. London: Basic Books, quote on page 9.
3. American Psychiatric Association 2000. Diagnostic and statistical manual
of mental disorders. (4th edition, text revision). Washington DC: American
Psychiatric Association.
Chapter 2
1. Williams, S. L., Williams, D. R., Stein, D. J., Seedat, S., Jackson, P. B. &
Moomal, H. 2007. ‘Multiple traumatic events and psychological distress:
The South Africa Stress and Health Study.’ Journal of Traumatic Stress, 20(5):
845–55.
2. Williams, D. R., Herman, A., Kessler, R. C., Sonnega, J., Seedat, S., Stein,
D. J. et al. 2004. ‘The South Africa Stress and Health Study: rationale and
design’. Metabolic Brain Disease, 19: 135–47.
3. Amnesty International. 2007. Annual report 2007. London: Amnesty
International Publications.
4. Truth and Reconciliation Commission. 1998. Truth and Reconciliation
Commission of South Africa report, Vol. 3. Cape Town: CTP.
5. Although the authors reject the use of racially constructed terms as
discriminatory, it is nevertheless necessary to use these terms insofar as they
reflect the racialised nature of the oppression perpetrated by the South African
state under the apartheid system. The term ‘black South Africans’ here refers
to South Africans who were categorised by the Population Registration Act
during apartheid as ‘African’, ‘coloured’, ‘Asian’ or ‘Indian’.

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  6. Coleman, M. 1998. A crime against humanity: analysing the repression of the
apartheid state. Johannesburg: Human Rights Commission.
  7. TRC, 1998, vol. 3.
  8. Ibid.
  9. Kaminer, D., Grimsrud, A., Myer, L., Stein, D. & Williams, D. R. 2008.
‘Risk for posttraumatic stress disorder associated with different forms of
interpersonal violence in South Africa.’ Social Science and Medicine, 67:
1589–95.
10. TRC, 1998, vol. 3
11. Ibid.
12. Kaminer et al., 2008.
13. Truth and Reconciliation Commission. 1998. Truth and Reconciliation
Commission of South Africa report, Vol. 1. Cape Town: CTP.
14. See CSVR website, http//:www.csvr.org.za
15. Gear, S. 2002. Wishing us away: challenges facing ex-combatants in the ‘new’
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16. Altbeker, A. 2007. A country at war with itself: South Africa’s crisis of crime.
Johannesburg: Jonathan Ball, quote on page 12.
17 . Seedat, M., Van Niekerk, A., Jewkes, R., Suffla, S. & Ratele, K. 2009.
‘Violence and injuries in South Africa: prioritising an agenda for prevention.’
Lancet Special Issue: Health in South Africa, August 2009: 68–79.
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Shaw, M. 2002. Crime and policing in post-apartheid South Africa:
transformation under fire. London: Hurst and Co.
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injury in South Africa: fatal injury trends and international comparisons.’
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20. Altbeker, 2007.
21. Kaminer et al., 2008.
22. Norman, R., Matzopolous, R., Groenwald, P. & Bradshaw, D. 2007. ‘The
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23. Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M. & Nelson, C. B. 1995.
‘Posttraumatic stress disorder in the National Comorbidity Survey.’ Archives
of General Psychiatry, 52(12): 1048–1060.

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86. See Arrive Alive website, http//:www.arrivealive.co.za.
87. Williams et al., 2007
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97. Kessler et al., 1995.

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98. Williams et al., 2007.
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100. Kessler et al., 1995.

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99. Griffin, M. G., Uhlmansiek, M. H., Resick, P. A. & Mechanic, M. B. 2004.
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3. Ibid.
4. Foa, E. B. & Rothbaum, B. O. 1998. Treating the trauma of rape: cognitive
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10. Janoff-Bulman, 1992.
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12. Ehlers & Clark, 2000.
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17. Everly & Lating, 2004.

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Foa & Rothbaum, 1998.

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30. Janoff-Bulman, 1992.
31. Lebowitz, L. & Roth, S. 1994. ‘“I feel like a slut”: the cultural context and
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33. Thacker, 2008.
34. Bennett, K. K., Compas, B. E., Beckford, E. & Glinder, J. G. 2005. ‘Selfblame and distress among women with newly diagnosed breast cancer.’
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35. Janoff-Bulman, 1992.
36. Ibid.
37. Herman, 1992
38. Janoff-Bulman, 1992.
39. Frazier, P. A. 2000. ‘The role of attributions and perceived control in recovery
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Resick, P. A. 1993. ‘The psychological impact of rape.’ Journal of Interpersonal
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40. Bennet et al., 2005.
41. Foa & Rothbaum, 1998.
42. Frenkl, L. 2008. ‘A support group for parents of burned children: a South
African children’s hospital burns unit.’ Burns, 34(4): 565–9.
43. Janoff-Bulman, 1992.
44. Ibid.
45. Thacker, 2008.
46. Janoff-Bulman, 1992.
47. Frankl, V. 1964. Man’s search for meaning: an introduction to logotherapy.
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48. Tedeschi, R. G. & Calhoun, L. G. 2004. ‘Posttraumatic growth: conceptual
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49.
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Polatinsky, S. & Esprey, Y. 2000. ‘An assessment of gender differences in the
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Kaminer, D., Booley, A., Lipshitz, M. & Thacker, M. 2009. ‘Post-trauma
meaning making among South African survivors of different forms of trauma.’
Paper presented at the Coping and Resilience International Conference,
Dubrovnik/Cavtat, October.
Roe-Berning, S. 2009. ‘The complexity of posttraumatic growth: evidence
from a South African sample.’ Unpublished Masters dissertation. University
of the Witwatersrand, Johannesburg.
Linley, P.A. 2003. ‘Positive adaptation to trauma: wisdom as both process
and outcome.’ Journal of Traumatic Stress, 16(6): 601–10.
Tedeschi & Calhoun, 2004.
Harvey, M. R., Mischler, E. G., Koenen, K. & Harney, P. A. 2000. ‘In the
aftermath of sexual abuse: making and remaking meaning in narratives of
trauma and recovery.’ Narrative Inquiry, 10(2): 291–311.
Janoff-Bulman, R. & McPherson Frantz, C. 1997. ‘The impact of trauma
on meaning: from meaningless world to meaningful life.’ In M. Power &
R. Brewin (eds), The transformation of meaning in psychological therapies:
integrating theory and practice, pp. 91–106. Chichester: Wiley.
Tedeschi & Calhoun, 2004.
Lantz, J. & Lantz, J. 2001. ‘Trauma therapy: a meaning centered approach.’
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Linley, P. A. & Joseph, S. 2004. ‘Positive change following trauma and
adversity: a review.’ Journal of Traumatic Stress, 17(1): 11–21.
Helgeson, V. S., Reynolds, K. A. & Tomich, P. L. 2006. ‘A meta-analytic
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Zoellner, T. & Maercker, A. 2006. ‘Posttraumatic growth in clinical
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Linley & Joseph, 2004.
Helgeson et al., 2006.
Zoellner & Maercker, 2006.
Tedeschi & Calhoun, 2004.
Ibid.
Butler, 2007.

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64. Levine, S., Laufer, A., Hamama-Raz, Y., Stein, E. & Solomon, Z. 2008.
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Powell, S., Rosner, R., Butollo, W., Tedeschi, R.G. & Calhoun L.G. 2003.
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65. Zoellner & Maercker, 2006.
Chapter 5
1. Herman, J. L. 1992. Trauma and recovery: from domestic abuse to political
terror. London: Pandora.
2. Friedman, M. 2004. Post-traumatic stress disorder: the latest assessment and
treatment strategies. Kansas City: Compact Clinicals.
3. Raphael, B. & Dobson, M. 2001. ‘Acute posttraumatic interventions.’ In J.
Wilson, M. Friedman & J. Lindy (eds.). Treating psychological trauma and
PTSD. pp. 139–158. New York: The Guilford Press.
4. Ibid., quote on page 141.
5. Ibid., quote on page 145.
6. Mitchell, J. T. 1983. ‘When disaster strikes.’ Journal of Emergency Medical
Services, 8: 36–9.
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8. Friedman, 2004.
9. Mitchell, J. T., 1983.
10. Horowitz, M. S. 1992. Stress response syndromes. Northvale, N. J.: Jason
Aronson.
11. Dyregov, A. 1997. The process in psychological debriefings. Journal of
Traumatic Stress, 10(4): 589–607.
12. Rose, S. & Bisson, J. 1998. ‘Brief early psychological interventions following
trauma: a systematic review of the literature.’ Journal of Traumatic Stress,
11(4): 697–710, quote on page 698.
13. Ibid.
14. Ibid.
15. Foa, E., Rothbaum, B., Riggs, D. & Murdock, T. 1991. ‘Treatment of
posttraumatic stress disorder in rape victims: a comparison between
cognitive-behavioural procedures and counselling.’ Journal of Consulting
and Clinical Psychology, 59(5): 715–23.

Foa, E. & Rothbaum, B. 1998. Treating the trauma of rape. NewYork:
Guilford Press.
16. Resick, P. & Schnicke, M. 1992. ‘Cognitive processing therapy for sexual
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17. Meichenbaum, D. 1994. A clinical handbook/practical therapist manual
for assessing and treating adults with post-traumatic stress disorder (PTSD).
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18. Ehlers, A. Clark, D., Hackmann, A., McManus, F. & Fennel, M. 2005.
‘Cognitive therapy for post-traumatic stress disorder: development and
evaluation.’ Behaviour Research and Therapy, 43: 413–31.
19. Foa & Rothbaum, 1998.
20. Resick & Schnicke, 1992.
21. Meichenbaum, 1994.
22. Ehlers, A. & Clark, D. M. 2000. ‘A cognitive model of post-traumatic stress
disorder.’ Behaviour Research and Therapy, 38: 319–45.
23. Rothbaum, B., Meadows, E., Resick, P. & Foy, D. W. 2000. ‘Cognitivebehavioral therapy.’ In E. B. Foa, T. M. Keane & M. J. Friedman (eds).
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White, M. & Epston, D 1990. Narrative means to therapeutic ends. New
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31.
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Kaminer, D., Stein, D., Mbanga, I. and Zungu-Dirwayi, N. 2001. ‘The Truth
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Krupnick, J. L. 1980. ‘Brief psychotherapy for victims of violent crime.’
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Horowitz, 1992.
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Peterson, P., Prout, M & Schwarz, R. 1991. Posttraumatic stress disorder: a
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Friedman, 2004, quote on page 53.
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Krupnick, 1980.
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Edwards, D. 2009. ‘Treating posttraumatic stress disorder in South Africa:
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46. Prout, M. & Schwarz, R. 1991. ‘Posttraumatic stress disorder: a brief
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incidences: Part II.’ Psychoanalytic Psychotherapy in South Africa, 11: 8–13.
54. Garland, C. 1998. ‘Thinking about trauma.’ In C. Garland (ed.). Understanding trauma: a psychoanalytical approach, pp. 9–31. London: Karnac.
55. McCann, L. & Pearlman, L. 1990. Trauma and the adult survivor. New York:
Brunner Mazel.
56 . See Medical Foundation website, http//: www.torturecare.org.uk
57 . See IRCT website, http/:www.irct.org
58. Grootenhuis, K. 2007. ‘Therapeutic dilemmas in working with African
refugees in South Africa.’ Unpublished Masters dissertation. University of
the Witwatersrand, Johannesburg.
59. See CSVR website, http//:www.csvr.org.za, for the full report.
60. Foa, Davidson & Frances, 1999, cited in Marotta, S. 2000. ‘Best practices for
counsellors who treat posttraumatic stress disorder.’ Journal of Counselling
and Development, 78(4): 492–6.
61. Southwick, S. & Yehuda, R. 1993. ‘The interaction between pharmacotherapy
and psychotherapy in the treatment of posttraumatic stress disorder.’
American Journal of Psychotherapy, 47(3): 404–11.
62. Ibid., quote on page 408.
63. Marotta, 2000, quote on page 494.
64. Tucker, P. & Trautman, R. 2000. ‘Understanding and treating PTSD: past,
present and future.’ Bulletin of the Menninger Clinic, 64(3): 37–52, quote on
page 44.

176

Endnotes

65. Southwick & Yehuda, 1993.
66. Friedman, 2004.
67. Akinsulure-Smith, A. M. 2009. ‘Brief psychoeducational group work
treatment with re-traumatized refugees and asylum seekers.’ Journal for
Specialists in Group Work, 34 (2): 137–50.
68. Ibid., quote on page 58.
69. Friedman, 2004.
70. See National Peace Accord Trust website, http//:www.NPAT.org.za
71. Soderlund, J. 1999. ‘Go wild: wilderness therapy for trauma.’ New Therapist,
4: 32–3, quote on page 33.
72. See National Peace Accord Trust website.
73. Themba Lesizwe was an organisation set up with funding from the European
Union aimed at establishing a National Network of Trauma Care Providers
in South Africa and with hopes of creating wider Southern African links.
The original partners were the CSVR Trauma Clinic, the Natal Survivors
of Violence Project and the Cape Town Trauma Centre for Survivors of
Torture and Violence. However, the organisation expanded to include other
urban and rural bodies providing services of various kinds to trauma victims.
Themba Lesizwe held several conferences to discuss trauma intervention
programmes and initiatives and created a forum in which ideas could be
shared. There was an effort to document best practice and to establish a
common research data base of clients and interventions. Unfortunately the
organisation could not be sustained after the funding ran out in 2006–07.
74 . Khulumani, meaning ‘speak out together’, was the name of an organisation
formed to give expression to victims of apartheid who had testified at
the TRC or who had suffered from political violence but chose not to
become involved with the TRC. It was a self-help group that played both
a supportive and a lobbying function. For example, Kulumani arranged for
memorial and remembrance services and held regular meetings at which
members would share thoughts and feelings about their losses. In addition,
Khulumani lobbied the government for reparation for victims of apartheid,
and the organisation is still involved in a legal battle with large multinationals
over apartheid exploitation and the need for reparation. The group worked
initially under the auspices of the CSVR but then became an independent
organisation and expanded from a Johannesburg base into other regions.
The organisation has been less visible of late and seems to have lost some of
its post-TRC momentum.
75. Friedman, 2004.
76. Tucker & Trautman, 2000, quote on page 43.
77. Marotta, 2000, quote on page 494.
78. Ibid.

177

Traumatic Stress in South Africa

79 . Cited in Tucker & Trautman, 2000, quote on page 44.
80. Tucker & Trautman, 2000.
81. Eagle, G. 2005b. ‘Grasping the thorn: the impact and supervision of
traumatic stress therapy in the South African context.’ Journal of Psychology
in Africa, 15(2): 197–208.

Edwards, D. 2005a.

Edwards, D. 2005b. ‘Critical perspectives on research on post-traumatic
stress disorder and implications for the South African context.’ Journal of
Psychology in Africa, 15(2):117–24.
82. Grootenhuis, 2007.
83. Straker, G. & the Sanctuaries Counselling Team. 1987. ‘The continuous
traumatic stress syndrome: the single therapeutic interview.’ Psychology in
Society, 8: 46–79.
84. Ibid.
85. Edwards, 2005a.

Straker, 1987.
86. Grootenhuis, 2007.
87. Eagle, G. 2005a. ‘Therapy at the cultural interface: implications of African
cosmology for traumatic stress intervention.’ Journal of Contemporary
Psychotherapy, 35(2): 199–210.

Straker, G. 1994. ‘Integrating African and Western healing practices in South
Africa.’ American Journal of Psychotherapy, 48(3): 455–67.
88. Eagle, 2005a.
89. Louw, D. & Pretorius, E. 1995. ‘The traditional healer in a multicultural
society: The South African Experience.’ In L. Adler & B. Mukerji (eds).
Spirit versus scalpel: Traditional healing and modern psychotherapy, pp.41–57.
Westport, Connecticut: Bergin & Garvey.
90. Benn, M. 2007. ‘Perceived alterations in racial perceptions of victims of violent
crime.’ Unpublished Masters dissertation. University of the Witwatersrand,
Johannesburg.
91. Ibid.
92. Sibisi, H. 2008. ‘The understanding and approach of trained volunteer
counsellors to negative racial sentiments in traumatized clients.’ Unpublished
Masters dissertation. University of the Witwatersrand, Johannesburg.

Fletcher, T. 2008. ‘How do psychodynamically oriented therapists understand,
respond to, and work with negative racial sentiments amongst traumatized
clients?’ Unpublished Masters dissertation. University of the Witwatersrand,
Johannesburg.
93. Sibisi, 2008.
94. Fletcher, 2008.

178

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95. Meintjes, B. 1999. ‘Where violence has been: rural trauma work.’ New
Therapist, 4: 18–22.
96. Edwards, 2005b
97. Christie, K. 2000. The South African Truth Commission. Great Britain:
Macmillan.

Gibson, J. L. 2004. Overcoming apartheid: can truth reconcile a divided
nation? Cape Town: HSRC Press.

Stein, D., Seedat, S., Kaminer , D., Moomal, H., Herman, A., Sonnega, J. et al.
1998. ‘Impact of the Truth and Reconciliation Commission on psychological
distress and forgiveness in South Africa.’ Social Psychiatry and Psychiatric
Epidemiology, 43: 462–8.
98. Eagle, 2005b.

Wilson, J. P. & Lindy, J. D. 1999. ‘Empathic strain and countertransference.
In M. J. Horowitz (ed.). Essential papers on posttraumatic stress disorder, pp.
518–43. New York: New York University Press.
99. Edwards, 2005a.
Chapter 6
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2. Myer, L., Stein, D., Jackson, P., Herman, A., Seedat, S. & Williams, D. 2009.
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secondary school completion.’ South African Medical Journal, 99(5): 254–
356.
3. Seedat, S., Nyamai, C., Njenga, F., Vythilingum, B. & Stein, D. 2004.
‘Trauma exposure and post-traumatic stress symptoms in urban African
schools: survey in Cape Town and Nairobi.’ British Journal of Psychiatry,
184: 169–75.
4. Ensink, K., Roberstson, B., Zissis, C. & Leger, P. 1997. ‘Post-traumatic stress
disorder in children exposed to violence.’ South African Medical Journal,
87(11): 1526–30.
5. Shields, N., Nadasen, K. & Pierce, L. 2008. ‘The effects of community
violence on children in Cape Town, South Africa.’ Child Abuse and Neglect,
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6. Ward, C. L., Flisher, A. J., Zissis, C., Muller, M. & Lombard, C. 2001.
‘Exposure to violence and its relationship to psychopathology in adolescents.’
Injury Prevention, 7: 297–301.
7. Ward, C., Martin, E., Theron, C. & Distiller, B. 2007. ‘Factors affecting
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Cairns, E. & Dawes, A. 1996. ‘Children: ethnic and political violence   –  a
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24. Barbarin et al., 2001.
25. Cluver, L. & Gardner, F. 2006. ‘The psychological well-being of children
orphaned by AIDS in Cape Town, South Africa.’ Annals of General
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26. Duncan, N. & Rock, B. 1997a. ‘Going beyond the statistics.’ In B. Rock
(ed.). Spirals of suffering: public violence and children, pp. 69–114. Pretoria:
HSRC Publishers.
27. Emmet, T. 2003. ‘Social disorganisation, social capital and violence
prevention in South Africa.’ African Safety Promotion: A Journal of Injury
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28. Qouta et al., 2003.

Shannon et al., 1994.

Yule, W. 2003. ‘Early intervention strategies with traumatised children,
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29. Nader, K. O. 1997. ‘Assessing traumatic experiences in children.’ In J. Wilson
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30 . Nader, 1997, quote on page 306.
31. Terr, L. 1991. ‘Childhood trauma: an outline and overview.’ American Journal
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32. Ibid.
33. Ibid.
34. Ibid.
35. American Psychiatric Association, 2000.
36. Ibid.
37. Terr, 1991.
38. Ibid.
39. Ibid.
40. Eth, S. & Pynoos, R. S. 1985. ‘Developmental perspectives on psychic trauma
in childhood.’ In C. Figley (ed.). Trauma and its wake, pp. 36–52. New York:
Brunner Mazel.
41. Erikson, E. 1950. Childhood and society. New York: Norton.
42. Yule, W., Perrin, S. & Smith, P. 1999. ‘Post-traumatic stress disorders in
children and adolescents.’ In W. Yule (ed.). Post-traumatic stress disorders:
concepts and therapy, pp. 25–50. Chichester: John Wiley and Sons.
43. Reported in interview with school principal on 702 radio station in early
March, 2008. The school march was also documented in local newspaper,
The Northcliff Melville Times, 10–16 March, 2008.
44. American Academy of Child and Adolescent Psychiatry 1998. ‘Practice
parameters for the assessment and treatment of children and adolescents

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45.


46.
47.

48.

49.
50.
51.

52.

53.
54 .

55.

56.
57.
58.
59.

60.
61.

with posttraumatic stress disorder.’ Journal of the American Academy of
Child and Adolescent Psychiatry, 37(Supp.): 4–26.
Barbarin et al., 2001.
Dawes, A. & Tredoux, C. 1989. ‘Emotional status of children exposed to
political violence in the Crossroads squatter area during 1986/87.’ Psychology
in Society, 12: 33–47.
Qouta et al., 2003, quote on page 265.
Gil-Rivas, V., Chen Silver, R., Holman, E., McIntosh & Poulin, M. 2007.
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Levy, S. & Lemma, A. 2004. ‘The impact of trauma on the psyche: internal
and external processes.’ In S. Levy & A. Lemma (eds). The perversion of
loss   –  psychoanalytic perspectives on trauma, pp. 50–70. New York: Brunner
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Janoff-Bulman, J. 1992. Shattered assumptions: towards a new psychology of
trauma. Toronto: Free Press.
Rock, B. 1997. ‘Introduction.’ In B. Rock (ed.). Spirals of suffering: public
violence and children, pp. i–v. Pretoria: HSRC Publishers, quote on page v.
Butchart, A., Phinney, A., Check, P. & Villaveces, A. 2004. Preventing
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Duncan, N. & Rock, B. 1997b. ‘Overview.’ In B. Rock (ed.). Spirals of
suffering: public violence and children, pp. 31–42. Pretoria: HSRC Publishers,
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B. Rock. 1997.
Duncan, N. & Rock, B. 1997c. ‘Children and violence: quantifying the
damage.’ In B. Rock (ed.). Spirals of suffering: public violence and children,
pp. 43–67. Pretoria: HSRC Publishers.
Langa, M. & Eagle, G. 2008. ‘The intractability of militarised masculinity: a
case study of former combatants in the Kathorus area, South Africa.’ South
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Cluver & Gardner, 2006.
Ibid., quote on page 13.
Ibid., quote on page 13.
Cluver, L., Fincham, D. & Seedat, S. 2009. ‘Posttraumatic stress in Aidsorphaned children exposed to high levels of trauma: the protective role of
perceived social support.’ Journal of Traumatic Stress, 22(2): 106–112.
Yule, 2003.
Seedat, S., Stein, D., Ziervogel, C., Middleton, T., Kaminer, D., Emsley,
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62.



63.

64.

65.
66.

67.
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reuptake inhibitor in children, adolescents, and adults with posttraumatic
stress disorder.’ Journal of Child and Adolescent Psychopharmacology, 12(1):
37–46.
Cohen, J. A., Berliner, L. & March, J. S. 2000a. ‘Treatment of children and
adolescents.’ In E. B. Foa, T. M. Keane & M.J. Friedman (eds.). Effective
treatments for PTSD: practice guidelines from the International Society for
Traumatic Stress Studies, pp. 106–38. New York: Guilford.
Cohen, J. A., Berliner, L. & March, J. S. 2000b. ‘Treatment guidelines:
Treatment of children and adolescents.’ In E. B. Foa, T. M. Keane & M.J.
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International Society for Traumatic Stress Studies, pp. 330–2. New York:
Guilford.
Pynoos, R. S. & Eth, S. 1986. ‘Witness to violence: the child interview.’
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Leibowitz, S., Mendelsohn, M. & Michelson, C. 1999. ‘Child rape: extending
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See National Peace Accord Trust website, http/:www.NPAT.co.za
See REPSSI website, http//:www.REPSSI.co.za
Shields et al., 2008.
Ward et al., 2007.
The South African Institute for Journalism Studies has recently been looking
into policy in this regard.

Chapter 7
1. See South African Human Rights Commission website for report, http//:www.
sahrc.org.za
2. Manson, S. P. 1997. ‘Cross-cultural and multiethnic assessment of trauma.’
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Marsella, A. J., Friedman, M. J. & Huland Spain, E. 1996. ‘Ethnocultural
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Marsella, M. J. Friedman, E. T. Gerrity & R.M. Scurfield (eds). Ethnocultural
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3. Kim, U. & Berry, J. W. 1993. ‘Introduction.’ In U. Kim & J. W. Berry (eds).
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Manson, 1997.
4. Kleinman, A. 1986. Social origins of distress and disease. New Haven: Yale
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Lewis-Fernandez, R. & Kleinman, A. 1995. ‘Cultural psychiatry: theoretical,
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Swartz, L. 1998. Culture and mental health: a Southern African view. Cape
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5. Peltzer, K. 1998. ‘Ethnocultural construction of posttraumatic stress
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ABOUT THE AUTHORS

Debra Kaminer is a senior lecturer in the Department of Psychology at
the University of Cape Town. She conducted her doctoral dissertation
on the psychological effects of giving testimony to the Truth and
Reconciliation Commission, while based at the Medical Research
Council’s Unit on Anxiety and Stress Disorders. She has also published
journal articles and book chapters, and presented conference papers,
in the areas of childhood trauma and PTSD, the link between different
forms of violence and PTSD in the South African population, and the
use of testimony and trauma narratives in interventions with survivors.
In addition to her research, she has counselled trauma survivors
in her own clinical practice, supervised the clinical work of trainee
psychologists working with traumatised adults and children, and
provided consultation for a number of volunteer organisations that
work with trauma survivors. She is currently conducting research aimed
at documenting the knowledge accumulated by trauma counsellors and
clinicians in South Africa.
Gillian Eagle is a professor of Psychology in the School of Human
and Community Development at the University of the Witwatersrand.
She has worked in the traumatic stress field as researcher, clinician
and activist over a period of about twenty-five years. She has offered
counselling, training, supervision and consulting services to a range of
non-governmental organisations working in the trauma field, including
People Opposing Women Abuse (POWA), Durban Rape Crisis, the
Organisation for Appropriate Social Services in South Africa (OASSSA),
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the National Peace Accord Trust (NPAT), the South Africa Institute for
Traumatic Stress (SAITS) and the Centre for the Study of Violence and
Reconciliation (CSVR). Her doctorate was on the experiences of men
who had been victims of violent crime and she has supervised a number
of research studies in the traumatic stress field. She has presented at
several international and national conferences and published journal
articles and book chapters on a range of topics relating to traumatic
stress. Although her interest in the field is broad, she has a particular
interest in attributional, gender-related and socio-political aspects of
trauma. She continues to work in the area of traumatic stress as both
clinician and researcher.

206

INDEX

adolescents 7, 15, 122, 126, 128,

134–136, 144, 152
direct victims or witnesses 122–
124, 126, 128
abuse
exposure to violent crime 124
and adulthood 122
at risk 107
of children 44, 148, 151
sexual abuse 19, 127
chronic 151
adrenergic blockers 104
and early or prolonged
adulthood

trauma 48
abusive relationship patterns 48
and inequities in society 4
psychiatric effects of trauma in
physical abuse 21–22, 44, 52

SA 49–58
physical, sexual and emotional
adversity
17
finding value and purpose in
prolonged exposure to 44–47, 57

72–77
women and children in the home
identification of meaningful
48

outcomes 73
see also intimate partner abuse;
affect dysregulation 129
prolonged abuse; sexual
African National Congress (ANC)

abuse; substance abuse
13, 119
accident, traumatic 36, 68, 75
aggressive outbursts 51
accidental injury 8–9, 148
agoraphobia 42–43
active participation models 107
AIDS 128
acute (or ‘frontline’) interventions
Congolese orphans 127
83–88
orphans 127, 138
see also debriefing
parental bereavement 137, 138–
Acute PTSD 33, 82
139
Acute Stress Disorder (ASD) 33–34, shame and stigmatisation 139
80, 82, 103, 104, 125, 126
story book project 144
adaptation to trauma 153
see also HIV/AIDS
Please note: Page numbers in italics
refer to Figures, Tables and Boxes.

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Traumatic Stress in South Africa

alcohol consumption 14–15
alternative interventions 80
altruistic social causes 74
American Indian Sweat Lodge

practices 107
Amnesty International 9
ANC, see African National Congress
ancestors 114
anger, difficulty with modulating

151
anti-apartheid
activists 49
struggle 10
anti-Arab prejudice and 9/11 116
anti-black sentiments 115
anticipation of injury and
traumatisation 130
anticonvulsants 104
antidepressants 103
anti-ethnic sentiments 115
anxiety 29, 50, 51, 81–82, 89–90, 97,
103, 153
adolescents 104
anticipatory 130
children 125
management 109, 113
anxiolytic medications 103–104
apartheid era 9–13, 154
children and trauma 126, 137
political violence 49–50
raids of counselling centres 50
applied kinesiology 96–97
appreciation of self 79
armed car hijackings 15
armed forces 138
armed robberies 52, 86
arrest 138
ASD, see Acute Stress Disorder
assumptions 79
making sense of violent people
67–68
pre-existing and negative 62

shattering of 61–63
‘stuff happens’ versus ‘a greater
plan’ 63–66
asylum seekers 102, 106, 111
attachment, attacks on 136
attempted murders 52
see also murder
attitudes, changed 130
authority
loss of faith in 129
over traumatic material 106
autonomy, development of 133
avoidance
objects, situations and people 89
symptoms 32, 53, 54, 78, 79, 94,
109, 131, 150
of traumatic material 148
behavioural changes 53
belief systems 35–36, 40, 60, 61, 65,
69–70, 72, 79
fundamental 153
loss of 129
see also schemas
benzodiazepines 104
bereavement, traumatic 12, 23–24,
75, 95
and children 144
loss of child 108
making sense of 65
men and women 24
best practice 108–109
bewitchment 114
biological factors 36
bipolar disorder 103
blanking out 44
body-oriented interventions 80–81
Borderline Personality Disorder
46–47, 130
BPP, see Brief Psychodynamic
Psychotherapy


208

Index

brain
amygdala 37
childhood development and

trauma 46
hippocampus 36, 37
imaging studies 36
imaging technology 103
structure and functioning 37
Brief Psychodynamic Psychotherapy
(BPP) 92–94
burn injuries 23, 148
Camden Trauma Clinic (London) 83
simple and complex forms of

trauma 83
cancer 68, 69, 70, 75, 108
caretakers 99, 133–136, 140–141
reports 128
support 139
cash-in-transit heists 15
cash transport business 84
causal explanations and linkages

62–63
cause-and-effect laws of universe 63
CBT, see Cognitive Behavioural
 Therapy Centre for the
Study of Violence and
Reconciliation (CSVR) 12,
13, 113
characterological defects 67
childhood
burn injuries 23
chronic pelvic pain 45
conversion of emotional distress
into bodily pain 45
developmental difficulties 125
developmental stages 151–152
disability 23
histories of trauma 38
identification with adults 147
indecent assault against children
19

non-natural death 23
personality formation 122
rape 19, 128
sexual abuse 19, 44, 45, 128
soldiers 138
trauma 98
trauma and brain development
46
violence 19
vulnerability of abused children
40
childhood trauma treatment
community interventions 139
counselling 139
debriefing 140
group psychotherapy 139
individual treatment 139
organisational interventions 139
parent or caretaker support 139
pharmacotherapy or drug

treatment 140
psychotherapy 140
children and trauma 122–123
aggression 126, 127
behaviour 122
demographic features 124
developmental differences in

presentations 132–135
developmentally specific

manifestations 152
familial dimensions 135–136
impact of different forms 129–

132
intervention (case study) 142–

143
prevalence 123–129
social and community dimensions
135–139
treatment 139–141, 144–145
Type I and Type II Disorders

129–131

209

Traumatic Stress in South Africa

choice-point in survivor’s life 76
chronic illness 75
Chronic PTSD 33, 82
chronic trauma exposure 45, 152
CIDI, see Composite International
Diagnostic Interview
CISD, see Critical Incident Stress

Debriefing
civil conflicts 124
class differences 124, 153
Cognitive Behavioural Therapy
(CBT) 88, 89–91, 105, 106, 113, 140
and EMDR intervention 97
psychoeducational component
90
treatment protocol 83
cognitive map of the world 61
Cognitive Processing Therapy (CPT)
89
cognitive restructuring 89, 97, 113
cognitive theories 36
Cognitive Therapy (CT) 89, 109
coherence, sense of 39–40
cohesion 136
collective creative activities 107
colonisation and oppression 13
combat-related trauma exposure 85
community
cohesion 81
economically disadvantaged 48
initiatives 6
interventions 119–120
ongoing violence 153
psychology perspectives 136
re-engagement with 81
stability 136
support and resilience 154
violence 48–49, 77, 126, 144
work 94
community-based interventions 80,
81, 144–145

compassion
and empathy 73–74
fatigue 121
Compassionate Friends 108
complex PTSD concept 44, 46, 48
case study 47
Composite International Diagnostic
Interview (CIDI) 55–56
comprehensibility, search for 62
concentration difficulties 43, 133–

134
consciousness, alterations in 44
continuous community violence

28–29, 58
continuous traumatic stress
syndrome 48–49, 110–114
continuous traumatisation 77, 152,
154
controlling abuser 45
coping 2, 152
avoidant styles of 53
comparing with other survivors
71–72
mechanisms 44–45
and resilience 153
resources 113
short-term strategy 79
styles 40
core beliefs, see assumptions
counselling 80
long-term 82
sense of choice in engaging in 82
counselling, short- and medium-term
88
brief psychodynamic approaches
92–94
integrative approaches 94–96
mainstream approaches 88
countertransferences 121
couple counselling 101
CPT, see Cognitive Processing

Therapy

210

Index

adolescents 127
children 125
mild 29
vulnerability for 40
desensitisation to trauma 26–27, 96,
97
DESNOS, see Disorders of Extreme
Stress Not Otherwise
Specified
detachment from self 33, 44–45, 130
detention without trial 9, 11, 49, 52,
138
diagnostic symptom, severity of 82
disease 139
study of global burden 14
discrimination 137
disempowerment
educational 37
feelings of 152
disillusionment 133
Disorders of Extreme Stress 48,

149, 151
Disorders of Extreme Stress Not
 Otherwise Specified
(DESNOS) 44
displaced children 125
dissociation 33–34, 44–45, 129
Dissociative Identity Disorder 44,
deaths

98, 130
politically motivated 12
distraction technique 97
see also bereavement, traumatic
distress 2, 23, 28, 38, 55–56, 66, 67,
debriefing 82, 83–84, 110
68, 73, 140, 146, 153
children 140
in caretakers or mother 132,
group and individual 85

135–136
risk for development of

and
fear 31
pathology 87
forms
of 125
see also Psychological Debriefing
hardiness
or resiliance to 39
(PD)
levels 70, 77–78, 123
Delayed-onset forms of PTSD 33,
protection of children from 144

82
denial of difficulties 79
subjective experience of 59
depression 42, 43, 50, 51, 53, 54, 55, domestic abuse and violence 4, 8–9,
56, 104, 149
53, 77, 126
creative models of therapy 107, 141,
144
crime 8, 75, 67–68
criminal justice system 110–111,

113, 115
criminal victimisation rate 14
criminal violence 8–9, 13–15, 52,

128
crisis intervention 83
Critical Incident Stress Debriefing
(CISD) 85
optimal dosing concept 86
psychoeducational component
86
seven steps of intervention 85
crossroad in survivor’s life 76
cross-sectional research 57
CSVR, see Centre for the Study of

Violence and Reconciliation
CT, see Cognitive Therapy
cultural belief frameworks 65
traditional African 81
cultural differences 153
cultural hybridity 6
cultural norms and expectations 63
cutting of self 45
cutting-off defences 130

211

Traumatic Stress in South Africa

degree of violence 21
see also intimate partner violence
downward comparison 71
drug
habit and crime 67
treatment 80, 104
DSM-IV-TR Diagnostic Criteria 30,
129, 130–131, 152
dysthymia 42, 43
EA, see Employee Assistance
eating disorders 45
economic deprivation 49
economic stressors 51
education 123
high school 123
state 154
structures 125
verbal and reading ability 128
Ego-Psychology tradition 93
EMDR, see Eye Movement
Desensitisation and Reprocessing
emergency
interventions 83
service workers 85
support 88
emic perspective on mental health
149–150
emotional humiliation and

degradation 11
emotionally damaging experiences
29–30
emotional numbing 50
Employee Assistance (EA) personnel
86
environment 45–46, 110, 111, 113,
122, 135
environmental experiences 37
environmental factors 36
fears and real threats 113
environmental interactions 40
equilibrium, seeking to re-establish
62

etic perspective on mental health

149–150
evidence-based practice, see best

practice
ex-combatants 51, 85
self-help and peer support
groups 108
Technikon SA and CSVR

programme 102
existential crisis 60
ex-liberation soldiers 13
explanatory strategies 76
exposure
techniques 96, 113
to trauma by children 123–125
to trauma in South Africa 148
exposure-based approaches 96–97
exposure-oriented therapy 103, 109
Eye Movement Desensitisation and
Reprocessing (EMDR) 88,
96, 97–98
faith and belief systems 65
ancestors in spirit world 65, 66,
114
cause-and-effect 65–66
‘crisis of faith’ 65
Hindu concept of karma 65–66
prayer 113, 144
religious ceremony 113
witchcraft 66
family
instability 124
separation from 125
violence 128
fantasy
guided 113
lives of children 133
fatigue 55
female(s)
gender and PTSD 37
university students 19–20

212

Index

fire fighters 85
flashbacks 31–32, 35, 51, 103, 109
fragmentation, feelings of 44
Freud 80
functioning, impairment of 43
fundraising for trauma organisation
74
gang(s) 14
culture 67
membership 15
rape 21, 25
violence 48
gastrointestinal discomfort 45
gender 37, 40, 124, 137
gender-based violence 16–21, 53,

151
gene-environmental factors 40
general distress 55
genetic and environmental

interactions 40
genetic basis 38
genetic vulnerability 40
genocide 9, 124
Goldstone Commission 137
group
initiatives 6
interventions 141, 144–145
psychotherapy 105–108
support for pupils 134
therapy 101
guilt feelings 45, 109
gun warfare 48
hallucinations 132
health and educational structures
breakdown 124–125
hijacking 32, 52
armed 15
case study 34
historical circumstances and events
124

HIV/AIDS 4, 25, 53–54, 68, 152
adherence to treatment 53
group psychotherapeutic
interventions 108
see also AIDS
HIV-positive children 141
homicide rate 14
honour, defending of 15
hopelessness, unrelenting 129
house arrest 138
human-inflicted trauma 126
human rights
abuses 9, 51, 67
violations 108
Human Rights Watch 18
hyperarousal symptoms 104, 109,

131, 150
see also physical arousal
hypnotherapy 94
IFP, see Inkatha Freedom Party
impaired cognitive functioning 50
incest, study of survivors 67
indirect exposure to trauma 148
indirect traumatisation 23–24
individual psychotherapy and
counselling
acute or ‘frontline’ interventions
83–88
context 81–83
see also counselling, short- and

medium-term
individual therapy 101
information-processing approach 94
injury 8, 75, 128
Inkatha Freedom Party (IFP) 13,

119
insight-oriented approach 94, 103
integrative approaches 94–96
inter-gang violence 14
inter-group
mediation 119
prejudice 115

213

Traumatic Stress in South Africa

International Rehabilitation Council
for Torture Victims (IRCT)
101
interpersonal bonds 81
interpersonal intimacy 73
interpersonal violence 4, 67
interventions 80–81
approaches 153
preventive and secondary 124
principles of 96
societal level 120, 139
traumatised child (case study)

142–143
see also individual psychotherapy
and counselling;
pharmacotherapy
interviews 51, 128, 149
intimate partner abuse 16–17, 21,

44, 53, 147, 151
see also domestic abuse and

violence
introspection 106
intrusive symptoms 78, 131
images 35
recollections 54
intrusive thoughts 109
IRCT, see International
Rehabilitation Council for
Torture Victims
irritation 55
Israeli military 84
Khulumani organisation 108
killings, politically motivated 12,

138
see also murder
language
assessment in first language 56
barriers 90–91
groups 15
linguistic differences 153

legal services 130
life
prior experiences 99
stories, re-authoring of 91
traumatic events 123
life-threatening events, exposure to
55
life-threatening illness 25, 68
lithium 104
lobbying 92
local knowledges 147, 150–151, 152,
154
locus of control, internal and

external 39
logotherapy theory (Victor Frankl)
72–73
longitudinal research 57
long-term approaches to trauma
therapy 98
multi-dimensional treatment

101–102
psychodynamic treatment 98–

101
loss, experiences of 45, 108, 129,

136
love and acceptance, need for 45
male-on-male violence 15
marginalisation, economic and

political 152
masculine behaviour, normative

notions of 15
mass displacement of people 124
meaninglessness, sense of 79
meaning-making 79, 106, 153
in adaptation to trauma 152–153
contextual influences 6
individual influences 6
meaning systems 6, 60, 72
culturally unique 149
Medical Foundation (United

Kingdom) 101

214

Index

medicalisation of suffering 41
memorials 119–120
memories 29
repeatedly perceived 130
traumatic 35
visualised 130
memory disturbances 148
mental avoidance 32
mental health 1, 3, 6, 47
access to resources 55–56
of children 122–123
problems 6
research approaches 149–150
unmet needs 51
workers 154
military
interventions 83
violence and Palestinian children
125
mining sector accidents 26
mood
disorders 42
stabilisers 104
moral concerns 3
mortality surveys 14–15
non-intentional injury 22
motor vehicle accidents (MVAs) 44,
86, 128
pedestrians 22
see also road traffic accident

injuries
muggings
asylum seekers 111
youth at risk 15
multi-dimensional treatment 98,

101–102
Multiple Personality Disorder, see

Dissociative Identity Disorder
multiple trauma exposure 9, 57, 58,
152, 153

multiple traumatic stress 110–114
multiple traumatisation 24–25
murder
of political activists 10
rate in South Africa 14
of young black men 12
MVAs, see motor vehicle accidents
narrative constructivist 91
narratively organised memory 36
narrative therapy 91–92, 140
National Network of Trauma Service
Providers (Themba Lesizwe) 107
National Peace Accord Trust

(NPAT) 106, 144
natural and supernatural world 66
natural disasters 36, 68, 86, 125–126
negative stereotypes 115
negativity about future 90
neoterics or power therapies 88,

96–98
neurobiological features 38
neurobiology of traumatic stress 103
neurochemical response to trauma
37–38
Neurolinguistic Programming (NLP)
96–97
NGOs, see non-governmental

organisations
nightmares 51, 103, 133
NLP, see Neurolinguistic
Programming
non-governmental organisations

(NGOs) 5, 107, 154
non-intentional injury 22–23
see burn injuries; road traffic

accident injuries
non-sexual violent crime 14, 53
NPAT, see National Peace Accord

Trust
numbing 32, 130, 150

215

Traumatic Stress in South Africa

occupational deployment 101
occupational skills development 119
occupations and trauma 54–55
‘omens’ or premonitions about

events 131
opportunistic criminal assaults 48
oppression 4, 67
oral story telling practices 91
orphaned children 125, 127, 138
over-generalisation 90
pain 45
no medical basis 51
perception 132
panic
attacks 104
disorder 51
paralysis in parts of the body 45
paramedics 85
parental distress 135–136
parents 135–136
psychoeducation of 140
pathology, children at risk of 128
PD, see Psychological Debriefing
PE, see prolonged exposure
peer support and networks 108
People Opposing Women Abuse

(POWA) 3
perceptions
of self 73
of therapy 99–100
perpetrator
intentional state of 67
motivations of 67
personal agency or potency 91
personal and social ills 4
personal competence and control 61
personal identity, disturbed sense

of 44
personality
changes after catastrophic

experience 44

features 39–40
formation of children 122
pharmacology (drug treatment) 80
pharmacotherapy 103–105
philosophy of life 74
phobias 42, 43, 149
physical arousal (hyperarousal) 33,
53
physical assaults against women and
children 147
physically threatening experiences
29
intense fear, helplessness or

horror 31
physical symptoms 125
PIE, see Proximity, Immediacy and
Expectancy
play therapy 109, 140
policing 130
political activists 111
abductions of 9, 10, 12
political detention 10, 11
political prisoners 50, 51
political protestors 10
political repression 92, 137
political violence 4, 8, 9–13, 50, 51,
147
adult men and women 13
black male youths and children
13
children during apartheid 126
exposure to 12–13
‘severe ill-treatment’ 12
see also under apartheid era
post-trauma
benefits (study) 63, 64, 75
growth 75
meaning-making 75
pathology 153
resilience 153
space 153
variables 40

216

Index

Post Traumatic Growth Inventory

(PTGI) 74–75
Posttraumatic Stress Disorder

(PTSD) 1–2, 6, 28, 80
case study 34
children 123, 125–129
community violence 48–59
comorbid psychiatric disorders
43, 43, 55, 104–105, 149
controlled clinical trials of
psychotherapeutic treatment
109
diagnosis of symptoms 29,

126–127
diagnostic category 149
disorders associated with 42–43
explanations for 35–40
medication 103
politics of 40–42
psychiatric and social
perspectives 41–42
risk for developing 36
symptoms 31–33
symptom scales 149
versus normal trauma reactions
29, 31–34
poverty 23, 38, 67, 137, 148, 152,

154
POWA, see People Opposing

Women Abuse
power, collaborative 91
powerlessness, feelings of 61
premonitions about events 131
primary health care clinics (SA) 55
priorities, re-ordering of 74
projective tests 128
prolonged abuse 28, 57–58, 151
prolonged exposure (PE) 89
prolonged trauma 129
prosecution 92
protection, formal systems of 113

protective factors 39
protest politics, youth involvement
in 137–138
Proximity, Immediacy and

Expectancy (PIE) 84
psychiatric disorders 28
post-apartheid era 50–51
psychiatric medication 103
psychoanalytic trauma treatment

98–101
psychodynamic psychotherapy 94,
105, 140
psychodynamic therapy 88
psychodynamic treatment 93–94,

98–101
psychoeducation 109, 119, 140
Psychological Debriefing (PD) 85,
86
psychological first aid 83, 88
psychological growth 153
psychological torture 11
emotional humiliation and
degradation 11–12
fear of reprisals 12
shame and humiliation 12
psychological trauma 2
Psychology in Society (journal) 50
psychosocial support 101
psychosocial theory of development
(Erikson) 133
psychotherapeutic intervention 6, 80
individual- or group-focused 81
see also counselling, short- and
long-term psychotherapy,
short-or long-term 82
psychotic symptoms and
hospitalisation 105
psychotropic medication 80–81
PTGI, see Post Traumatic Growth
Inventory
PTSD, see Posttraumatic Stress

Disorder
public testimony 92

217

Traumatic Stress in South Africa

questioning of self 79
questionnaires 56, 149
race 124
groups 15
sensitivities 6
racial differences 153
racial sentiments 116
implications 117–118
racism 115
rape 18, 36, 57
legal definition of 18
and sexual assault 18
survivors 53, 67, 70, 94, 151
Rape Crisis organisation 3
rapid eye movements 97
reality-based fear 133
reckless behaviour 134
recovery
context 137
environment 110
redefining the event and impact

71–71
re-education camp attendance 138
re-experiencing of trauma 31–32,

35, 53, 103, 131, 147, 150
see also flashbacks
refugee populations
African and Asian 91
Africans in South Africa 101–

102, 112
children 141
children living in camps 125
Sudanese in Uganda 57, 150
victims of torture in Europe and
England 101
rehabilitation, physical and
psychological 101

relationships 46, 56–57, 73–74, 136
abusive 17
familial 20
improvements in 73

patterns in 45
with therapist 99
relational networks 105–106
relaxation
techniques 113
training 89
repetition compulsion 35
repetitive behaviours 130
research 4–7, 44
cross-sectional 57
international field 5–6, 58
moral and academic concerns 3
neurobiological and
developmental 46
qualitative 5, 150, 152
quantitative 5
moral and academic concerns 3
physical violence against women
16–17
populations of trauma survivors
78–79
psychiatric effects of trauma

49–58
published in South Africa 148–
149
resources 136
barriers to 90–91
response to traumatic incidents 123,
131
restitution 92, 120
retributive acts 115
rigidity of identity 138
risk-taking 15
rituals 119–120
and practices 81
for protection 132
road traffic accident injuries 4, 22,
54
serious car accident 44
robberies
armed 52, 86
rate in South Africa 14, 15

218

Index

use of firearms 15
use of knives 15
youth at risk 15
role-plays 90
saccadic or rapid eye movements 97
SADF, see South African Defence

Force
SADHS, see South African
Demographic and Health
Survey
safety, sense of 81, 82, 110, 111
Sanctuaries Counselling Team

111–113
SANDF, see South African National
Defence Force
SASH, see South African Stress and
Health
schemas 35–36, 40, 60, 61, 69–70
accommodation 35
assimilation 35
school
playground games about violence
146–147
problems 125
violence 48, 152
violence in Western Cape 146
school-based projects 139
security
industry (SA) 84
systems 154
sedatives 103–104
selective serotonin reuptake

inhibitors (SSRIs) 103
self-blame 40, 45, 68–72, 140
behavioural 68–69, 70
characterological 69–70
self-capacities, development of 100
self-destructive behaviours 129
self-esteem 69–70, 151
self-help initiatives 108

self-medication 43
self-psychology
models of intervention 110
orientation 100
self-recrimination 90
self-reflection 106
self-reliance 101
self-report
measures 128
symptom scales 150–151
self-sufficiency 101
self-worth 69–70
sensory experience 36
sexual abuse 19, 44, 45, 127, 128,

144
sexual assaults 36, 48, 52, 147
degree of violence 21
rates of fatal assaults 148
sexual coercion 16, 144, 148
sexual molestation 18
sexual violence 4, 16, 17–18, 148
under-reported 20
shame, feelings of 45, 46, 109
significance, search for 72–79
explanatory strategies 76
single event traumas 131
SIT, see Stress Inoculation Training
skills training 101, 102
sleep
difficulties 43
disturbances 103, 109
sleeping tablets 103–104
social activists 154
social activities 144
social alienation 115–116, 138
social bonds 106
social capital 136
social inequalities 41
social isolation 45
social phobia 42, 43
social problems 4

219

Traumatic Stress in South Africa

social support
AIDS-orphaned children 139
lack of 38–39
social welfare systems 154
social withdrawal 53
societal attitudes of blame 70–71
societal stability 136
society, power imbalances in 41
socio-economically disempowered
154
socio-economic status 58
socio-political circumstances 124
somatic complaints 51, 150, 152
somatisation disorder 50, 55, 129
South African Defence Force

(SADF) 84–85
South African Demographic and
Health Survey (SADHS)
intimate partner physical abuse
17, 18
sexual abuse in childhood 19
South African Human Rights

Commission
panel hearings 146
school violence 152
South African National Defence

Force (SANDF) 54, 84
South African Police 54
South African Stress and Health
(SASH) study 9, 10, 56
abusive childhood 21–22
adults 14
intimate partner abuse 17, 18
men and women detained 11
political violence and psychiatric
disorder 52–53
sexual contact in childhood 20
sexual violence and coercion 20
Spiral Therapy group 107
spiritual framework 65
sport 113, 144

SSRIs, see selective serotonin

reuptake inhibitors
state education 154
state-perpetrated violence 9–10
black male youths 10–11
state repression 137
state security forces 11
state-sponsored violence 50
stress 2–5, 40, 44, 48–49
coping with 37
current life stress and PTSD 38
environment 28, 46
hormone (cortisol) 38
levels 38
response to 38, 41
treatment of short-term 105
work 85
Stress Inoculation Training (SIT)

89, 90
stressors 90, 113, 122, 123, 125, 137
basic survival needs 152
economic 51
multiple life 38
subjective emotional pain 78
subjective feeling of ‘helpless terror’
31
subjective physical health 78
substance
abuse 42, 43, 45, 51, 54, 126,

134, 138, 149
dependence 104
suicide 45, 86
superego, harsh or benign 99
support 88
at early stage 82
lack of 38
networks 39
supportive group psychotherapy

105, 106, 113
survival, basic needs for 152
symbols of remembrance 144
systemic interventions 140

220

Index

talking about/remembering trauma
32
talking-based therapy and

counselling 80, 141, 144
Tavistock Clinic (London) 98–99
‘tea and sympathy’ 88
team-building 106
tear-gassing 138
technique-based approaches 97
testimony therapy 91–92
TFT, see thought field therapy
‘The child interview’ 140
therapeutic forms 83
therapists
advocacy roles 113
autonomy of clients 116
and clients 111–113, 153
own values 116
role of 100, 113–114
value system of clients 116
Thought Field Therapy (TFT) 96
thought-stopping 89
threats, real and imagined 113
Three Province Study 18, 19
TIR, see traumatic incident

reduction
torture 9, 10, 11, 36, 52, 57, 92, 95,
138
DSM-IV-based interview 50–51
political prisoners 50
survivors in Malawi 57, 150
treatment programme 101
traditional African healers 114
traditional family and community

structures 13
traditional/indigenous practices

114–115
traffic injuries, see road traffic
accident injuries

tranquillisers 103
transference and counter-

transference 98
trauma 2–3
cumulative and continuous 49
exposure to in South Africa 6,

48–49
factors inherent in 40
factors pre-dating 40
healing groups 107
impact of work on practitioners
121
positive and negative outcomes
77–79
positive transformation after 75
processing and integrating 81
prolonged exposure to 44–47
to the psyche 2
psychological literature 72–73
Trauma Clinic of CSVR
(Johannesburg) 95
trauma-related fears 109
trauma-specific fears 130
trauma therapy, long-term
approaches to 98–102
traumatic desensitisation 94
traumatic events
children and extraordinary events
123–124
developing explanations 60
factors inherent in 40
immediacy of 82
reflective processing 79
subjective interpretation of 99
Traumatic Incident Reduction (TIR)
96
traumatic stress 2–5
traumatisation 137
ongoing risk of 49
strategies for preventing 4
traumatised populations 151
traumatology, see traumatic stress
TRC, see Truth and Reconciliation
Commission

221

Traumatic Stress in South Africa

trust 111–112
in justness of universe 61
loss of 45
Truth and Reconciliation
Commission (TRC) 9–12, 67,
119–120
public testimony 92
turning point in survivor’s life 76
twins, studies comparing 38

Visual Kinaesthetic Dissociation
(VKD) 96
VFD, see Visual Kinaesthetic

Dissociation
vulnerability
feelings of 79, 153
and lack of control 62

unemployment 13, 85
UNICEF report 137
unworthiness, feelings of 45
urban settings and rural
communities 124
vicarious resilience 121
vicarious traumatisation 121
victimisation 15, 63–64, 127, 137
Vietnam War veterans 107
vigilantism 115
violence 8, 92
and aggression of perpetrator

67–68
exposure of children to 123–124
indirect exposure of adolescents
127
ongoing structual violence 152
political factions in townships 11
prevalence of exposure 10
prevention 144
see also childhood physical abuse;
criminal violence;
gender-based violence;
political violence
violent assault 14, 36
violent crime 4, 44, 52, 86
see also non-sexual violent crime

war 44, 101, 124, 137
watershed in survivor’s life 76
wealth disparities 6, 13
weapons 14, 15
welfare 130
Wilderness Therapy 85, 106–107,

144
adolescents at risk 107
eco-psychological, Jungian
oriented 106
sex workers 107
withdrawal 45
witnessing of traumatic event 31, 50,
124, 148
see also indirect traumatisation
Wits Trauma Model 95
work-place incidents 86
work-related accidents 25–26
work stress 85
xenophobia 115
xenophobic attacks 13, 111
youths at risk 13, 15
involvement in protest politics

137
state-perpetrated violence 10–11
Youth Stress Clinic (SA) 127

222