AT EASTER 1990, a mob of Soweto teenagers attacked Sugar, a young
Rastafarian accused of raping girls at the local school. In a fury of
vengeance, the teenagers felled him with stones, severed his head and carried
it through the streets impaled on a broomstick. It was early morning and young
children going to school were stopped in their tracks by the pectacle.
For many people in South Africa鈥檚 black townships such horror became part
of daily life during the final decades of apartheid 鈥� a system that brutalised
the population. Violence became the standard way of resolving differences when
all the normal channels of communication were closed: the media was censored,
gatherings restricted and political meetings banned.
And there is little sign of the violence resolving itself now that
apartheid is gone and South Africa has its first democratically elected
government. Apartheid鈥檚 legacy is a culture of violence that will take a long
time to change, says psychologist Vivi Stavrou, who works at the Institute for
a Democratic Alternative in South Africa in Durban. 鈥淚n South Africa violence
has become the single most effective way to get and to keep power,鈥� she
says.
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Psychologists are concerned about the effects of this widespread violence
on the mental health of the generations of children, black and white, who have
grown up in this environment, and wonder what the long-term implications could
be for a society struggling to rebuild itself. Little is known about the
extent of traumatisation because studying the effects of the system was
considered subversive until 1990, when former president F. W. de Klerk made
the reform speech that marked the beginning of apartheid鈥檚 demise. Recent
research, however, suggests the psychological damage is considerable.
Last year, Beverley Killian and Barbara Mason of the Psychology Department
at the University of Natal, Pietermaritzburg, studied more than 400 black
children in primary schools and cre`ches for signs of psychological
disturbance. KwaZulu/Natal is South Africa鈥檚 most strife-torn region. For more
than ten years the black population has been engaged in 鈥渓ow intensity鈥� civil
war based on political rivalry and historic clan feuds that in 1992 alone
claimed 3500 lives. The townships bear the scars of conflict in burnt and
broken houses, abandoned boarded-up shops and post offices, and the pockmarks
of bullets everywhere.
Domestic violence is also rife, says Ruth Bhengu, who works with Killian on
the Natal Programme for Survivors of Violence, a research and rehabilitation
programme based at the university. Bhengu, a community worker who counsels
traumatised township children, grew up with domestic violence and can well
understand its dynamics. Apartheid, she says, devastated black family life.
Traditional Zulu households are patriarchal and authoritarian. But the migrant
labour system, which affected most Zulu men and denied them the right to take
their wives and children with them to the 鈥渨hite鈥� cities, undermined their
status. When they retumed, it was to find the women capably running the show
and their children politicised 鈥� questioning their father鈥檚 attitudes and
authority and perhaps taking an active part in the struggle against apartheid.
As a result, many men resorted to alcohol and physical abuse.
Constant vigilance
But migration was only one of many destructive forces that affected black
families across the nation. Relationships were undermined, too, by children
witnessing the humiliation of their elders by whites, which ranged from being
shouldered off the pavement or refused service in shops and bars to rough and
arbitrary arrest at dead of night. Many who grew up in the revolutionary 1970s
and 1980s found it hard to understand the apparent passivity of the older
generation and so ceased to respect them or trust in their judgment and
strength.
Virtually no one in the black community remains untouched by violence. Even
so, Killian and Mason were shocked by their findings, for they tried to avoid
sampling children in the most troubled areas. 鈥淲e wanted to see what the
average black child had been exposed to,鈥� says Killian.
In the primary school study, they asked 300 children between the ages of 8
and 12 years to complete a questionnaire, helped by a teacher in the case of
the younger ones, giving details of the age and sex of the children, where
they lived and of their parents or the main person who looked after them. In
addition, teachers and parents filled in a checklist of 28 symptoms that most
psychologists recognise as being indicative of depression and stress.
Every child exhibited at least one symptom on the checklist, while the
average was eight to nine symptoms. By far the most common symptom among the
schoolchildren was hypervigilance. Constantly keeping a watch for danger is
indicative of chronic anxiety, says Killian. More than half the children had
trouble sleeping, and 43 per cent experienced frightening dreams almost every
night. Forty-one per cent suffered flashbacks in which they relived
distressing experiences, while 38 per cent had eating disorders such as loss
of appetite, 23 per cent felt frightened much of the time and 12 per cent
wished they were dead.
While it is not that unusual to find some of these symptoms in children, it
is rare for them to be present at the levels and intensity that Killian and
Mason found. They concluded that 18 per cent of the children were affected by
emotional problems. By comparison, studies of children of comparable age in
Europe and London found 2.5 and 5 per cent affected respectively. Killian
warns that these studies are not strictly comparable, but they give an
indication of the seriousness of their findings in Kwazulu/Natal, which did
not involve children living in the areas most affected by violence.
Killian and Mason also concluded 鈥渆xtremely conservatively鈥� that 9 per cent
of the children were clinically depressed, while 13 per cent had post-
traumatic stress disorder (PTSD), a condition which impairs a person鈥檚 ability
to work, relax and sustain close relationships.
PTSD was first described in 1980 after psychiatrists in the US reported
that Vietnam veterans were still suffering the psychological effects of combat
experience many years after the war. Experts now recognise that PTSD can
afflict anyone who has experienced trauma 鈥� whether once-off as in a rape,
earthquake or accident, or long-term as in a war or chronically violent
environment.
Diagnosis is based on the presence of a combination of symptoms which are
intense enough to prevent someone from functioning effectively. The symptoms
range from an emotional numbing and a loss of interest, motivation and belief
in the future to an exaggerated jumpiness, irritability and outbursts of
anger. Other symptoms include distressing reactions to external stimuli such
as sound and smell associated with the event and recurrent recollections of
the event that intrude on other activities, such as reading or working, and
disrupt concentration. The same condition 鈥� poorly understood then 鈥� was known
as 鈥渘ostalgia鈥� and 鈥渟oldier鈥檚 heart鈥� in the American Civil War, 鈥渟hell shock鈥�
in the First World War, and 鈥渃owardice鈥�, 鈥渃ombat neurosis鈥� or 鈥渓ack of moral
fibre鈥� in the Second World War and the Korean War.
When it came to the pre-schoolchildren 鈥� 148 in all between the ages of 2
and 6 years 鈥� Killian and Mason asked them to draw a picture of something that
had happened to them, good or bad. The value of drawings in assessing
children鈥檚 emotional states is contentious, admits Killian. But she says the
pictures she collected were very revealing of the world the children inhabit
and their reaction to it. The Sun 鈥� a powerful positive image in 鈥渘ormal鈥�
children 鈥� appeared in less than 3 per cent of pictures, while 84 per cent
were associated with violence: 33 per cent drew violence in action (guns
firing, spears, soldiers or policemen), 15 per cent drew people fleeing and 23
per cent drew the aftermath of violence (corpses, injured people being put in
ambulances, houses burning or refugees carrying bundles). Only 15 per cent of
the drawings contained the kind of images we normally consider to be
appropriate to that age group 鈥� such as mums, dads, and siblings, homes and
flowers.
From her assessment of the drawings and the symptom checklists, Killian
suggests that 108 of the 148 pre-schoolers showed signs of PTSD. Girls and
boys appeared to be about equally affected. Interestingly, those who produced
the most disturbed drawings were least likely to be suffering from PTSD,
possibly they were not suppressing their experiences as much as those who
could not put their feelings into a picture.
Gill Straker, professor of psychology at the University of the
Witwatersrand, Johannesburg, believes Killian鈥檚 figures for PTSD are
鈥渞ealistic鈥�. From her own research in black townships in the Transvaal she
estimates that between 13 and 20 per cent of youngsters are seriously affected
by their traumatic experiences. Crucially, in one of the few long-term studies
done, Straker found that the degree of psychological damage was not directly
related to the degree of violence, but to the way the child perceived it.
During the period 1987 to 1992, she looked at teenagers in Alexandra, near
Johannesburg. When her study started, South Africa was still in a state of
emergency, with soldiers occupying the townships, but by 1992, apartheid was
on the way out and the soldiers had gone. But, unexpectedly, the children
seemed to be more emotionally disturbed during 1992 than during 1987. The
reason, she says, is that in 1987 the enemy was visible. In 1992, at a time of
apparent peace, the state had allegedly resorted to destabilising the
townships by using agents provocateurs to provoke black on black violence.
鈥淭hen the enemy wasn鈥檛 so clear, he was working from within and it was much
easier to make mistakes and kill the wrong person,鈥� explains Straker.
Hidden trauma
Michael Simpson, a psychiatrist with long experience of treating
apartheid鈥檚 trauma victims, says we should be cautious when studying data on
the prevalence of PTSD at any one time. 鈥淲e know from extensive experience
from Vietnam and South America to the Falklands that trauma sometimes take
five, ten or even more years after an event to manifest itself.
Some of the most startling data from Killian and Mason鈥檚 Kwazulu/Natal
study come from 8 to 12-year-olds talking about their personal experience of
violence. Of the 300 children studied, 8 said that they had killed a person,
11 admitted being part of a group that had killed someone, 13 had witnessed
assault and 47 had had their homes torched. The research did not sketch in the
circumstances, but a case seen by Bhengu gives some indication of how children
get drawn into taking part in violent acts.
Bhengu鈥檚 patient is now 18. When he was 10, his father was killed in front
of him. The boy knew his father鈥檚 murderers, and vowed he would kill them all.
Over the next three years, the child killed 19 people. Thrown out by his
family, today he is homeless, unemployed, dodging the police and in despair.
He told Bhengu recently he was considering suicide: he no longer sees himself
as human and has no sense of belonging.
According to Straker鈥檚 book Faces in the Revolution, a study of young black
anti-apartheid activists, loss of self-worth is not only a result of violence
but a root cause. Many of her subjects joined the struggle to search for some
meaning beyond their own seemingly pointless existence. Allegiance to a
greater cause made them prepared to fight for a cause and to carry out acts,
such as destroying their schools, that appeared not to be in their own
interests, and even to kill.
Certainly, the people at the centre of township violence tended to be
teenagers who, in 1976, took the lead in the struggle against the system. That
was the year of the Soweto Uprising when soldiers shot down schoolchildren who
were protesting against the imposition of Afrikaans as the language of
instruction.
Black youth became prime targets of government repression. Official figures
show that between 1984 and 1986 鈥� a period of township uprisings known as 鈥渢he
people鈥檚 war鈥� 鈥� 300 children under 18 years were killed by police and 1000
were wounded; 11 000 were detained without trial; 1000 were arrested for
protesting; and 173 000 were held in police cells awaiting trial.
Given the cruelty of apartheid and its brutalising effects, one would have
imagined its demise should have brought nothing but good. But the manner of
its going 鈥� not by defeat or victory in a war that swiftly replaced the old
order with the new, but through a gradual realisation that the system was
rotten, followed by four years of negotiated transformation 鈥� has created
problems of its own.
It is a transformation so profound that there are no certainties left for
anyone. Between the wholesale scrapping of one system and the painstaking
elaboration of another, people have been caught in a limbo where all old
points of reference are gone and new ones are yet to evolve. Thus the
emotional scars of the apartheid years are not confined to the black
population. While most whites lived lives of comfort, it was at a price: high
walls around their homes, fierce dogs, armed security guards at the touch of a
鈥減anic button鈥� and regular bomb drills in the schools. And then, in 1990, a
government that had appeared strong and offered certainties if not justice
began to change all the rules, making friends of enemies and declaring the old
laws null and void.
Loss of innocence
鈥淚t鈥檚 a fundamental truth that the most painful time to live is a time of
transition, when everything is in the melting pot,鈥� says Dr A, a Johannesburg-
based psychiatrist who prefers not to be named for reasons of professional
ethics. In his practice he sees many young white men who were conscripted into
the armed forces straight from school aged 17 or 18. They have been
particularly badly affected by political change because the old regime
demanded absolute loyalty and forced many to use violence in its defence. Only
whites were conscripted and conscientious objectors were jailed.
鈥淧TSD was typical of our patients until the late 1980s. But then added to
the familiar symptoms of PTSD we began to see anger towards the system that
had let them down,鈥� says Dr A. For the first time, too, there were signs of
overt guilt. In the past his patients were traumatised by the loss of friends
in battle. Today they鈥檙e traumatised by the loss of innocence, he says. 鈥淭hey
were taught that the enemy was the ANC which was equated with communism, which
in turn was equated with being nonhuman. But suddenly they鈥檙e seeing the
`enemy鈥� as a person with a family, who reads newspapers and speaks the same
濒补苍驳耻补驳别.鈥�
He cites the case of a young white man who, during his national service
seven years ago, killed a black woman and child. Such an act was not army
policy, but many of the conscripts were emotionally immature and killing black
people tended to earn peer respect. His patient, who came from a wealthy
Johannesburg family, had tried once, unsuccessfully, to talk to his father
about the incident and had since repressed it. But after drifting from job to
job in civilian life and being tormented by a recurrent nightmare based on the
atrocity, he finally sought help.
The re-humanisation of the enemy raises agonising questions and the spectre
of self-doubt for men like this. In South Africa the former enemy was not a
foreigner but a fellow countryman who today may be sitting in parliament. And
the devaluation of the cause for which young servicemen fought and lost
friends by the very people who first expounded it has added a unique
dimension. 鈥淔or the politicians to stand up and say simply `we apologise鈥� is
not enough for the personal price the soldiers paid鈥� says Dave Fitzpatrick-
Cockram, a clinical psychologist who also sees ex-servicemen.
Worst affected by this 鈥渂etrayal鈥� are former members of Koevoet (Afrikaans
for 鈥渃row bar鈥�), the crack counter-insurgency squad trained to kill rebels in
former South West Africa, now Namibia, which was ruled by Pretoria until 1989.
Though the officers were white, the majority of fighting men were volunteer
blacks for whom army life represented primarily a secure job with good pay and
perks. Back in civilian life, many of the blacks are having a terrible time
coming to terms with their role according to several ex-Koevoet members. Up to
a third of their former colleagues, they say, have committed suicide. Official
confirmation of this toll is impossible, however, since no records are
kept.
Even those who never actively engaged with apartheid are vulnerable to the
uncertainties of transition. The staff at the Vista Psychiatric Clinic near
Pretoria have seen an abnormally high and increasing case load of white
adolescents suffering psychological problems such as depression, anxiety,
anger and eating disorders including anorexia. 鈥淭here鈥檚 a lot of literature on
adolescence as a period of adjustment,鈥� says Fitzpatrick-Cockram, who works at
Vista. But in this situation, adolescents in a period of adjustment have to
deal with a society that鈥檚 also struggling to adjust. 鈥淭hat parallel is a
minefield,鈥� Fitzpatrick-Cockram says.
鈥淢ost vulnerable are white children from the more rigid, authoritarian
homes where change is hard to contemplate, let alone discuss between the
generations. The parents are struggling with the challenge to their values and
lifestyles, and the children have nowhere to turn.
Acknowledging the past
How long will the psychological effects of apartheid persist with a new
government, new vision and new frames of reference in place? Nobody knows.
However, most mental health professionals agree that healing will not happen
unless the past is fully acknowledged. A controversial suggestion is that a
truth commission be set up to examine abuses of human rights under apartheid.
It is crucial too, say experts, that South Africa鈥檚 leaders recognise the role
black children played in the struggle and the enormous price they paid in
terms of lost education, family life and the death of friends. Young blacks
are hungry to play their part in the new South Africa; they must begin to see
real improvements in their living conditions and opportunities to escape from
their poverty if their frustration and potential for violence and crime is to
be neutralised.
But much is needed, too, in the way of specific mental health services.
During decades of political repression, a few South African psychologists and
psychiatrists developed some of the best expertise in the world in recognising
and treating PTSD. Those who worked with human rights lawyers bringing cases
against the security forces gained unusual insights into the traumatisation of
victims, says Simpson. 鈥淪o much of the original research into PTSD in America
was done on people who were still unwell years after the event, whereas we
have had a view of the process as it occurred that few other people have
丑补诲.鈥�
Simpson is one of the people who pioneered the use of drugs in the
treatment of PTSD. The newest range includes drugs such as buspirone (buspar)
and fluoxetine (prozac) that affect levels of the mood-regulating chemical
serotonin in the brain. These drugs appear to give good results when used in
conjunction with psychotherapy.
Such sophisticated treatment, though, reaches only a tiny fraction of those
who need it. In all there are about 2000 clinical psychologists and
psychiatrists to serve a population of some 40 million, and most of these are
in private practice. Over recent years, however, concerned psychologists have
started trauma centres in a number of cities offering counselling and a range
of therapeutic activities.
Terry Dowdall has founded one of these trauma centres in Cape Town.
Dowdall, who is head of the Child Guidance Clinic at Cape Town University, has
a long history of involvement with apartheid鈥檚 victims. He believes there has
to be a fundamental reappraisal of the role of mental health professionals.
For example, child psychologists at the CGC are now trained to work with
communities and to pass on skills to 鈥渇ront-line鈥� workers such as priests,
teachers and development workers so that they know how to recognise signs of
psychological distress, to encourage victims to talk, to listen
constructively, and to cope with the burden of other people鈥檚 confessions.
Counselling children
He and others are also pushing for regular time to be set aside in all
schools for classes 鈥渢o talk through the issues that are problematic in
society鈥�. The sessions should be supervised by a school counsellor specially
trained to encourage a culture of tolerance for other people鈥檚 points of view.
鈥淭he only way to learn tolerance,鈥� says Dowdall, 鈥渋s not through
political exhortation but by actually practising it in the classroom setting.鈥�
The counsellors鈥� job would also be to identify and refer children in need of
more intensive rehabilitation or therapy.
Meanwhile the psychology and education departments at the University of
Cape Town are developing a programme of education for tolerance and peace,
focusing on racism and how to combat it, for use in high schools. They aim to
produce a user-friendly handbook for teachers on the issues.
But Simpson believes a major shortcoming of such initiatives is that they
are not coordinated at a national level. What is needed, he argues, is an
integrated system with clear lines of referral from the front line to more
sophisticated levels of treatment for those who need it. Ideally the system
would include a 鈥渞apid response鈥� team of people specially trained to intervene
as early as possible after an event 鈥� as in rape crisis centres 鈥� and to talk
a person through the experience.
Simpson and some colleagues have recently set up the Institute of Mental
Health Policy Development to lobby for national coordination of services. He
is worried the new ANC-led government, faced with so many pressing social
problems, might let mental healthcare go by the board. 鈥淧eople who have the
energy to make a lot of noise tend to get what they want though they aren鈥檛
usually the most needy,鈥� he says. 鈥淚t鈥檚 the ones sitting shivering in the
corner or screaming with nightmares in the middle of the night who need help
yet who don鈥檛 get the ear of government. They鈥檙e the ones who are being
neglected at present.鈥�
