I am a registered counsellor in private practice in Johannesburg and I also provide psychological services in a specialised field helping survivors of brain injuries to overcome their trauma. I often feel, though, that SA as a whole is a survivor of trauma itself and that it is still struggling to deal with it, mostly because the trauma keeps recurring. The country as a whole needs treatment.
In a country with a high crime rate, acute trauma — a one-off event during which a person experiences a threat to their life — is one of the reasons my business stays afloat in our postpandemic economy. Most people don’t have the money for “talk therapy”, even though it is an investment in their future wellbeing and ability to cope with life. Most people can only prioritise money for counselling when trauma is holding them back from functioning as they know they can.
Trauma leaves a lingering sense of powerlessness or fear. An important part of treating it is determining exactly what it is about the traumatic event that produces such feelings of dread and despair. For some people it’s the intensity of their attacker’s anger, for others it’s the completely unpredictable nature of what happened. For yet others it’s the painful realisation that the world owes them nothing and they have to fend for themselves.
One client’s trauma was due to witnessing an execution, and then nothing changed. Everything about her seemed to carry on as usual. People around her expressed shock and condemnation, but then wanted things to return to “normal”. She felt confused, anxious, couldn’t concentrate, jumped at the slightest noise, couldn’t sleep, was weepy, and had a general feeling of not being herself. She needed some sense of response, some acknowledgment of the terrible event that had occurred and some measure to be put in place to limit its possible recurrence.
South Africans, if I imagine our population as a client, have been traumatised in much the same way. The psychological damage of apartheid and colonialism was caused by being exploited as noncitizens: not being allowed to have a say in who was governing them, not being allowed to move freely, not being allowed to be educated properly, getting punished violently and restricted by a psychopathic government.
If I imagine our population as a client, South Africans suffer from complex trauma, which is an experience of multiple and varied stressful and frightening events.
For most, this trauma has not passed. While there has been much progress since 1994, fundamentally nothing has changed; most people are still in the same position they or their forebears were a generation ago. Acute trauma is a single event, chronic trauma is ongoing, like abuse over years in childhood, and complex trauma describes the experience of multiple and varied stressful and frightening events, like living in a war zone.
Chris Hani Baragwanath Academic Hospital in Soweto, the world’s third-largest hospital, is characterised by medical practitioners as a war zone in terms of the number and severity of traumatic injuries it sees. Complex posttraumatic stress disorder presents with symptoms such as chronic anxiety and depression, dissociation, and emotional dysregulation. It also manifests in physical symptoms such as chronic inflammation leading to illness such as chronic pain or autoimmune diseases, insomnia, heart disease and so on.
In the biological mechanism triggered by trauma, the limbic system in our brains activates the fight/flight/freeze response, and prepares the body to face a threat to our lives. During this switch, nonessential bodily processes are halted or limited. Many changes occur, like blood rushing away from the organs towards the limbs and cortisol being pumped into the system to excite and energise the muscles.
The fight/flight/freeze response has evolved to be a temporary system in the body, one which is lifted once the threat has passed. The body is then supposed to switch into the rest/digest/heal state, in which we can process and recover from trauma, and the body and mind are in the correct state for thriving again. This switch can only happen if the brain understands the threat to have passed. For most South Africans, the threat has never passed.
Spending too much time in the fight/flight/freeze system dysregulates the body and the mind. Spending too much time under threat means that the body and mind’s physical ability to thrive is limited. Part of the psychological injury caused by trauma is that it disturbs our basic sense of trust in the world about us. We have an underlying, mostly unconscious trust that the world will unfold as we expect it to; gravity will bind us to the earth, food will taste as it did before, we will arrive at a workplace and be able to understand the words written on the paper in front of us.
When we experience trauma, this basic trust is disturbed and muddled, leading to the debilitating feeling of confusion and upset that is characteristic of the posttraumatic period. Apart from all the painful and distressing symptoms of complex trauma, our cognitions are affected. We may experience chronic anxiety and depression, we may be less empathetic, less forward-thinking, less able to regulate painful emotions such as anger and sadness. Trying to cope with these ailing cognitions might involve reaching for substances that dull the mind, trying to feel powerful through aggression and violence, or more passive behaviour such as procrastination or lethargic disconnection.
After being exploited as noncitizens for being black, South Africans are now being exploited as noncitizens for being poor.
South Africans have experienced the trauma of apartheid, a complex and serious trauma in itself, and are now experiencing the retraumatisation of being let down over and over again by their elected government, which promised to uplift them. After being exploited as noncitizens for being black, South Africans are now exploited as noncitizens for being poor.
Through my work for nonprofit Headway Gauteng, managing its counselling department, I have become familiar with some of the emotional experiences of our Soweto, Alexandra, and central Johannesburg clients. They consistently express their resigned lack of trust in institutions in their community because they have been let down in so many ways. They have no jobs to keep them fed and stimulated, cannot turn to the police when faced with threats, risk going to the clinic or hospital only when they can no longer ignore physical illness.
In 2016, stunting due to malnutrition was estimated to affect 27% of SA children, yet they have no social support for learning disabilities or developmental disorders or they are turning to drugs in the absence of any sense of optimism in the future. The social relief of distress grant may have saved some families from starvation, but it is far from the sort of intervention that uplifts and empowers: just ask those that were hosed down after social development minister Lindiwe Zulu got her photo opportunity.
Pre-Covid-19 data show 16.5% of people in our country suffered from mental health disorders. Our clients’ chronic illness complaints rise with their stress levels: high blood pressure, chronic headaches, body aches, diabetes, even cancer. I believe their complex traumatisation is to blame for — or at least contributing to — chronic illness. Many of our clients suffered strokes leading to permanent brain injury. These strokes can sometimes be explained by genetic conditions, but a frightening number is caused by high blood pressure.
In SA, cardiovascular disease deaths in women aged 35 to 59 is one-and-a-half times more likely than in the US, according to the World Heart Federation. What causes and worsens hypertension? Stress. Simply the stress from living with lack of services and the constant threats the poor face. Many of our clients also suffer from substance abuse disorders or are trying to love a family member with a substance abuse disorder. Some come across as frustratingly helpless; perhaps their complex posttraumatic symptoms are weighing them down too much for them to have energy for anything other than getting food for the day.
Other clients have suffered brain injuries due to car accidents. In 2019, SA’s motor vehicle fatality risk was 20 times that of the best-performing countries, according to the International Transport Forum’s Road Safety Report. I consider speeding and driving under the influence to be types of violence, a carelessness that often ends in the head injuries we treat.
The senseless looting and rioting in July 2021 is another example of short-sighted, chaotic acting out of desperation, seen even in the looters who loaded their stolen goods into fancy cars. What could be the cause of such endemic violence? Why is it that South Africans seem to have such dysregulated emotions that they are so aggressive with each other?
A microcosmic demonstration of the government’s let-down of its citizens is the Life Esidimeni tragedy. In 2016, more than 140 (that we know of) psychiatric patients died as a result of being transferred to smaller residences that were not equipped to care for them. We know that some of these patients succumbed starvation and dehydration. There are reports of medication being administered to patients arbitrarily because their medical records had been lost, some patients died of hypothermia. The whereabouts of 44 more patients are still not known.
In any other country the MEC responsible, Qedani Mahlangu, would have immediately had to resign, as well as the premier of Gauteng, David Makhura. Not only did that not happen, we had to watch pavilions being erected, probably at great expense, to shelter him and his entourage from the sun during memorial services. Mahlangu did resign, but only after several months and a report, and after six years, the matter is still being investigated, with judge Jowie Teffo recently decrying the delays.
An example of these delays is that Makgabo Manamela, the former Gauteng Health director, could not honour her court summons because she had a headache. It took an arrest warrant to get her to account to the judicial inquest. Not only is this disrespectful to the courts, it shows how seriously our government takes sufferers of mental health problems and their carers; it shows how our government treats its most vulnerable.
I saw South Africans’ lack of trust in their government during the Covid-19 pandemic. Many of our clients were wary of this strange phenomenon, something not within their frame of reference, and seemed to ooze suspicion that there was another agenda at play. Many could not understand why the coronavirus required unprecedented restrictions to movement and behavioural directives, and a vaccine seemed to them to be a bizarre requirement. Most of our clients came around after seeing other people being safe and after some education on the part of our organisation. Here it is important to note that it was us they trusted, and each other.
Putting myself in their shoes, I also wouldn’t trust someone who had promised jobs and electricity and housing, had delivered little of those things, inconsistently, and now wanted me to stay home from the job I got for myself. There has been no change in the way poor South Africans are treated. They have needed things to change since being neglected and abused during apartheid. Their basic trust in the government, which had been inflated with the hope and elation of democracy, has steadily and painfully deteriorated.
Even the Truth and Reconciliation Commission, as much as it achieved, was not about ordinary people. Psychologically speaking, I cannot escape the conclusion that this trauma is even more devastating than the first range of denigration. No one is coming. As a substitute for the sense of empowerment we need from a functioning social system, the sheer rush of stealing, fighting and speeding are great ways to experience pure power, even if only for a few minutes.
Many men experience huge pressure to provide for and to protect their families. This is the societal test of their masculinity, and society has put gender and occupation at the forefront of our identity formation. I can’t imagine the hopelessness that comes from feeling that you are at fault for not being able to provide for your nearest and dearest when joblessness is as high as 35%. Even though I would like swift and clear justice for all the millions of people who have been and continue to be let down by our government, I have come to accept that we are on our own.
There are currently no political parties giving South Africans a sunburst through the clouds. This acceptance has been liberating for me personally, I suppose because it means I am no longer wasting energy on expectations that cannot currently be met. For me and my practice, the answer to this national mental illness is emerging from the latest neuropsychological research. We are finally seeing empirical evidence for the coping mechanisms tried and tested over thousands of years by ancient philosophies. We are learning more and more about how the body expresses emotional distress and how we can soothe our nervous systems, with simple but consistent self-care. This can be seen as part of the democratisation of psychiatry.
Our days of relying on reactive psychiatry that only numbs symptoms at the cost of often worse side effects are numbered. I envision a future in which the poor will no longer have to stand in a queue at a public hospital only to be told that their psychological pain is not bad enough to be treated. The new wave of psychological therapies such as vagus nerve stimulation, cold exposure, and mindfulness are all therapies that can be said by any of us to be done for free in our own homes without a script from an aloof and dismissive doctor. Without the devastating medical bill too.
Part of what makes my work so rewarding is seeing our clients heal themselves. Many of our most vulnerable clients, like women caring for a survivor of brain injury with no source of income and no justice for the event that caused the brain injury in the first place, show remarkable and admirable resilience.
There is a theory of posttraumatic growth: the phenomenon of people reaching something like self-actualisation after a trauma, characterised by appreciation of life, improved relationships with others, a sense of new possibilities in life, increased personal strength and changes in spiritual engagement. I see this often in our clients. I asked one, a mother of a survivor of multiple strokes (secondary to HIV/Aids which she contracted from her unfaithful husband), how she was doing. She said she was grateful. I asked what for, and she responded that that morning she had opened her eyes, breathed, and walked herself to her mailbox. To her, that was enough.
When I try to encourage posttraumatic growth in a client, we work towards integrating the traumatic event into an understanding of the world and the self. It actually helps to know that the government is weak and corrupt and that everybody suffers from it in one way or another. This means accepting the limits of our control and exploring how our determination to survive has gotten us through trauma and can get us through it when it happens again.
I believe that SA can heal from its trauma, without the help of a dysfunctional government, by acknowledging the hurt, claiming our healing as our own, and being determined to survive. If we can integrate the trauma as part of our survival narrative, our posttraumatic growth can be limitless.
• Pienaar is a registered counsellor and runs the counselling service at Headway, https://headwaygauteng.co.za
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