Hamber, B. & Lewis, S. (1997). An Overview of the Consequences of Violence and Trauma in South Africa. Research report written for the Centre for the Study of Violence and Reconciliation, June.
Brandon Hamber & Sharon Lewis
Research report written for the Centre for the Study of Violence and Reconciliation, August 1997.
Brandon Hamber is an independent consultant.
Sharon Lewis is a former Researcher at the Centre for the Study of Violence and Reconciliation.
Violent crime and trauma are currently normative within South African society. Many commentators have come to refer to South Africa as a "culture of violence" - a society which endorses and accepts violence as an acceptable and legitimate means to resolve problems and achieve goals (Vogelman & Simpson, 1990). This paper briefly describes the extent of violence in South Africa, and explores the resulting psychological and social consequences. As an introduction, brief definitions of violence and trauma are provided, as well as a brief description of violence in South Africa in the 1980s and 1990s. The paper then discusses the category of Post-Traumatic Stress Disorder and the implications for a society with a high number of victims of violence - with a particular emphasis on the concept of vicarious traumatisation.
Definitions of Violence and Trauma
Trauma can be defined as an event that overwhelms the individual's coping resources. Traumatic situations are those in which the person is rendered powerless and great danger is involved. Trauma generally includes events involving death and injury, or the possibility of death or injury. These experiences are unusual and out of the ordinary, and do not constitute part of the normal course of life. The word trauma is generally used to include both natural catastrophes (such as hurricanes, floods or fires), and man-made violence (such as war, concentration camp experiences and other forms of victimisation) (Matsakis, 1992). One form of psycho-social trauma1 is violence.
Mckendrick & Hoffmann (1990) argue that what constitutes violence is always a social construction, and consequently acts of violence deemed as legitimate in one society or cultural group may be considered illegitimate or culturally unacceptable in another. In much of the academic literature, both physical and psychological components are included in the definition of violence, and definitions of violence can be seen to include not only abuse, but also neglect. This infers two dimensions of violence: acts of commission and acts of omission (Mckendrick & Hoffmann, 1990). Walter (1969, cited in Mckendrick & Hoffmann, 1990) defines violence as:
Destructive harm...including not only physical assaults that damage the body, but also...the many techniques of inflicting harm by mental or emotional means. (p. 8)
In a paper entitled Public Health and Violence Prevention by Mercy, Rosenberg, Powell, Broome and Roper (1993) the following definition of violence is cited:
...the threatened or actual use of physical force or power against another person, against oneself, or against a group or community, that either results in or has a high likelihood of resulting in injury, death or deprivation. (p.2)
Etzioni (1971) suggests however, that a distinction can be made between physical violence and acts of economic or psychological coercion. The differentiation is linked to the issue of the victim's greater scope for "choice" in psychological abuse, and the greater threat of death inherent in physical assault, Etzioni (1971) writes:
While economic and psychic pressures can be very powerful indeed, except in limited conditions they leave the ultimate decision to the subject - the pressures reduce but do not eliminate his/her freedom. When physical force is used, however - when a person is jailed, gagged, or shot - under most conditions she/he has no choice left in the matter. (p. 712)
The injuries resulting from violence may be either physical or psychological. Often, however, psychological abuse is an aspect of the violation of the victim in physical violence, as is the case in torture and wife battery. Acts of violence include suicide or attempted suicide, as well as interpersonal crimes such as rape, domestic and child abuse, elder abuse, or assault (Foege, Rosenberg, & Mercy, 1995). Thus violence can be physical and/or psychological in nature, and there can be a further distinction between intentional and unintentional forms of violence. This paper focuses mainly on intentional violence, which is physical in nature and categorised under the headings criminal, domestic and structural violence.
The Extent of Violence in South Africa
Statistics seem to support the view that South Africa is an extremely violent country. A 1996 study indicated that over a period of five years, about 70 percent of the urban population in South Africa were victimised at least once (van Dijk, 1996). The experience of being violently victimised in South Africa has become a statistically normal feature of everyday life in the urban and rural setting. South African Police Service (SAPS) figures indicate that in 1996 there were a total of 25 782 reported murders, 28 516 attempted murders and 12 860 car hijackings. In terms of sexual violence, there were a total of 50 481 rapes. South African children are not exempt from violence. In 1996, 20 333 crimes of a sexual nature were reported to the Child Protection Units, while there were 8 626 reported assaults of children.
These statistics, however, are likely to gravely underestimate the incidence of violence. In reality they are likely to reflect patterns of reporting, as opposed to the actual incidence of crime. With regard to rape, for example, it is estimated that only one in 20 to one in 35 rapes are ever reported to the SAPS (People Opposing Women Abuse, 1995). This would indicate that approximately one million women were affected by this crime in 1996. The treatment accorded to victims of gender violence by police personnel also often constitutes secondary victimisation. Police insensitivity and ill-treatment of these victims, in combination with ignorance of the legal provisions protecting women reporting a crime, can result in feelings of helplessness and reluctance to report rape (Jackson, 1997). As a result, there is a huge discrepancy between the numbers of cases reported to the police and estimates of the real incidence (Jackson, 1997; Vetten, 1995).
Comparatively speaking, the incidence of violence in South Africa is extremely high. In 1996, the homicide rate for South Africa was estimated at about 61 per 100 000 inhabitants. This is compared to approximately 9 per 100 000 in the United States and 1 per 100 000 in the United Kingdom. Countries such as Brazil, which have more comparable histories to South Africa, show similar yet less dramatic trends in violent crime (Roelefse-Campbell & Campbell, 1996). Violence has become the second highest cause of death in Brazil after heart disease (LAWR, 1995 cited in Roelefse-Campbell & Campbell, 1996) and certain cities have similar patterns of violence as those seen in South Africa. Brazil witnesses on average 39 000 murders a year, compared to the approximate 25 000 in South Africa. South Africa, however, has a population of approximately 45 million, whereas Brazil has a population of approximately 150 million. In Columbia, when the Medellin drug cartel was operating in the city of Medellin in 1993, the homicide rate was an alarming 450 murders per 100000 (Roelefse-Campbell & Campbell, 1996b).
These sort of broad statistics - particularly focusing on mortality - give an overall view of the impact of violence, however, they miss the largest incidence of crime and violence which is related to injuries both intentional and unintentional. It is estimated that for every death in Cape Town there are 80 injuries (Butchart, Peden, Bass, du Toit & Lerer, 1996). Using this figure, a simple calculation and extrapolation indicates there were over two million South Africans who suffered some sort of violent injury in 1996.
Although these statistics can be useful in making broad comparisons, the figures need to be understood in context. In South Africa, there are flashpoints of violence and the statistics (which are often disputed anyway) generally indicate national averages. In reality the probability of being murdered in certain areas (for example, wealthy suburbs) remains significantly lower than in other areas. The statistics may produce a high total, but pockets of relative safety still exist when compared to other very dangerous areas which inflate the national means and often lead to perceptions that violent crime is uniform in its incidence in South Africa.
Recent police statistics (Crime Information Analysis Centre - CIAC, 1997) support the view that violent crime is by no means uniform across the country. For example, homicide rates are highest in the Western Cape, then the Northern Cape and then only Gauteng. Assault (grievous bodily harm) is highest in the Northern Cape and then the Western Cape and then Gauteng. Whereas robbery, theft of motor vehicles, assault and attempted murder are all highest in the Gauteng Province. These statistics seem to support the view that there are enormous differentials when discussing incidence of violent crime. Furthermore, recently it has been shown that violence and crime are increasing in the rural areas and are not simply an urban phenomenon, as it is often mistakenly assumed.
In South African the majority of intentional injuries and fatalities occur during inter-personal disputes between people who know each other and not, as it is often commonly believed, in attacks by unknown criminals during pre-meditated robberies and the like. An analysis of murders in the Eastern Cape in 1996 revealed that 93% of murder cases were linked to alcohol and drugs (CIAC, 1997).2 Similarly, in the Northern Cape the overwhelming majority of cases of murder showed no planning or motive and that alcohol and family disputes played a dominant role (CIAC, 1997). Similar tendencies were also observed in the Free State and Mpumalanga. Thus, there is an increasing need to focus on violence in the inter-personal setting as one of the major concerns with regard to violent crime in South Africa.
Contextualising Violence in South Africa
Although violence became a focus of research in the 1980s, South African history, from the time of colonisation, has always been characterised by violence. In the 1980s, the most documented form of violence was termed "political violence". Political violence can be seen as any act of destruction which impacts on the power relations in society (Cock, 1990). In South Africa this form of violence was characterised by arbitrary arrests, detention without trial, civil unrest, acts of sabotage, harassment, torture, "disappearances" and murder of political opponents and rivals (Cock, 1990). Political violence has received enormous coverage in the media, and in recent exposure by the Truth and Reconciliation Commission (TRC).
Most of this violence was orchestrated by the state and was targeted at victims both inside and outside the borders of South Africa. Many of the victims were very young and generally the families and relatives of these activists also suffered varying degrees of harassment and direct physical harm. There was also violence between rival political and social groupings. As a result, South African society was placed under continual stress of potential violence, either through acts of sabotage as the liberation movement resisted state control, or more often as was the case, living in dangerous, tumultuous and tightly policed townships.
The period of 1990-1994 was also characterised by unprecedented intra and inter-community conflict often fanned by so-called "third force" activity sponsored by the state. The pervasive nature of this violence, and the systematic implementation of the apartheid system, has undermined the moral, interpersonal and social fabric of South African society. In the 1980s and the 1990s academic and media focus tended to fall only on this so-called political violence. However, the focus on these types of violence may well have masked many other forms of violence. For example, statistics of the former homelands have only been included in police figures since 1996. In addition, domestic violence has been notoriously under-documented.
Since 1990, the beginning of the political transition period, reports of political violence have decreased, although not disappeared. The Human Rights Committee documented deaths of 800 people due to political violence in 1995, and the Christmas day Massacre of 18 ANC supporters in the Shobashobane area in Kwazulu-Natal is evidence that political violence has continued to some degree. Recent trends indicate increased levels of what is now labelled "violent crime" from 1990 to the present. It is possible, however, that in the past, some criminal violence could have been mislabelled as political violence as the boundaries between the two are blurred and subject to ideological bias.
Reports indicate that violent crime has increased at a greater rate than property crime and less serious offences since the election of the new government (Glanz, 1995). However, the most recent police statistics (CIAC, 1997) do not indicate an increase in recent crime ratios. A comparison of quarterly crime ratio statistics (January - March) over the years 1994 -1997 with regard to the 20 most serious crime tendencies reveals that none of these tendencies increased (about 48% of all serious crime decreased and 52% stabilised) during the first quarter of 1997 (CIAC, 1997).
Nonetheless, many South Africans still remain exposed to high levels of differing forms of violent crime, including public violence, rape, hijacking of cars, aggravated assault, aggravated robbery and murder. Some victims of violence subsequently also seem to be committing violent acts themselves. Their actions are often associated with vigilantism and self-administered "justice". Increasing reports of this type of action against suspected criminals have been reported (Weekly Mail, 1997) and there is a likelihood of an increased trend of citizens taking law into their own hands. Increasingly perhaps, summary justice appears quicker and more effective (Shaw, 1997) and there is a lack of faith in the criminal justice system. Morris (1987) asserts that victims of criminal violence, if untreated, are at risk for perpetrating acts of retributive violence, or for displacing their aggression within the familial context.
Although the more public forms of criminal and political violence have been discussed here, and generally receive the majority of focus in the media, this should not overshadow the numerous other forms of violence, in particular, intentional violence committed in the home. This includes child abuse, wife battery, domestic assaults and acquaintance rape. These "hidden" forms of violence, which are generally targeted towards women and children and the other more vulnerable sectors of society, affect more people than the types of violent crime documented above. Wife battery and child abuse are frequent occurrences in South Africa, although few reliable statistics are available. Many researchers are of the opinion that the incidence is widespread (Welch, 1987; Segel & Labe, 1990). A report by the Institute for Security Studies (1996) comments on the lack of adequate documentation of acts of violence against women and children:
Depending on the degree of violence, the attitude of the investigating officer and the weapon used, the police will document domestic violence as common assault, rape, general sexual harassment or murder. This makes it difficult to assess how much domestic violence is reported, and the response to it. ...For example, a knife attack on a woman by her partner will be recorded as "aggravated assault", or "assault with intent to commit murder". (Jackson, 1997, p. 1)
The report continues:
Police members dealing with victims often do not regard rape and domestic violence as crimes, while the police have traditionally used inappropriate crisis intervention techniques that avoid arrest and seek to reconcile the assailant and the victim....Where the police and courts do respond, action is generally ineffective, and guided by vague and inconsistent policies. (Jackson, 1997, p.1-2)
In many cases, the victims of this violence are averse to reporting the offenders. This may be due to emotional and financial vulnerability, guilt about reporting a family member, or the belief that the perpetrator, by virtue of his or her authority in the home, was justified in the abuse. Literature in the area indicates that women are more likely than men to know the perpetrator of violence, to be attacked in their own homes, and to be blamed for the violence committed against them (Morris, 1987). In South Africa African woman seem to be at highest risk for this type of violence. The annual incidence of violence experienced by African women was more than ten times that of their white counterparts (Trauma Review, 1996). The more rural provinces, and less economically developed areas, like the Northern Cape also show the highest incidence of reported rape (CIAC, 19967). Ironically, these are the areas with the most limited psycho-social support services for woman and children.
A recent study by the Human Sciences Research Council (HSRC), conducted from 1 July 1994 to 30 June 1995, based on 4606 cases reported to the Child Protection Unit, indicated that 62% of children were victims of crimes of a sexual nature, 14% of common assault, 11,1% of serious assault, while the remainder were victims of crimes such as kidnapping and murder. Of the cases analysed, 83,5% of the perpetrators were known to the victims, 35,3% of the crimes were committed in the child's home, and 23,7% in the offender's home. Children, like battered women, are often subject to repeated acts of violence, and the perpetrators are most often a family member (Jackson, 1997). Furthermore, it has been indicated that 50% of men who abuse their wives frequently abuse their children (Domestic Abuse Project, 1996).
Social inequality and enormous deprivation caused by the apartheid system are at the root of much of this violent crime. Internationally, and in South Africa, there is increasing evidence to show that poor people bear most of the brunt of violence in society (cf. Mercy et al., 1993; Louw, A. Louw & Shaw, undated; HSRC survey cited in Louw & Shaw, undated), although this should not be used to assume that high levels of poverty always result in increased levels of violence and crime in communities. Mercy et al. (1993) argues that there are numerous dimensions related to high levels of community violence and these include over-crowding, family disruption, weak social structures, high population concentrations, population transiency and social norms which encourage the use of violence to cope with difficulties.
However, despite the relationship between poverty and violence - which as was stated is not always necessarily to be assumed - violent crime in South African society as a phenomenon has multiple causal factors which extend beyond mere statistical relationships. Some of these include, to mention a few, a patriarchal society where women and children are devalued and vulnerable, the development of a culture of violence where violence is seen as a legitimate means to achieve goals particularly because it was legitimised by most political role-players in the past, the deregulation of state control during the negotiations period, as well as the perception that there will be no serious consequences for criminal activity and the opening of South African borders to criminal syndicates and operations since the shift to democracy (cf. Hamber, 1997a; NCPS, 1996; Simpson, 1993; Simpson & Rauch, 1991).
Preventable violent unintentional injury is also often overlooked as another major form of violence in the country (Butchart, Hamber, Seedat & Terre Blanche, 1995; Seedat & Butchart, 1996). Many people in South Africa are subject to or witness accidental forms of violence like domestic burns and motor vehicle collisions. Whereas the World Health Organization has estimated that the rate of non-natural death, mostly due to trauma, constitutes 5,2% of overall global fatalities, in South Africa this figure is estimated to be as high as 16% (van der Spuy & de Wet, 1991). Natural disasters and large scale accidents (e.g. mining accidents) are also often forgotten when one thinks of the different types and impact of violence on individuals.
In addition, many South Africans are subject to structural forms of violence. Structural violence refers to unequal power relationships and manifests in unequal life chances. In its most basic form, the systematic deprivation and racism underpinning apartheid can be seen as a form of structural violence. Structural violence also results in other types of violence. In the past this has been evident in explicit state violence (for example, forced removals and the persecution of those opposed to state structures and policies). The devastating impact of structural forms of violence on mental health should also not be ignored. The psychological consequences of deprivation are endless. These include the mental and physical developmental impact of poor nutrition on children and the anxiety, depression and stress-related conditions caused by poor living conditions and occupational circumstances.
While large scale political conflict and criminal violence and particular brutal acts of violence tend to receive attention, the more micro-effects of violence that ripple through communities may go unnoticed. For example, violent intra-community conflict can cause the destruction of the social fabric and culture of communities, and disrupt schooling, resulting in incremental disadvantage over time. These different types of violence affect both individuals and society as a whole.
The following sections discuss the enormity of the impact of this violence, and the resultant psychological consequences.
The Psychological Effects of Violence
According to current literature, beliefs, expectations and assumptions about the world play a pivotal role in determining the effects of victimisation (McCann & Pearlman, 1990). Janoff-Bulman (1985) asserts that the experience of trauma shatters three basic, healthy assumptions about the self and the world. These are: the belief in personal invulnerability ("it won't happen to me"); the view of the self as positive; and the belief that the world is a meaningful and orderly place, and that events happen for a reason. Violence, or trauma that is inflicted by a fellow human being, shatters a fourth belief: the trust that other human beings are fundamentally benign. These four assumptions allow people to function effectively in the world and to relate to others. After an experience of violence, the individual is left feeling vulnerable, helpless, and out of control in a world that is no longer predictable.
There is always a significant subjective component in an individual's response to a traumatic event. This can be seen most clearly in disasters where although a broad cross-section of the population is exposed to objectively the same traumatic experience, individual psychological reactions are markedly different. Some of these individual differences in susceptibility may stem from pre-existing social, cultural and psychological factors. The individual's reaction is as much about the actual traumatic incident as it is about their pretraumatic personality structure and their available personal resources, coping strategies and extended support structure. The cognitive appraisal of the event is of primary importance (Ramsay, Gorst-unsworth & Turner, 1993).
Post-Traumatic Stress Disorder
Post-Traumatic Stress Disorder (PTSD) is a diagnostic category used to describe symptoms arising from emotionally traumatic experience(s). According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition or DSM-IV (American Psychiatric Association, 1996), the disorder presumes that the person has experienced a traumatic event involving actual or threatened death or injury to themselves or others, and where they felt fear, helplessness or horror. There are three main symptom clusters in PTSD. First, the intrusive cluster. Intrusions can take the form of repeated, unwanted and uncontrollable thoughts of the trauma, and can include nightmares and/or flashbacks. Second, the avoidant cluster. These symptoms consist of the person's attempt to reduce exposure to people or places that may elicit memories of the event (or intrusive symptoms). This also involves symptoms such as social withdrawal, emotional numbing and a sense of loss of pleasure. The final category is termed hyperarousal, and refers to physiological signs of increased arousal, such as hypervigilance, or increased startle response.
Although these reactions are disturbing, particularly for the victim, they are considered to be normal responses to abnormal events. Trauma symptoms are to some extent adaptive, and Baldwin (1996) argues that they originally evolved to assist the individual to recognise and avoid other dangerous situations. In some cases these symptoms resolve within a few days or weeks of a traumatic experience. It is only when many symptoms persist for weeks or months, or when they are extreme and debilitating, that the diagnosis of PTSD can be made. Risk for PTSD increases with exposure to trauma, and multiple or chronic trauma experiences are likely to be more difficult to overcome than most single instances Baldwin, 1996). Epidemiological estimates suggest that the incidence and lifetime prevalence rates of PTSD in the general population are around 1% - 9%. These levels increase markedly for young adults living in inner cities (23%) and for wounded combat veterans (20%). In particularly violent areas, the incidence may be even higher. In South Africa, for example, it was found that of a sample of 95 political displacees in Kwazulu-Natal in 1990, 87% had symptoms which fulfilled the criteria for the diagnosis of PTSD (Michelson, 1994). There is also evidence that early traumatic experiences (during childhood), especially if these are prolonged or repeated, may increase the risk of developing PTSD after traumatic exposure as an adult (Baldwin, 1996).
PSTD is not the sole response to traumatic experiences. All emotional responses are intersected by other psychological issues which may confront the individual after exposure to a trauma. For example, bereavement related issues are often paramount if, for example, a person close to the victim was killed. Or, in the aftermath of a disfiguring trauma such as a burn, an individual would have to deal with psychological issues around body-image. Political exiles and refugees, who are often subject to a range of direct acts of trauma, would also have to cope with separation from their families, displacement and social integration problems. In addition, it has also been shown that the exposure to traumatic events can be associated with the onset of psychiatric disorders (Solomon, Mukilincer & Flum, 1988).
The individuals who have presented at the Truth and Reconciliation Commission provide a useful example of the complexities of dealing with trauma. A plethora of psychological symptoms and signs have been observed in those who have testified. On the whole, most individuals have presented with a mixture of issues related to social, psychological and medical problems. Uncomplicated post-traumatic stress has not been a common feature mainly because, in most cases, individual past traumas (e.g. being tortured, abuses by the police, etc.) have been overshadowed by present psychological and social problems. Furthermore, the ability to draw direct causative links between the initial trauma (i.e. the situation or violation presented to the TRC in a statement or through a hearing) and the present difficulties experienced by most survivors has generally been complicated by the protracted time that has passed since most violations occurred. In some cases, survivors and families have testified about violations that took place in the 1960s.
Dire social circumstances have made it difficult for individuals to deal with or prioritise past psychological traumas. At times, so-called present difficulties (i.e. occupational problems, substance abuse, relationship breakdowns, etc.) are symptoms of long-term traumatisation which has been compounded by impoverished living conditions. However, at other times, the impoverished living conditions (e.g. over-crowding, hunger, being forced to work away from home, etc.) have heightened the primary trauma and have also in themselves caused a range of new psychological difficulties and problems.3
Straker & The Sanctuaries Counselling Team (1987) assert that the term post traumatic stress disorder is a misnomer in the South African context. In particular, they were referring to individuals living in South Africa's black townships, who were subject to continuous stress. This stress was attributed to the high levels of violence in the townships, characterised by confrontations between: the South African Defence Force and Police and various sectors of the community; black anti-apartheid groups and right wing vigilantes who were more supportive of the status quo; and inter-group fighting among rival anti-apartheid groups such as UDF and Azapo (Straker & The Sanctuaries Counselling Team, 1987). In terms of therapeutic interventions for PTSD, the most serious difficulty was in regard to the inability to protect the individual from further trauma.
Types of Victims
A victim or survivor of violence is often mistakenly only presumed to be the person who was directly affected by a trauma or violent incident. In reality, the traumatic experience of a direct victim may also adversely affect many other individuals with whom the victim may have contact. This process has been labelled "secondary traumatisation" (Figley, 1983). The traumatic nature of violence means that any contact with the traumatic material - through witnessing or hearing of the event - can have a contaminatory and deleterious effect.
Indirect victims can include witnesses to the event, as well as the families and relatives whose loved ones have been victimised or murdered. Those who in some way have contact with narratives of violence or trauma (e.g. journalists, those in the helping professions) can also be traumatised, and may be considered victims if they experience any adverse reactions. Many people are traumatised vicariously by reading, hearing or even seeing footage of a violent incident. Post-traumatic stress symptoms have also been noted in emergency workers who are at the scene of violent crimes or environmental disasters or accidents involving loss of life (Mitchell, 1985).
Recently, signs of trauma have been acknowledged and identified in staff members of the Truth and Reconciliation Commission, who are constantly faced with the harrowing stories of victims of violence. In a recent interview Dr Boraine, Vice-Chairperson of the Commission, commented, "It revisits you in the early hours or late at night...you are haunted by terrible images..." (Sunday Times Metro, February 16, 1997). High levels of traumatisation have been observed in all regions where the TRC has operated with many of the staff. Some of these symptoms and signs of vicarious traumatisation which TRC staff have experienced have included nightmares, paranoia, emotional bluntness, physical problems (e.g. headaches, ulcers, exhaustion, etc.), high levels of anxiety, irritability and aggression, relationship difficulties and substance abuse related problems (Grenville-Grey, 1997 cited in Hamber, 1997b).4 Problems of vicarious traumatisation have also been experienced by some of the journalists covering the TRC proceedings (cf. Krog, 1996). On a collective level, through a process like the TRC which publicises the traumas of the past, the likelihood of the entire society being affected in some way is also a possibility.
Other types of vicarious traumatisation can include "second-generation" trauma survivors, these are most often the relatives or children of those who have been traumatised. This has been most clearly documented with the second generation of Holocaust survivors (Danieli, 1982; 1985; Freyberg, 1980) and Vietnam combat veterans (Kehle & Parsons, 1988), who have experienced severe social and psychological difficulties.
Those vicariously exposed to trauma can suffer from symptoms similar to those of direct victims. Symptoms that have been documented include: feelings of exhaustion and hopelessness, health problems, paranoia, and early "burn-out". Emotional and relationship problems, as well as substance abuse may also occur. At times those vicariously traumatised can act-out victim-aggressor patterns or overindentify with victims. Broad existential questions with respect to the meaning of life can also trouble humanitarian and care workers (Pergamenchtchik, 1996).
It is also important not to adhere to a static view of victimisation. An individual can assume multiple roles over a period of time. For example, a person may have been a victim, a perpetrator and a witness to violence across their life time. When considering the emotional response to a trauma, all of these factors need to be considered. Furthermore, traumas are not always isolated and can extend over a period of time. For example, surviving torture or prolonged incarceration during a hostage drama. Often, individuals may be exposed to multiple traumas simultaneously. In one incident an individual may be traumatically wounded, while at the same time witness another person being killed. Other individuals live in a state of continuous trauma, for example, in a war situation.
Is Post-Traumatic Stress Disorder Pathological?
Current literature and clinical understandings consider post-traumatic stress a normal reaction to an abnormal event. However, the use of terms like "disorder" and "syndrome" may imply an over medicalised or pathological understanding of trauma. The medical paradigm tends to interpret trauma as abnormal, and instructs mental health professionals to identify and diagnose victims and treat the pathological responses (Boyden, 1994). A continued focus on psychological rehabilitation can give the impression that a PTSD response is in fact always the source of pathology. In reality, the response is a normal and understandable one to an abnormal event.
A continued focus on the psychological distress of individuals can also promote the stereotypical view that survivors of violence are irreparably damaged. As a result, the ways in which individuals cope with trauma and in many cases master its impact, can be overlooked. For example, the media, at times, fails to report on the complexities and differing reactions to the social phenomenon of rape. Instead they tend to focus on the "drama" of serial rape or choose to report on - and have frequently sensationalised - the human dramas of the victims. This often involves painting doomsday scenarios of victims who are irreparably damaged and for whom there appears to be no solution and no future. These are precisely the wrong messages to convey to the 20 or so other women whose rapes go unreported for every reported rape case. These scenarios promote maladaptive rape myths, and deny the experiences of the women and children who have survived the ordeal of rape and who have embarked on a process of healing.
It would also be erroneous to see conflict or violence as always resulting in complete breakdown of social, community and psychological functioning. Some communities and individuals can become extremely good at coping with adversity. Local and indigenous coping strategies, patterns of social resilience and ways of dealing with vulnerability may need to be identified and worked with rather than introducing foreign concepts of coping (Boyden, 1994).
At the same time, one needs to guard against overvaluing existing supports, many of which may have been destroyed by pervasive violence or as was the case with family structures under the apartheid system, severely undermined by the migrant labour system. This could deny people services and supports which could be assimilated or even altered by existing practices, thus providing maximum assistance.
With respect to collective and social rehabilitation in South Africa, the social process of reconciliation is not always about diagnosing and treating pathology. After decades of violence, all of South African society has been traumatised to some degree. This requires social rehabilitation, an area that the TRC has been designed to address but the need for ongoing individual medical and psychological support services to thousands of victims needs to remain a national priority (cf. Hamber, 1995a; 1995b; 1996a; 1996b; 1997b). However, where societal functioning and cohesion has been damaged, or where there is abject poverty, repairing community and cultural bonds and structures may be as important as psychological assistance.
After prolonged and extensive social traumas like civil strife, the damage to both the social structure and to individuals requires intervention. The legacy of civil conflict can permeate all aspects of civil society and government institutions for years after the conflicts, often resulting in further forms of violence. Authoritarianism and resultant human rights violations by the police, despite the instatement of democratic governments and even with some state investigations into the past, are still common in countries like Brazil, Argentina and Chile (cf. Hamber, 1998; Pinheiro, 1994; Pinheiro, 1996). In South Africa high numbers of fatalities related to the work of the police remain a problem. In the months April, May, June and July 1997 it was reported by the Independent Complaints Directorate (ICD) that 255 people died in police custody or due to police action.5 This may point to ongoing levels of impunity within the police services and insufficient checks and balances in terms of police operations despite a formal democratic disposition.
As much as the authoritarianism of past regimes can live on for many years so to can the psychological effects of large scale traumas. Reeler (1995), in his work with the Mount Darwin community in Zimbabwe, demonstrates how the devastating physical and psychological effects of violence are still present 15 years after the end of the war. Many Shona families in Zimbabwe continue to suffer under the spectre of the trauma of the "disappearances" of the Matabeleland massacre, and are unable to overcome the psychological, spiritual impact and financial impact of the event (cf. Mupinda, 1995). Similar phenomenon have also been noted in a range of South American countries. The family members of the "disappeared" have continued, sometimes decades after the incident, dealing with the trauma of the "loss" and social ramifications of the events (cf. Danieli, 1992; Hamber, 1998; Jelin, 1994; Valentine, 1995).
The consequences of the high levels of violent victimisation permeate increasingly widely into South African society, and few, if any, South Africans can remain unaffected. Vast numbers of South Africans are likely to struggle to relate to other individuals due to shattered trust, and feelings of grief and loss; to have difficulty in the workplace due to intrusive trauma symptoms; and to be left with an overwhelming sense of anxiety, anger and vulnerability. This leaves many South Africans with raised levels of fear, suspicion and aggression - all of which deleteriously affect their daily functioning.
The majority of South African victims of violent crime are likely to feel unsupported and hopeless, and to have lost faith in the effectiveness of the criminal justice system. These feelings are likely to intensify if they receive no psychological and social support, and if their first interface with the criminal justice system, for example with the police, is contentious and fails to meet their immediate needs. If ignored, certain victims of past violence are at risk for becoming the perpetrators of retributive violence or displaced social and domestic violence (National Crime Prevention Strategy - NCPS, 1996; Simpson, 1996). The recent trends in increased violence through vigilantism (usually targeted against criminals but frequently resulting in clashes with the police) and the ongoing spiral of political revenge and retribution in Kwazulu-Natal, bear testimony to this thesis. This phenomenon has also been observed in child victims of violence. The research of Dawes and Tredoux (1990) and Malepa (1990) highlight the fact that children exposed to violence will more readily become perpetrators of violence themselves. Similarly, studies have found that women who were beaten were at least twice as likely to beat their children than mothers who were not abused (Domestic Abuse Project, 1996).
The National Crime Prevention Strategy (1996) recognises this danger, and argues that in the case of violent crime, victim empowerment and effective support can break the cycle of violence and therefore can be viewed as preventative. Thus, trauma counselling and a range of other interventions with traumatised individuals, can be considered effective in alleviating and preventing the consequences and effects of violent victimisation. These interventions can be numerous including victim-care strategies like providing shelters for battered women and the establishment of crisis centres particularly in under-resourced and rural areas.
Foege, Rosenberg and Mercy (1995) argue that from a public health perspective, it is possible to elucidate the causes of violence, and to suggest interventions to lessen its incidence. Multiple levels of prevention are necessary to combat violence and trauma. These include primary prevention (e.g. education), secondary prevention initiatives (e.g. psycho-social and medical services) and finally, tertiary preventative services, such as trauma counselling. At the same time accurate information is needed concerning violent "hot-spots", as well as reliable epidemiological data and a range of practical research endeavours that could help understand and minimise the incidence of violence. Accurate data collection can also help identify risk factors for violence (e.g. substance abuse, fire-arms, etc.) and in so doing contribute to targeted and directed intervention strategies.
Measures also need to be taken by the government to restore faith in the institutions of safety, security and justice, as well as to instil a renewed sense of safety and hope in the lives of South Africans. An effective justice-orientated approach, as one of the components of addressing violence, also needs to make provision for victims within the criminal justice system and includes the sensitive reception by the police services (for example, gender sensitivity in rape cases), appropriate referral to support agencies, provision of advice on preventative measures and supported involvement in court proceedings against offenders (Department of Health, 1997).
Above all else South Africans also need to address the social and economic causes of violence. This not only relies on managed development and addressing the enormous social disparity in the country but there also needs to be a recognition of the complexity of the issue of violence. Poverty does not cause violence and social disparity does not inevitably lead to violent crime, although inquisitive crime as a result of the disparity, may be more common. All sectors of the society need to focus on developing safe communities, to take cognisance of the individual behavioural determinants of violent action and to seriously address the culture of violence' in South Africa which mutates into so many forms of trauma.
1 In the medical context trauma refers to any physical injury caused by heat, energy, electricity, chemicals or other agents (Trauma Review, 1996). However, this paper refers mainly what can be termed psycho-social trauma, i.e. an event that overwhelms an individual's coping resources.
2 There is indisputable evidence in South Africa that the majority of injuries and fatalities are alcohol related (cf. Lerer, 1992; Louw & Shaw, undated; Rocha-Silva, 1992; van der Spuy, 1993) and that alcohol plays a major role in pedestrian and vehicle collisions (cf. van der Spuy & de Wet, 1991; Wolvaardt, 1996).
3 This information on the psychological impact of the TRC was extracted from Hamber (1997b). The observations and symptoms outlined are mainly made through the work of the Centre for the Study of Violence and Reconciliation and recorded from an interview with Trudy de Ridder from the Trauma Centre for Victims of Violence and Torture in Cape Town, June, 1997.
4 Interestingly, the data-processors and others who have had to work with cases on paper or computer, have manifested more symptoms than those working directly with traumatised individuals. This situation probably arose because those working with individuals directly have had more space to integrate the information received into their own cognitive schemata based on a full understanding of the difficulties faced by the traumatised individual. For example, the traumatised individual may show signs of coping, resilience or having support systems. Thus making the traumatised individual's problem seem less drastic and consequently affecting the interviewer or TRC worker to a lesser degree. For those working with statements or computer data there is less chance for this cognitive integration to take place, and on top of this, the quantities of traumatic information processed is much greater. In response to these levels of traumatisation the TRC did set-up some internal support structures that appear to have worked relatively successfully within the constrained environment of the TRC (Hamber, 1997b).
5 A high proportion of these deaths were caused by shootings by the police. However, it is not clear what proportion of these deaths, or those in custody, are the result of unlawful actions on the part of the police (cf. Bruce, 1997a; 1997b).
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Types of Violence
Summary of HSRC Study on Crimes Against Children
The first national study of crimes against children was conducted by the HSRC from 1 July 1994 - 30 June 1995. Some of its major findings, based on a study of 4606 cases reported to the Child Protection Units, were:
Source: January/February 1997
DSM IV Criteria for Posttraumatic Stress Disorder
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 a threat to the physical integrity of self or others.
(2) the person's response involved intense fear, helplessness or horror. Note: In children, this may be expressed instead by disorganised or agitated behaviour.
B. The traumatic event is persistently reexperienced in one (or more) of the following ways:
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 conversions associated with the trauma
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
E. Duration of the disturbance (symptoms in criteria B, C. & D) is more than 1 month.
F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important functioning.
acute: if duration of symptoms is less than 3 months
with delayed onset: onset of symptoms is at least 6 months after the stressor
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