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Rape and sexual violence in South Africa: A case study of trauma
Abstract
For a country not at war, South Africa presents with one of the highest levels of violent and gender-based crime in the world. Such hostile violations of human rights present a major social and public health malady, with consequential increases in demand for mental health care intervention. Restricted resources within the public health sector impel time-limited interventions be offered to victims requiring amelioration of traumatic symptoms. This chapter demonstrates the use of a short-term integrated therapeutic approach to treat a woman presenting with posttraumatic stress disorder (PTSD) following a recently experienced rape and brutal assault. The brief intervention shows positive results, with the survivor no longer meeting the criteria for PTSD at the end of treatment.
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This article seeks to explore why, 21 years after apartheid, South Africans are so violent and why crime, even petty crime, is unique because of its extraordinary level of violence. This article seeks to interrogate the role of humiliation in extreme violence and its devastating consequences for an emerging democracy. The article discusses the psycho-political theories and approaches that inform the theoretical perspective adopted, and explores the historical and patriarchal roots of entrenched humiliation in South Africa. It engages with the 'humiliation dynamic' to explore the ongoing and escalating violence in South African society. The article concludes that systemic humiliation, peculiar to South Africa and its apartheid history, is central in understanding extraordinary violence. Humiliation, deeply-rooted in the landscape of social memory, endures and is fuelled by the frustration of human rights, which leads to further and more extreme forms of violence and crime.
Posttraumatic stress disorder (PTSD) is a common reaction to traumatic events. Many people recover in the ensuing months, but in a significant subgroup the symptoms persist, often for years. A cognitive model of persistence of PTSD is proposed. It is suggested that PTSD becomes persistent when individuals process the trauma in a way that leads to a sense of serious, current threat. The sense of threat arises as a consequence of: (1) excessively negative appraisals of the trauma and/or ist sequelae and (2) a disturbance of autobiographical memory characterised by poor elaboration and contextualisation, strong associative memory and strong perceptual priming. Change in the negative appraisals and the trauma memory are prevented by a series of problematic behavioural and cognitive strategies. The model is consistent with the main clinical features of PTSD, helps explain several apparently puzzling phenomena and provides a framework for treatment by identifying three key targets for change. Recent studies provided preliminary support for several aspects of the model.
In this article a practitioner oriented review of the literature on the treatment of post-traumatic stress disorder is used to construct a phase-based model that can serve as a basis for case formulation and treatment planning. Treatments shown to be efficacious in randomized controlled trials are listed and two discourses about them are contrasted. One calls for therapists to implement treatments scrupulously according to the manual, the other calls for flexibility and responsiveness to contextual understanding of the situation and personality of individual clients. Evidence for the centrality of the principles of this latter discourse for professional practice is summarized from work on case formulation, standards for therapist competence, and the concept of evidence-based practice. This provides the foundation for a model for treatment of PTSD, both simple and complex, that has five levels which represent increasing degrees of depth of clinical work. In accordance with the phased approach, conditions at one level need to be satisfied before proceeding to work on a deeper level. At each level specific areas of clinical focus are highlighted including risk management (at level 1), building the therapeutic alliance (at level 2) and trauma-focused work (at level 3). The model serves as a broad structured summary of accumulated clinical knowledge about PTSD and its treatment that provides an evidence-based foundation for assessment and treatment planning.
The article presents a model for formulating and planning treatment for post-traumatic stress disorder (PTSD) in South Africa derived from the existing literature and in conjunction with a review of a series of studies of cases treated using the guidelines of Ehlers and Clark's cognitive therapy. It is argued that the construction of psychotherapies (or even components of psychotherapy) for PTSD in terms of traditional categories ("psychodynamic", "cognitive-behavioural", "narrative" etc.) is misleading and unhelpful. Instead, superordinate concepts derived from thinking about evidence-based practice provide a more grounded focus on the practical issues faced by therapists treating PTSD. These concepts, which include competences and metcacompetences, therapist responsiveness, stages of therapy and case formulation, provide a basis for a genuinely integrative approach. The proposed model suggests seven broad areas of clinical focus for work with PTSD which can be arranged at three levels of priority: level 1 crisis intervention and stabilization; level 2 promoting engagement with treatment, and level 3 selection, sequencing and timing of active treatment interventions. Material from the case series is used to illustrate the application of the model.
Objectives
Rape has been found to be the trauma most commonly associated with Posttraumatic Stress Disorder (PTSD) among women. It is therefore important to be able to identify those women at greatest risk of developing PTSD. The aims of the present study were to analyze the PTSD prevalence six months after sexual assaults and identify the major risk factors for developing PTSD.
Methods
Participants were 317 female victims of rape who sought help at the Emergency Clinic for Raped Women at Stockholm South Hospital, Sweden. Baseline assessments of mental health were carried out and followed up after six months.
Results
Thirty-nine percent of the women had developed PTSD at the six month assessment, and 47% suffered from moderate or severe depression. The major risk factors for PTSD were having been sexually assaulted by more than one person, suffering from acute stress disorder (ASD) shortly after the assault, having been exposed to several acts during the assault, having been injured, having co-morbid depression, and having a history of more than two earlier traumas. Further, ASD on its own was found to be a poor predictor of PTSD because of the substantial ceiling effect after sexual assaults.
Conclusions
Development of PTSD is common in the aftermath of sexual assaults. Increased risk of developing PTSD is caused by a combination of victim vulnerability and the extent of the dramatic nature of the current assault. By identifying those women at greatest risk of developing PTSD appropriate therapeutic resources can be directed.
The authors report on a randomized, controlled clinical trial on the treatment of posttraumatic stress disorder (PTSD), comparing manualized psychotherapy to wait-list control. This is the first study to evaluate Brief Eclectic Psychotherapy (BEP), which combines cognitive–behavioral and psychodynamic approaches within one treatment method. Forty-two police officers with the diagnosis of PTSD participated in the study; 22 were randomly assigned to the treatment group and 20 to the wait-list control group. Assessments of PTSD and comorbid conditions were made 1 week before treatment, after treatment session 4, upon termination of treatment (16 sessions), and at follow-up 3 months later. As expected, no significant differences between groups were observed at pretest or at session 4. At posttest and at follow-up, BEP had produced significant improvement in PTSD, in work resumption, and in some comorbid conditions.
Violence and injuries are the second leading cause of death and lost disability-adjusted life years in South Africa. The overall injury death rate of 157.8 per 100,000 population is nearly twice the global average, and the rate of homicide of women by intimate partners is six times the global average. With a focus on homicide, and violence against women and children, we review the magnitude, contexts of occurrence, and patterns of violence, and refer to traffic-related and other unintentional injuries. The social dynamics that support violence are widespread poverty, unemployment, and income inequality; patriarchal notions of masculinity that valourise toughness, risk-taking, and defence of honour; exposure to abuse in childhood and weak parenting; access to firearms; widespread alcohol misuse; and weaknesses in the mechanisms of law enforcement. Although there have been advances in development of services for victims of violence, innovation from non-governmental organisations, and evidence from research, there has been a conspicuous absence of government stewardship and leadership. Successful prevention of violence and injury is contingent on identification by the government of violence as a strategic priority and development of an intersectoral plan based on empirically driven programmes and policies.
Data were obtained on the general population epidemiology of DSM-III-R posttraumatic stress disorder (PTSD), including information on estimated life-time prevalence, the kinds of traumas most often associated with PTSD, sociodemographic correlates, the comorbidity of PTSD with other lifetime psychiatric disorders, and the duration of an index episode.
Modified versions of the DSM-III-R PTSD module from the Diagnostic Interview Schedule and of the Composite International Diagnostic Interview were administered to a representative national sample of 5877 persons aged 15 to 54 years in the part II subsample of the National Comorbidity Survey.
The estimated lifetime prevalence of PTSD is 7.8%. Prevalence is elevated among women and the previously married. The traumas most commonly associated with PTSD are combat exposure and witnessing among men and rape and sexual molestation among women. Posttraumatic stress disorder is strongly comorbid with other lifetime DSM-III-R disorders. Survival analysis shows that more than one third of people with an index episode of PTSD fail to recover even after many years.
Posttraumatic stress disorder is more prevalent than previously believed, and is often persistent. Progress in estimating age-at-onset distributions, cohort effects, and the conditional probabilities of PTSD from different types of trauma will require future epidemiologic studies to assess PTSD for all lifetime traumas rather than for only a small number of retrospectively reported "most serious" traumas.
Violence by clients towards prostitutes has seldom been the focus of public and academic interest, yet it is a major health issue. 1 2 Concern has mostly focused on the potential of prostitutes to transmit sexual infections, notably HIV, to their clients and subsequently partners.3 Features of female prostitution that have a direct impact on the health of prostitutes but not the health of others have therefore tended to be overlooked. The scant research that is available on violence by clients shows that prostitutes who work outdoors in particular routinely confront clients who are verbally, sexually, and physically violent towards them. 4 5 We report on the prevalence of violence by clients against female prostitutes working either outdoors or indoors in three major British cities.
During 1999 three female researchers (SC, MB, and Catherine Benso) contacted 240 female prostitutes; 115 worked outdoors (40 in Leeds, …
This case study presents the results of a counselling intervention with a rape survivor. The woman was twenty-nine years old at the time of the violation. The objective of this study was to explore the dynamics which the woman engaged in coping with the experience of the rape and the resources accessed as part of the healing process. A four leg trauma counselling model is discussed as a short term integrated therapeutic approach. Data was collected and analyzed using a qualitative approach employing a case study method (Terreblanche and Durrheim, 1999), to provide a rich description of the context in which the rape sufferer's symptoms were embedded. The results of this study indicate that re-tellings of the trauma narrative may assist post-trauma recovery. The model was experienced as useful in dealing with this rape survivor because of its clear structure which is comprehensive enough to address most of the needs and concerns of trauma survivors.
The paper argues that the integrative psychotherapy approach is ideally suited to the treatment of psychological trauma. A brief term intervention model, devised by psychotherapists working with trauma in the South African context, is presented to illustrate this premise. It is asserted that post-traumatic stress represents a disorder in which dysfunction occurs both internally and externally according to Freud at the interface of these two aspects of psychological functioning, i.e. at the ego boundary. Disturbance manifests in recognizable cognitive, behavioural and somatic symptoms and in addition carries unconscious associations and anxieties. The ideal approach to treatment thus appears to be to draw on the relative strengths of both the psychodynamic and cognitive-behavioural schools. Existing trauma intervention models reflect the centrality of integration in many respects, although this does not seem to be explicitly recognized. The five components of the model referred to above are outlined and each component is explored in terms of its efficacy within both a cognitive-behavioural and a psychodynamic framework. The paper argues that the clinical success of the model lies in its integrative perspective and that psychotherapy integration should be recognized as the approach of choice in the treatment of traumatized individuals.
The attrition of rape cases from the criminal justice system (CJS) remains high and there is a paucity of research in relation to marginalized groups. Sex workers (SWs) are vulnerable to sexual violence due to the nature of their work. They are also unlikely to report such violence to police for a range of reasons. Two stages of research sought to describe the victim, perpetrator, and offense characteristics of SW rape and to examine the attrition of these cases. All rapes and attempted rapes (N = 1,146) reported to police in a large city in the South West of England over a 21-year period were examined; 67 cases involved SWs. Data were extracted from police files in line with the variables of interest. Secondary analysis of the total number of SW rapes (n = 67) resulted in a profile of these cases. A matched pairs study revealed significant differences in victim, perpetrator, and assault characteristics between SW (n = 62) and non-sex-worker (NSW) samples (n = 62). Although no significant difference was found in terms of attrition from the CJS, SW cases were observed to secure more convictions for rape than NSW cases. The implications of the findings for practice and future research are discussed.
© The Author(s) 2015.
This article explores the meanings of rape for 15 women at the University of Cape Town (UCT), South Africa, who claim to have not experienced rape. It is based upon qualitative interviews with these women and offers a discursive analysis of their talk. The article shows that the women tend to distance the actual occurrence and threat of rape. At the same time, they assume a natural vulnerability to rape with the result that they imagine and fear it as always possible in the course of their daily lives. The article reconstructs the ways in which the women's imagination and fear of rape adversely impacts upon their sense of safety, agency and belonging in South Africa today. Illustrating the power of discourses to shape both subjective and social realities, it concludes that feminist research and activism must pay attention to the discursive dimensions of the rape crisis in South Africa.
This paper identifies barriers to HIV risk reduction among women street sex workers in Cape Town. To gain access to the study population, investigators undertook observational fieldwork for 9 months. This initial trust‐building period allowed for the mutual identification of issues to guide the remainder of the research. Twenty‐five individual interviews and four focus groups were then conducted. The following were identified as barriers to the uptake of risk reduction: the role of regular partners and ‘special clients’ in determining condom use; client resistance to condom use; accessibility of condoms and lubricants; client violence and forced unprotected sex; police violence and lack of protection; substance use among workers; access to health care services; inappropriate genital hygiene practices; inappropriate assessment by workers for sexually transmitted diseases in themselves and clients; and, the role of gatekeepers. Future interventions need to better understand the social context in which street‐based sex workers are exposed to HIV risk. They need to be designed and implemented in partnership to develop sex workers' capacity to reduce the risk of HIV transmission among themselves, and their clients.
focus primarily on principles of analytic theory of technique and discuss the modifications in these principles called for in the focal psychoanalytic psychotherapy of posttraumatic stress disorder (PTSD)
analytic model in the treatment of PTSD / biological metaphors: analogues to PTSD / special psychic configuration of traumatic events / three central tasks in psychoanalytic psychotherapy [therapeutic posture in PTSD treatment, current life stress and traumatic reactions, clinical issues in the three phases of treatment (PsycINFO Database Record (c) 2012 APA, all rights reserved)
The paper argues that the integrative psychotherapy approach is ideally suited to the treatment of psychological trauma. A brief term intervention model, devised by psychotherapists working with trauma in the South African context, is presented to illustrate this premise. It is asserted that posttraumatic stress represents a disorder in which dysfunction occurs both internally and externally, according to Freud at the interface of these two aspects of psychological functioning, i.e., at the ego boundary. Disturbance manifests in recognizable cognitive, behavioral, and somatic symptoms and in addition carries unconscious associations and anxieties. The ideal approach to treatment thus appears to be to draw on the relative strengths of both the psychodynamic and cognitive-behavioral schools. Existing trauma intervention models reflect the centrality of integration in many respects, although this does not seem to be explicitly recognized. The five components of the model referred to above are outlined and each component is explored in terms of its efficacy within both a cognitive-behavioral and a psychodynamic framework. Illustrative case material is provided to demonstrate the mechanisms at work in each case. The paper argues that the clinical success of the model lies in its integrative perspective and that psychotherapy integration should be recognized as the approach of choice in the treatment of traumatized individuals.
This paper presents the results of a meta-analysis of the treatment outcome studies of different types of psychotherapeutic approaches for sexual assault victims experiencing PTSD or rape trauma symptoms. There were 15 outcome studies identified for inclusion in the meta-analysis dating from 1988–2005, and these studies comprised 25 treatment conditions. Separate meta-analyses were conducted according to study design (independent samples and repeated measures), in keeping with meta-analytic conventions. The overall results for the two meta-analyses were highly consistent, and effect sizes were in the large range for independent samples (g = .91) and repeated measures treatments (g = .90). Effects were maintained at follow-up from 6–12 months after treatment. Studies represented diverse treatment approaches, and most treatments were effective in improving outcome according to symptom reduction. A number of moderating variables were examined. Better outcomes were achieved with individual therapy compared to group approaches. The use of semi-structured approaches and homework techniques were positively related to the magnitude of effect size.
This article reviews empirical support for treatments targeting women sexually assaulted during adolescence or adulthood. Thirty-two articles were located using data from 20 separate samples. Of the 20 samples, 12 targeted victims with chronic symptoms, three focused on the acute period post-assault, two included women with chronic and acute symptoms, and three were secondary prevention programs. The majority of studies focus on posttraumatic stress disorder (PTSD), depression, and/or anxiety as treatment targets. Cognitive Processing Therapy and Prolonged Exposure have garnered the most support with this population. Stress Inoculation Training and Eye Movement Desensitization and Reprocessing also show some efficacy. Of the four studies that compared active treatments, few differences were found. Overall, cognitive behavioral interventions lead to better PTSD outcomes than supportive counseling does. However, even in the strongest treatments more than one-third of women retain a PTSD diagnosis at post-treatment or drop out of treatment. Discussion highlights the paucity of research in this area, methodological limitations of examined studies, generalizability of findings, and important directions for future research at various stages of trauma recovery.
Sex workers are particularly vulnerable to sexual assault. However, until recently, there were significant barriers to the prosecution of those who raped sex workers. Prostitutes were seen as 'commonly' available to men, as always consenting to sex and thus as incapable of being raped. This article examines 5 1 judgments - from the United Kingdom, Australia, Canada and New Zealand - where evidence of prostitution was presented between 1829 and 2004. It demonstrates an important change in the 1980s and 1990s when, for the first time, men began to be prosecuted and convicted for raping sex workers. This change was partly due to rape law reform, but also to feminist activism and broader changes in social attitudes to rape. The article argues that sex workers have recently been 're-made' in law as women vulnerable to rape, as individuals able to give and withhold sexual consent. This development needs to be taken seriously so that law and policy addressed to the sex industry works to enlarge (not reduce or constrain) the making of prostitutes as subjects with consensual capacity. This necessarily involves attention to more legal rights for prostitutes, as workers, and calls into question the conceptualisation of prostitution as always involving rape.
Brief Eclectic Psychotherapy (BEP) is a manualized psychotherapy for posttraumatic stress disorder (PTSD) which has proven effective for police officers. This article reports on a randomized clinical trial using BEP to treat other types of PTSD patients recruited from an outpatient clinic. Twenty-four patients were randomly assigned to a treatment or a waitlist group. Assessment of PTSD was made before and after the treatment period (4 months). No significant differences between the groups were observed at pretest. By posttest, BEP had effectively reduced PTSD as well as general anxiety symptoms in the treated group of outpatients as compared to the waitlist group.
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Feminism and the South African polity: A failed marriage
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