That South Africa has unusually high levels of inter-personal violence is clear from the country's crime statistics and regular news reports about violent crime. The knock-on effects on the mental health of people in the country are less easy to quantify.
There is, however, evidence that the country's high levels of violence are contributing to high levels of mental health conditions. In some cases, experts say, the shadow cast by violence can be very long, with exposure to violence and trauma in childhood being associated with mental health problems in adulthood.
The latest piece of evidence comes from a study on the impact of traumatic events in adulthood and adverse childhood experiences (ACEs) on depression, anxiety, and stress scores of outpatients receiving psychiatric care at two public mental health treatment facilities in Johannesburg. The researchers found that ACEs - which can include sexual abuse, physical abuse, neglect, and interpersonal violence - are "highly prevalent in low-resource settings and associated with adverse psychological outcomes".
According to Dr Michael Galvin, one of the study authors, they asked participants about their experiences based on a list of ten forms of ACEs, noting that these ten are part of multiple possible ACEs that may not have been included in their list. "The first one," he tells Spotlight, "was about verbal abuse by a parent, the second was with physical abuse by a parent, the third was sexual abuse by someone in the household, fourth was emotional neglect, fifth was sort of material neglect, [meaning] not having enough to eat, dirty clothes; six was if your parents were separated or divorced, seven was if you witnessed usually gender-based violence or domestic abuse, eighth was if there was drugs or alcohol used in the household when you were a child, ninth was if there was mental illness or suicide in the household when you were a child, and then the tenth was incarceration of people in your household while you were a child."
Galvin says for the study they interviewed 309 patients at two psychiatric units in two public hospitals in Johannesburg. He is cautious about generalising the study findings to the prevalence of ACEs in South Africa as a whole but concedes that many studies (longitudinal and also systematic reviews) - mostly from developed countries - have highlighted this link between ACEs and mental health outcomes.
He also stresses that the study looked at what had happened during childhood but also adult traumatic experiences and the impact of both on adult mental health. "So it looked at the relationship between adverse childhood experiences and traumatic events that have occurred during adulthood, and how those two together impact adult mental illness. So, ACEs are only half of the equation [with] the other half being traumatic experiences during adulthood and we had a whole list of adult traumatic experiences that were different from the ones experienced during childhood." Among these, he said, were, for example, lack of medical care, extended periods of homelessness, imprisonment and separation from family, serious injury from a fight, rape, being a victim of a violent attack, and murder of a family member. There was also a category where study participants could add other experiences.
One of the most common and most serious underlying causes of ACEs is child sexual abuse. - Dr Michael Galvin
According to Dr Aneesa Molla, who was also involved in the study, their findings "of elevated risks of poor mental health outcomes associated with ACEs are consistent with previous research indicating that ACEs have cumulative negative impacts on physical and mental health during adulthood". Molla tells Spotlight that despite South Africa, "being a developing country and, [given that] a lot of the studies being done are in developed or first world countries, it basically still shows the same thing - that this is a worldwide thing. It's like a one-in-three kind of thing, but obviously, here, there are many more undiagnosed people walking around or seeking different kinds of healthcare as opposed to normal medical care," she says.
Molla says studies have shown that in other parts of sub-Saharan Africa, youths who have experienced trauma frequently show increased aggression, anger, depression, hopelessness, withdrawal, and social isolation. She says in South Africa, while few studies have examined ACEs among local populations, the few that exist have found high rates of ACEs. She referred to one study that looked at ACEs in a cohort of children in Soweto that found that 35% had four or more ACEs.
Adverse childhood experiences and mental health
According to Galvin, one of the most common and most serious underlying causes of ACEs is child sexual abuse. "And then there's also a lot of physical abuse," he says. "Then also neglect - so not taking care of a child may lead to the child experiencing deprivation of food, water, medical care, anything considered essential."
Some mental health practitioners working closely with mental health issues and survivors of trauma agree that childhood trauma can impact mental health in adulthood.
Marthé Kotze-de Beer, Director of the organisation Healing Leaves, says, "When we talk about ACEs now, we are talking about any potentially traumatic events that take place within the developmental childhood years. What causes ACEs to be so potentially harmful is the fact that they take place during the time when a child's brain is still developing." Healing Leaves is a Free State-based organisation that works on restoring dignity to those who have experienced trauma, adversity, and shame, through community-based relational intervention programmes.
Kotze-de Beer says, "This intense stress, especially without proper support systems in place, has the potential to negatively affect the way in which a child's brain will develop and how their body will learn to respond to stress, and this impacts their mental and physical health throughout their lifetime."
She notes a recent study conducted by the Wits/Medical Research Council Developmental Pathways for Health Research Unit that suggested that around a quarter of people in South Africa suffer from probable depression, with significant variation between provinces. The study showed a clear association between the respondent's ACE scores and their likelihood of experiencing both depression and anxiety. The association held after adjusting for socio-demographic confounders, which suggests that the relationship may well be causal. In this regard, the researchers wrote that their finding is "in line with previous literature stating that the early years of life are crucial in determining mental health outcomes in later life". 3 402 people from across the country were interviewed for the study.
The study found that 1 in 3 South African children have experienced some form of sexual abuse. 15.1% of respondents reported experiencing some form of neglect, which is slightly lower than the global average of 16.3%.
According to Kotze-de Beer, the best data in South Africa on the prevalence of ACEs comes from the Optimus Study that was conducted among high school-aged learners across South Africa in 2016. "The study found that 1 in 3 South African children have experienced some form of sexual abuse. 15.1% of respondents reported experiencing some form of neglect, which is slightly lower than the global average of 16.3%," she says. "34.8% of respondents reported having experienced physical abuse, which is higher than the global average of 22.2%."
According to her, "It is also worth noting that many of the events that constitute ACEs are still heavily stigmatised and have a great deal of shame around them, so reporting may be lower than actual prevalence levels, which means we do not know the whole scope of the problem."
Types of ACEs
"Stress from an ACE is different from the everyday stress that children experience," says Dr Alicia Porter, a psychiatrist working in the private sector. Porter says ACEs are significant in that they are linked to not only mental illness in adulthood but also chronic physical health conditions and substance abuse.
"ACEs can lead to health problems like asthma, diabetes and heart disease. They can also impact behaviour, learning, and mental health," she says. "They [ACEs] can be categorised into three groups - abuse, neglect, and household challenges or dysfunction. Expanded ACEs consist of additional items that measure exposure to bullying, community violence, neighbourhood safety, racism, [or] living in foster care," she says.
Another private sector psychiatrist, Dr Terry Henderson, notes the intergenerational effects of ACEs.
"Trauma experienced by a parent that is untreated will affect their ability to parent and, therefore, their children are more likely to be exposed to adverse events. So you often see that parents who have had trauma or a very difficult childhood have had no support, no intervention. Their children are compromised in that they're unavailable as adequate parents," she says. "There's a strong sense of what we call cross-generational trauma. Where trauma is not treated and therefore transferred to children. And so it goes through the generations."
Trauma experienced by a parent that is untreated will affect their ability to parent and, therefore, their children are more likely to be exposed to adverse events. - Dr Terry Henderson
According to Henderson, if one doesn't have a successful adolescence, then they are unlikely to have successful adulthood unless there is an intervention. "So individuals are less likely to achieve at school, are less likely to have tertiary education, and therefore less likely to achieve professionally and have opportunities in the workplace," she adds.
Violence as a trigger
The experts Spotlight spoke to see high rates of violence (experienced as a child or an adult) as a risk or contributing factor to mental health conditions.
Kotze-de Beer, for example, says that while violence is not the only aspect negatively affecting the mental health of people in South Africa, reducing the rates of violence, especially against women and children, would have a marked effect on rates of mental illness.
What to do?
According to the authors of the recent study conducted in Johannesburg, part of the solution is "to strengthen and scale innovative combination interventions that holistically address the needs of people in low-resource settings".
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Both Molla and Galvin note that mental healthcare provision in South Africa should include more psychosocial care for psychiatric patients, as currently, the majority of patients receiving treatment at public facilities receive little to no counselling or therapy due to monetary constraints.
Molla says often in communities, we see neglect of a child but then ignore it. She says it will help to make communities aware of what traumatic events are and what the reporting channels are. "I think it helps [to get] outside help and links to where the services are available. They are there. I think it's just people aren't using them, or they don't even know how to access them." In this respect, she says, community healthcare workers can play a big role in communities and they can be a safe source of information.
Porter says that it is important to strengthen families and to "promote social norms that protect against violence, positive parenting practices, [and] prevention efforts involving men and boys".
She says it can also help to connect children with activities and caring adults, school or community mentoring programmes, and after-school activities. She also agrees with Molla that it can also help to educate people about ACEs and intervene to lessen immediate and long-term harms through therapy, family-centred treatment, and treatment of substance use. Early learning programmes and affordable preschool and child-care programmes can also help, she says.
According to Kotze de-Beer, the best way for adults to raise resilient and mentally healthy children is to start by healing and processing their own traumas.
"Adults who have not recovered from their own traumas are more likely to be mentally ill, struggle with substance abuse, and have dysfunctional relationships. It is also vitally important that we educate parents, teachers, and other community members about trauma. Many of the 'problem' behaviours we see in children within our communities are not signs that today's children are bad or that they are not receiving enough discipline, [but] rather that many of these behaviours are signs of trauma," she says. "Recognising this difference is the key to how we interact with these children. Treating them as 'bad kids' and wanting to shun or punish them is not going to help heal their trauma."
She says what is more helpful is "understanding the causes of trauma, knowing what signs and behaviours to look out for, and learning practical ways in which to support these children and promote their healing".
