Violence Breeds Violence

This blog will be dealing with the issue of community violence, and the effects of this on mental health.

Just last week a 6 year old girl was shot in the head while playing in the garden outside her home – the result of gang shootings. Newspaper headlines have told of community members in the local informal settlement taking it upon themselves to punish people suspected of various crimes. These punishments take the form of a public ‘necklacing’ - a tyre is placed around the suspected perpetrators neck, and then set alight. In the two most recent incidents of this happening, the community members, including children, watched two men burn to death.

If events like these are your normal, day-to-day experience, the effect on mental health can be as lethal as the effects of toxic chemicals on physical health (Wandersman & Nation, 1995).

It has been found that women who observe community violence, even if they are not personally involved in it, are twice as likely to suffer from depression and anxiety (Clark, Kawachi, Canner, Berkman & Wright, 2008).

Additionally, while some children who witness and experience community violence may seem unaffected, many are likely to experience psychological problems. Some may become withdrawn, anxious and fearful, while others may deal with their stress and fear through aggressive behaviour that makes them feel powerful and in control.

It is also important to note that children who have suffered a trauma have fewer resources available to them in terms of dealing with usual, age appropriate developmental challenges, such as making friends and managing school work. This is because so much of their energy is focussed on keeping the traumatic memory at bay. They may have difficulty concentrating on their present, because they are so concerned about the negative memories associated with what they have witnessed or been involved with in the past (NYU Child Study Centre).

Additionally, studies on the intergenerational cycle of violence have shown that children who are a traumatized, are more likely to commit crimes when they grow older (NYU Child Study Centre).

These findings are particularly worrying for a country where such a large proportion of the population live in either informal settlements or areas governed by gangs; communities where violence is rife.

The effects of community violence are far reaching, may follow individuals into their adult lives, and may, indeed shape the way a person is able to function in their day-to-day life. Violence breeds violence. The cycle needs to be stopped.

Dissociation and Trauma

It’s a concept that many see in the movies.  The situation where one experiences a trauma and then “erases” it from their minds, and they are only reminded of it years later by some trigger in their environment.  Frightening as this may seem, it is in fact a phenomena referred to as dissociation.  It is, of course, not quite as it is shown to be in movies though, as the memory is not exactly erased. Detachment could be as simple as daydreaming, however this is considered to be a non-pathological form of dissociation.

The DSM-IV defines dissociation as “a disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment" (p. 477).  Psychologists dealing with dissociation in patients have explained dissociation as a possible detachment from immediate surroundings, or from the immediate physical and emotional reality.  It is important to note though that it is a detachment from reality and not a loss of reality.  If there was a loss of reality; the condition would be considered a psychosis and not a dissociation. It is also important to note that a dissociative memory is still an active memory, which is why it leads to disturbing intrusions.  This makes it different from a forgotten memory, as they are inactive.These dissociative episodes allow the person to compartmentalize perceptions and memories, which allows them to separate from the trauma while it is occurring.

In many situations, this detachment could be considered a coping or defense mechanism, which helps the person to master or minimalize the immediate stress.  This would be the case in the immediate aftermath of a severe trauma or during a trauma, only then would it be considered as a coping mechanism.  Following that, the detachment could mean that the person never truly processes the trauma and could lead to serious psychological dysfunctions and maladjustment.

The pathological forms of dissociation include dissociative disorders, such as: dissociative fugue and depersonalization disorders.  Dissociative fugue is when the person assumes a new identity, which is coupled with total amnesia of their “previous” life.  It can also include the person upping and leaving physically, however they will not know why they left, where they were going or what they did whilst away. Depersonalization occurs when the person feels that they are outside their body and are observing themselves from the outside.  Both of these clearly show the detachment from reality.  Apart from the above-mentioned, the pathological forms of dissociation include a sense of derealization, dissociative identity disorder (separate streams of consciousness, previously Multiple Personality Disorder) and Post Traumatic Stress Disorder. All of these dissociations can be unexpected intrusions, which would obviously be very unsettling to the sufferer.

Dissociation has been linked to victims of multiple forms of childhood trauma, whether physical, psychological or sexual, with the higher levels of dissociation being linked to the abuse starting at younger ages. It is also linked with amnesia of the dissociative period (Merckelbach H., Munis, P. 2001).  The level of dissociation has also been linked to the severity of the abuse (Drayer, N., Langeland, W. 1999). 

Dissociation can be caused by stress or trauma but can now be treated with a combination of techniques. The main treatment usually used for dissociation is psychotherapy, which involves talking to a therapist who will assist in working through the underlying cause of the dissociation.  The psychotherapy can also include hypnosis to help the client access the underlying issue.  Other types of therapy include creative art therapy (to help express emotions which they may ordinarily find difficult), cognitive therapy (help identify negative feeling and associations and replace them with health ones), as well as medication (such as tranquilizers, anti-depressants and anti anxiety medication).

Teach Me Trauma

When looking at the many problems that children in under-resourced schools face daily, one can often be at a loss at how best to help these children. When events such as abuse, rape, depression, self-mutilation, gangs and teen pregnancy are common, where does one start? How can one help? Is the answer to work one on one with these children, or with their families, or with their communities or with the political system of the day? Perhaps the answer is ‘all of the above’ and ‘take your pick’.

This blog will focus on the school environment as an area needing intervention – transforming the school environment from one that arguably perpetuates trauma, to one that is an effective part of a child’s social support system.

Duncan and Rock (1997, as cited on National Children & Violence Trust site) argue that the structure and routine of school life is “calming” for children, and thus enhances their capacity for resilience when faced with a traumatic event.

While this ought to, perhaps, be the case, in many schools it is not a reality. Rather than forming a buffer to trauma, too many schools are actually the site of trauma.

Amanda finds being in class incredibly stressful. Her fellow students are noisy and aggressive, while the teacher does nothing to maintain order. Due to a background of domestic violence, Amanda is hypersensitive to the unruly activity in the classroom and finds it almost impossible to concentrate. Thus, not only is Amanda traumatised at home, but also at school, leading to truancy and risk of failing the year.

Nandipha is teased and taunted by her class because she is a committed, well-prepared student and the ‘teacher’s pet’. The teachers do nothing while students make comments to Nandipha, such as, (on Nandipha writing an answer on the board) “your writing is as ugly as your face”. Nandipha dreads school and feels that she cannot cope much longer. She feels hopeless and desperate about her situation.

Often, in an attempt to maintain control of the classroom, teachers will mock and humiliate a child in front of the class. In one case, this resulted in two teens attempting suicide. Another teen, with ADHD, is victimised by the teacher, who, when he is being disruptive will announce to the class that the boy needs his ‘crazy pills’. Other teachers are feared by the students, who know that if they do not give the correct answer, the wooden chalkboard duster or a pen will be thrown at their head.

These real life examples highlight that in too many cases, school is not the calming, orderly environment that Duncan and Rock (1997) envision. As such, students are losing out on a potential source of support, safety, respect and discipline. And something needs to be done. Perhaps the answer is more teachers. Better teachers. Teacher training sessions. Inspiring and educating educators of the vital role they play – to uplift or destroy.

Schools need to be reclaimed so that they can indeed be environments that strengthen children and protect them from the trauma they experience in other areas of their lives.

 

Childhood Trauma: A life-long Burden to Bear?

There have been many studies done, a number of them being longitudinal, on the lasting effects of childhood trauma.  The results have been staggering and clearly indicate the consequences of suffering a trauma as a child.

Firstly, what is childhood trauma? The American Academy of Pediatrics (AAP) in 1992 defined it as a repeated pattern of damaging interactions between parent(s) [or, presumably, other significant adults] and child that becomes typical of the relationship."  These damaging patterns would include physical, verbal and sexual forms of abuse, as well as neglect and anything that would make the child feel worthless, unloved, insecure or endangered. Childhood trauma would also have to include single events, like the loss of a parent before the age of 12.  The less obvious childhood traumas also include continually moving house, divorce, isolation from stimulation, and parental fighting.

Usually the damage is caused by continuous traumas, but tho is not always the case, as stated above.  The reason for this is that with most single-event situations, as the child’s brain develops, it disposes of the synaptic connections that are responsible for remembering the event.  When the events are repeated, the brain builds more of these synaptic connections and so is much more likely to remember the events, although not always in the recoverable memory.  This means that the person’s traumas may influence their thoughts, actions and behaviours but they are unable to connect that with their trauma and are unable to view their trauma with complete accuracy and clarity. One can imagine that this could have some serious consequences in later life.

What are some of the consequences of childhood trauma? With all categories of abuse, there are physical and psychological and behavioural consequences that can manifest in later life. There are the obvious physical damages such as broken bones, bruises or even death. In the long term though, abuse has been shown to lead to impaired brain development, and poor physical health (allergies, arthritis, asthma, high blood pressure).  Psychologically, research has shown that childhood abuse can lead to low self-esteem, depression and relationship difficulties.  Furthermore, Silverman, Reinherz, & Giaconia (1996) revealed that 80% of young adults who had been abused as children, met the criteria for at least one psychiatric disorder.  These disorders included anxiety, depression, eating disorders and suicide attempts.  ADHD has also been found to be connected to childhood trauma.  With regards to behavioural consequences, research done by Johnson, Rew, & Sternglanz (2006) showed that those who were abused as children were more likely to partake in risky sexual behavior, often resulting in STD’s like HIV. Child abuse victims are also 3.1 times more likely to commit violent crimes as adults. Another common long-term consequence is that of substance abuse.

As a result of the above consequences, the abuse victim often finds it hard to reintegrate back into society, hold a steady job or engage in fulfilling relationships.  The effects vary depending on the type of abuse, the child’s personal characteristics as well as their environment. The effects may be severe or milder and may last for varying amounts of time.  In most cases, the consequences extend to the entire family and oftentimes the community of the victim. 1 in 3 vistims who were abused as children will go on to abuse their own children, continuing the cycle.  It would therefore be fair to say that the effects of childhood trauma, resulting from abuse (of any type), are a burden that is often carried for life.

Trauma in Burn Victims

A severe burn injury is one of the most traumatic experiences an individual can go through. There are nearly 1 million burn victims who find it challenging just to survive their injuries, and also experience psychological distress that can be devastating for the individual’s ability to cope. Several studies have indicated that trauma related to a burn injury may cause several psychological problems. Literature on burn victims has pointed out Posttraumatic stress disorder (PTSD), as a relatively common element after a burn injury. Other symptoms of anxiety and of depression are also common. Acute stress disorder (ASD), has also been found to be quite common psychological problem in the burn literature. The diagnosis of ASD requires that the individual has experienced a traumatic event and developed symptoms of dissociation, avoidance, anxiety, re -experiencing the traumatic event, and increased vigilance in response to the trauma. (Difede, J., et, al. 2002). Furthermore, research on burn injuries has indicated that up to 50% of burn victims will be diagnosed with depression, and over 30% of burn victims will have developed symptoms of anxiety one year after the injury.   Between 20% and 45% of burn victims have developed PTSD approximately one year after the incident (Sveen, J. 2011).

                                                                                                                                                                                 

Burn injury has acquired a distinctive position in the trauma literature, because burn victims are normally confronted with a multifaceted trauma complex, because of the many psychological and social aspects associated with burn injury. In a qualitative study undertaken with burn survivors in Sweden, interviews were conducted with the victims in order to gain an understanding of their trauma. The victims described feelings of dissociation, re-experiencing, avoidance, and intense grief (Millstone, S. 2008). In the case of severe burn injuries, for example third and fourth degree burns that destroy hair, nerves, glands, vessels, and burning all layers of the skin tissue, the survivors were left severely traumatized. Those that experienced facial burns were particularly affected. Many reported having avoided their mirror image, and a few expressed how months later they were still in denial when they saw their own reflection.  Unlike many burn victims, those with facial burn injuries wear the scars of their trauma for the world to see (Freund & Marvin 1990). In today’s society where image has become very important, it is very difficult for the individual to live with a face or body that is different (Millstone, S. 2008). The assumption often conveyed by the media is that having an altered appearance also means having a damaged personality or lack of intelligence. It is quite common for burn victims to receive curious stares, impulsive questions and hurtful remarks on a daily basis, which can result to increased self-consciousness. In response a burn victim will tend to become isolated and, or believe they cannot have intimate relationships (Freund & Marvin 1990).

However, the reality is that given the proper treatment, therapy, support and information to cope with the emotional, mental, and social issues, it is possible for burn victims to live normal, successful lives and enjoy fulfilling relationships and achievements, regardless of how extensive their injury may be.

Difede, J., et, al. (2002). Acute Stress Disorder After Burn Injury: A Predictor of Posttraumatic Stress Disorder. Psychosomatic Medicine. 64:826–834.

Freund P.R. & Marvin J.A. (1990). Post burn pain. In Bonica J.J. (eds) The management of

Pain,  2 end edn. Philadelphia: Lea and Febiger. pp. 481-489.

Millstone, S. (2008). Coping with disfigurement 1: causes and effects. Nursing Times; 104: 12, 24–25.

Sveen, J. (2011). Posttraumatic Stress and Cognitive Process in Patients with Burns. Acta Universitatis Upsaliensis. Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine 639. 58pp. Uppsala.

Teen Dating Violence

My co-counsellor and I were running a workshop on teenage pregnancy recently at an inner city school in Cape Town. The focus of my discussion during our workshop was mainly on healthy and unhealthy relationships.  Of the 60 participants, female grade ten learners, almost a third requested counselling after this topic discussion. I was taken by surprise when it emerged that the majority of these girls presented problems with teen dating violence. Most of them were victims of violence, being abused within the context of dating. Some others admitted to perpetrating abuse in their dating relationships. This was an unsettling discovery and I was prompted to further investigate date related abuse among teens.

Teen dating violence (TDV) is a serious and potentially fatal form of relationship violence in adolescence. The data shows very high incidence and prevalence of exposure to TDV among adolescents and teens, but it has been largely overlooked as an issue that can have serious and potentially fatal consequences. Adolescents have long been overlooked as a population that suffers from relationship abuse (http://www.cdc.gov/ViolencePrevention/pdf/TeenDatingViolence2012-a.pdf). Research literature on this age-group has been scarce and confusion remains in healthcare communities about the definition, implications and effective intervention methods.

The research literature does not provide a uniform definition on TDV, and definitions vary in comprehensiveness. The restrictive definition only includes ‘physical force or threats of force against a current or former intimate partner’, while a broader definition includes ‘a continuum of controlling or dominating acts that cause some degree of harm’ (Wekerle and Wolfe, 1999). It includes most commonly physical abuse, psychological/emotional/verbal abuse, and sexual abuse within the context of dating or courtship.

Bearing in mind that only 35% of youths between the ages of 13 -17 report crimes against themselves, the statistics tell a disturbing story (Close, 2005):


·        Almost 30% of teens age 14 – 17 report that they, or someone they know, has experienced dating violence;
·        1 in 5 female high school students report being abused by a boyfriend;
·        33% of teenage girls report having experienced physical violence by a dating partner;
·        38% of date rape victims are between 14 and 17 years old;
·        Between 1993 and 1999, 22% of all homicides against females ages 16 to 19 were committed by an   intimate partner;
·        The potential threat for violent behavior appears to escalate as the relationship becomes more serious

Many research studies have highlighted the serious consequences of dating violence (Joyce, 2004). Apart from physical injuries and fatalities, studies have shown a range of mental health issues arising from TDV: post-traumatic stress, lower self-esteem, decline in school achievement, and increases in eating disordersand substance use. Studies also revealed a prevalence of negative mood and behaviour following the abuse, and that these effects tend to be enduring over time.

Despite the alarming statistics TDV attract little national attention and although it causes significant damages, communities, authorities, schools, parents and victims continue to deny the seriousness of the problem. This minimization of the deleterious effects of TDV stresses the urgency for serious responses to the problem. It is a call for both intervention program initiatives and legal reforms.

In the United States some organisations have started to address the challenge of TDV by implementing programs that mainly focuses on prevention and education, or on counseling and intervention. Prevention and education programs seek to reduce TDV and to promote healthy relationships by teaching conflict handling, critical thinking and communication skills.They explore for example power and control, gender stereotypes, gender based violence and nonviolent ways to deal with disappointment and anger. Counselling and intervention programs intervene directly on teens’ lives and focus on support structures, behavioural changes and to enhance teens’ capacity to solve problems without abusing others (Foshee et al., 2004).

Unfortunately legal options available to teens are limited as they do not possess the same legal status, and therefore rights, as adults (Offenhauser&Buchalter, 2011). Furthermore, teens generally do not have the same resource options that are available to adult victims of violence, for example access to domestic violence shelters. In 2007, in response to a dating violence fatality, the Lindsay Ann Burke Act was passed and Rhode Island, US, became the first state to require that seventh to twelfth grade learners be educated about violence in dating relationships.

A better understanding of the risk factors and predictors of TDV can facilitate early intervention and better prevention programs. More research is however necessary on effective screening and intervention methods.Due to the damaging and ongoing negative impact that TDV has on the psychological health of adolescents, as well as being potentially lethal, pressure should be sustained for statutory reforms to ensure minors’ expanded access to the justice system. Awareness-raising programs in schools and communitiescould also make a contribution.

References

Close, S.M. (2005).Dating Violence Prevention in Middle School and High School Youth.Journal of Child and Adolescent Psychiatric Nursing, 18, 2–9.

Fact Sheet in Prevention and Control, (2012).Understanding Teen Dating Violence.http://www.cdc.gov/ViolencePrevention/pdf/TeenDatingViolence2012-a.pdf

Foshee, V.A., Bauman K.E., Ennett, S.T., Linder, G.F., Benefield, T., and Suchindran, C.(2004). Assessing the Long-Term Effects of the Safe Dates Program and Booster in Preventing and Reducing Adolescent Dating Violence Victimization and Perpetration.American Journal of Public Health, 94 (4), 619–24.

Joyce, E. (2004). Teen Dating Violence: Facing the Epidemic. Networks, 37(3), 1-9.

Offenhauser, P., Buchalter, A. (2011). Teen Dating Violence: A Literature Review and Annotated Bibliography. A report prepared by the Federal Research Division, Library of Congress, Washington, D.C., 235368.

Werkerle, C., & Wolfe, D. (1999).Dating violence in mid-adolescence: theory, significance, and emerging prevention initiatives.Clinical Psychology Review, 19(4), 435-456.

The Power of Family Versus the Powerless Family

Stephen Hobfoll’s Conservation of Resources (COR) theory teaches us that individuals become stressed when their resources are lost or threatened; resources being those things which we value - social status, positive social support, knowledge, certain personality traits, employment and so on.

The implication of a theory such as COR, is that a successful psychological intervention will focus on helping individuals and communities to build and strengthen particular resources in order to buffer the negative effects of stress and trauma.

The family unit has the potential to be an incredible source of support, acceptance and encouragement; shielding individuals from the effects of stress and trauma. In South Africa, however, too often the family unit is not functioning in this way. Rather, many families are crippled by broken relationships and multiple stressors such as financial shortages, drug and gang ridden communities and unemployment.

Weak, broken families can, in large part, be attributed to a general lack in parenting skills, and spousal/partner relationship skills. Children don’t confide in their parents, they learn early on that it is ‘better to cheat on your partner before they cheat on you’ and if not neglected and ignored, are punished by their parent’s fists. Many of the social ills that we see in contemporary society are, to a large extent, the result of family break down and dysfunction.

Naseera Ebrahim, a Parent Support Group Facilitator at the Parent Centre, states that many negative parenting styles are a result of parents’ own traumatic experiences that were never resolved. Ebrahim has found that when the parents that she works with realise that their parenting is hugely dependent on their own healing, they are then able to start their own journey of “personal growth and positive parenting”.

The Family Life Centre’s Liz Dooley believes that “we need to help family members learn the skills of communication, to talk to each other, to share and show acceptance and understanding of each other.  We need to help them to grow and change.  Parents should be role models for their children; showing love and tolerance for each other but also having boundaries and setting limits”.

John, a member of CASE’s Men’s Project (a community project  in Hanover Park, Cape Town), was equipped with parenting skills, marriage skills and helped to totally review what he sees as his role as the father and husband. Through this experience he says his life has been changed. He now talks to his children, and realises the importance of encouraging them and spending time with them. He sees his wife as an equal partner who needs his respect and care.

Bearing this information in mind, healthy families may be one of the most undervalued resources in South Africa and one of the most powerful tools for counteracting, and enabling individuals and communities to deal with traumatic events. Effective marriages and effective parent-child relationships create a stable, strong and fulfilling environment that can guard against the negative effects of trauma.