surviving

POST RAPE TRAUMA
POST TRAUMATIC STRESS SYNDROME

The Osman* children were tied up with their mother in the house, and beaten during a violent burglary. In the weeks that followed they changed from being happy and confident to clinging, bed-wetting, moody children. One child will no longer sit, walk or sleep near windows. She is terrified of the night. All the children's school marks plummetted, teachers noted that they were withdrawn, could not concentrate, the son picks fights with other children.

Little Pixy Naidoo* kept complaining of stomach aches until a thoughtful doctor at a hospital casualty ward sat and spoke with the child awhile - and ascertained that the "stomach ache" was the child's way of describing persistent sexual abuse.

Jane Magubane* was raped at home in front of her toddlers. The toddlers became fearful of men, they screamed if she returned to the house, when they played she noted they would sometimes tie each other up as the rapist had done to her and her friend.

Jabu Khumalo* thought he had coped well with a hijacking where he was driven around for four hours in the boot of his vehicle and released after a warning shot was fired close to him. But his wife observed he was restless in his sleep, sweat would often pour off him, his occasional scotch became two or three drinks a night.

Six months after surviving a gang rape, at a time when friends were noting how well she was coping, Maureen Jonsson* shot herself.

These stories, all true, are classic examples of the serious impact of Post Traumatic Stress Syndrome, a pervasive condition in the highly traumatised conditions of South African life.

Post traumatic stress was first identified in soldiers returning from Vietnam, and is still not entirely understood. Today it is recognised in children who witness domestic violence or experience abuse to adults who experience anything from a mugging to rape to a hurricane.

Simply put, it is the consequence of overwhelming, often life-threatening situations and the fear that ensues. It causes brain changes that can be picked up on brain scans and it can lead to the person who survived such terror later wanting to destroy themselves. The trauma can manifest in people not directly in danger - perhaps a person who witnessed a violent event, or maybe in children who have a parent that has been shot, raped or beaten up. No two people who experience the same traumatic event will experience PTSS in the same way, and many people can experience severe trauma without experiencing PTSS.

There is no "profile" for the sort of person who will experience it either, a tough military officer is just as likely to experience it, given the right conditions, as a timid housewife. Some research indicates it is more likely in people who have experienced abuse as children, but there is still not certainty on that. .

Many people with PTSS repeatedly re-experience the ordeal in the form of flashback episodes, memories, nightmares, or frightening thoughts, especially when they are exposed to events or objects reminiscent of the trauma. They may refuse to return to the scene of a rape, they may be terrified travelling in a car after being hijacked, the smell of alcohol can induce fear in a person attacked by a drunk, windy conditions can traumatise a person who experienced a hurricane The United States National Health Institute reports symptoms of PTSS including "substance abuse, anxiety disorders, headaches, gastrointestinal complaints, immune system problems, dizziness and chest pain."

Anniversaries of the event can also trigger symptoms. People with PTSS often experience emotional numbness, particularly in the first few days or weeks after the event - causing friends or relatives to comment on "how well" the individual is coping . However, by six weeks after the event, if not before, or sometimes only three to six months after, the person may lose that numbness and begin experiencing a range of PTSS symptoms such as sleep disturbances, depression, irritability or outbursts of anger. Feelings of intense guilt are also common - a person who survived an accident in which others died, may say, "why didn't I die?" After the Nazi Holocaust, many concentration camp survivors committed suicide because of feelings of guilt that they had survived when so many others had died.

People with PTSS usually try to avoid any reminders or thoughts of the ordeal. PTSS is usually diagnosed when symptoms last more than one month, they may disappear within six months to a year after the traumatic event, particularly if the person has received appropriate help (and here not all counsellors or psychologists are experienced in this field), but they may persist in one form or another for far longer.

Symptoms may only develop years later, in children, as an example, who have experienced sexual abuse and who suppress it or are not treated for the abuse at the time, they may only develop PTSS in their late 20s or late 30s often triggered by a relatively minor event - a car accident, a job loss, a relationship break up. US research shows that about a third of the men and women who spent time in war zones experience PTSS, if you consider that many townships resembled war zones in the final days of apartheid, it gives an idea of the potential seriousness of the syndrome in SA. One million US war veterans developed PTSS after serving in Vietnam.

Post traumatic stress syndrome even adapts itself to different traumas - it's symptoms vary from, say, rape survivors to those who have endured a hurricane. Veterans of the Gulf war experienced different ranges of trauma to those who served in Vietnam. In post rape trauma syndrome as an example, a person raped may fear or reject men, or resist intimacy. The US based Centers (note spelling and plural) for Disease Control note that rape survivors, "often manifest long-term symptoms of chronic headaches, fatigue, sleep disturbance, recurrent nausea, decreased appetite, eating disorders, menstrual pain, sexual dysfunction and suicide attempts. Sexual assault was found to increase the odds of substance abuse." Many of those symptoms are shared with other survivors of Post Traumatic Stress Syndrome, however, what is different for rape survivors is that forced oral sex very often leads to eating disorders at around six months after the event, and menstrual pain and recurrent nausea are more frequent in rape survivors.

In those who took part in the Gulf War between Iraq, the USA and Britain in the early 1990's symptoms are still being examined. Drue Barrett of the National Center for Environmental Health, at the Centers for Disease Control and Prevention notes that, "Gulf War military personnel were more likely than those who did not serve in the Gulf War to report symptoms suggestive of cognitive dysfunction, depression, chronic fatigue, post-traumatic stress disorder, and respiratory illness such as asthma and bronchitis." The respiratory illness, is interesting because chemical weapons were used in that war, but respiratory ailments are arising in troops who were nowhere close to chemical warfare zones. Fear of being exposed to those weapons often triggered respiratory problems. Not only combatants experienced PTSS, but non-combatants, who saw and feared what was happening to their colleagues.

Post traumatic stress syndrome costs the economies of countries, like South Africa with its high rate of crime, or those recovering from war or large numbers of displaced people - billions of rands in lost productivity, high health bills and a demoralised, aggressive, disaffected population.

Post Traumatic Stress is the enemy within that responds to the enemy without. It is not the body's way of coping - it is the psyche's way of saying, 'I survived and yet I wish I had died, I can't cope with the fear, the recurrent nightmares of my life being at risk.' And so survival becomes a form of inner suicide - that in cases will result in self inflicted injuries or death. But, one Johannesburg psychologist notes: "PTSS can be defeated - if fear is succesfully managed, it can become a tool of personal victory, growth and achievement - but to do that takes courage, time and a good support network." A rape survivor observes: "The privilege we have after experiencing severe trauma is that we get the chance to remake our lives; we can build beautiful structures, or we can huddle in the ashes. The choice is ours. But it helps too if you know and understand Post Traumatic Stress, so you don't think you're going crazy and when you behave in an inappropriate way, you can say to yourself, okay, I know what this is, I can manage this, I can get past this."

Severe domestic violence is one of the most common stressors for Post Traumatic Stress Syndrome. The psychological consequences can include depression, suicidal thoughts and attempts, lowered self-esteem, alcohol and other drug abuse. Research in the USA has shown that violence toward a spouse is associated with increased risk of the violent spouse also being abusive to the child. Boy children are more likely to be beaten up by their parents than girl children, and this in turn triggers a cycle of violence, with the boy later having a greater tendency to resort to violence to "solve matters".

Each year more than 10-million American children witness domestic violence within their families. And up to a fifth of pregnant women are beaten by their partners. There are no similar figures for South Africa but researchers believe they will be high. In Gauteng alone, a woman is killed by her partner every six days. US research, which is matched by findings in SA, show that women who are victimised by domestic violence are often likely to need medical attention, take time off from work, spend more days in bed, and suffer more from stress and depression. As violence in its frequency and severity against them increases they are also more likely to become"absent" mothers psychologically, their lives become so ingrained with fear that they may ignore the needs of older or more emotionally challenging children and focus only on, usually younger, less challenging children, or no-one as they battle to survive emotionally and physically. And so the cost of domestic violence to the children increases.

People who work with highly traumatised individuals, such as police officers or trauma workers, are also in danger of developing PTSS, not merely from the dangers of their work, but from dealing with acutely traumatised people day after day. After time and prolonged contact with such people they risk becoming emotionally blunted - they switch off to cope - and so those victimised by violence become less, and less likely to find the caring attention they need.

When Tygerberg Trauma Clinic in Cape Town was opened just over a year ago (as part two of the Medical Research Council's research into anxiety and trauma), Debbie Kaminer, a researcher with the unit says they anticipated it would be a "general trauma clinic" but "two thirds of the patients are children who have experienced sexual abuse. The typical patient is a 13 or 14 year-old girl who has been sexually abused, we also get some boys. Other incidents include witnessing gang violence or being a victim of criminal violence."

Kaminer says the children's experiences, "makes them very vulnerable to developing all sorts of things, Post Traumatic Stress is one. All have major depression, all sorts of anxiety problems and are vulnerable to substance abuse and behavioural problems." She says the three core symptoms of Post Traumatic Stress Syndrome are, "intrusive memories, images and flashbacks sometimes in the form of nightmares, or a child may emulate the event in play. Avoidance is when they try to avoid reminders of the trauma: places, feelings or people. Hyper-arousal, is a chronic state of feeling in danger and on guard, a person experiencing this may have an exagerrated startle response, they can't concentrate, are restless and don't sleep. Their body is still acting as if it is still experiencing the trauma, and this impacts on school and work functioning." Kaminer says, and international research supports this, that "we can treat the child or family, but at the end of the day we send them back to the environment they came from which hasn't changed. In a way that almost limits the help we can offer. There is some debriefing and referral in workplace but we find schools in particular, have many children who battle to cope. In the Cape we have had many schools contacting us because of childrens fear around the serial murders and bombings, there is regular gang violence. Schools are in serious crisis and have been asking for help."

Kaminer says "all elements in a debriefing after trauma can be carried out by teachers, doctors and parents; acknowledging the problem, saying it is understandable you feel this way, you are not mad, or sick. Encourage the children to express their feelings, fears and memories. There is a lot parents and teachers can do to help make children feel safer, simple things like regular routines around bedtime and going to school." And if the anxiety persists - get professional help.