Although there have been minor decreases in some non-violent categories of crime during 2017–2018, South Africa remains one of the most violent countries in the world (http:// www.statssa.gov.za/publications/ P0341/P03412018.pdf). Recent statistics show that murder rates have increased significantly, with 57 murders occurring per day at a rate of 35.7 people murdered per 100 000 population (https:// businesstech.co.za/news/government/270689/ south-africa-crime-stats-2018-everything-you-need-to-know/). Attempted murder increased from 18 205 per year to 18 233 in 2017–2018 (https:// businesstech.co.za/news/government/270689/ south-africa-crime-stats-2018-everything-you-need-to-know/). Common assault rates are also high, with 156 243 cases reported in 2018 (https:// businesstech.co.za/news/government/270689/ south-africa-crime-stats-2018-everything-you-need-to-know/)
In the last year, sexual offences and rapes in particular have additionally increased markedly; consistent with South Africa’s grim title of “the rape capital of the world” (SA 'rape capital' of the world. Archived 14 January 2017 at News24, 22 November 2005. Retrieved 15 November 2018). These statistics mean that South Africa has the fourth lowest safety index worldwide (https://www. numbeo.com/crime/rankings_by_country.jsp).
South Africans are exposed to violence and trauma on a daily basis. Because of this, Kaminer, Eagle & Crawford-Browne (2018) use the term “continuous traumatic stress” to describe conditions in South Africa and other settings characterised by frequent, ongoing violence and threat to communities. They argue that what is missing in the common diagnostic understanding of traumatic stress, is that there is the assumption that the trauma – the violence or threat to self – disappears, becoming a thing of the past (often after a single occurrence), and the individual has the opportunity to heal in a relatively safe post-traumatic environment. This is not the case in contexts characterised by protracted civil conflict, mass displacement of people or where there are high levels of criminal and community violence, as in South Africa – in these settings, trauma is ongoing, and traumatised persons are exposed to continuous traumatic stress in an objectively dangerous environment (Kaminer, Eagle & Crawford-Browne, 2018). A range of post-traumatic illnesses have emerged among South African patients, the most robust studies focusing on post-traumatic stress disorder (PTSD), generalized anxiety, depression and substance misuse (Kaminer, Owen, & Schwartz, 2018; Seedat, Stein & Carey, 2005). Relatively few studies have focused on dissociation.
Key studies on dissociation that do exist focus on the following: Bradfield (2011a; 2011b; 2013) writes about the role of dissociation in the intergenerational transmission of trauma; how internal numbness and emotional disconnection influences the ongoing affective and relational experience between mothers and their adult children. Christa Krüger, Peter Bartel and Lizelle Fletcher conducted a biologically-driven study, which demonstrates that dissociation is positively associated with decreased temporal theta activity and increased alpha-theta ratios on quantitative electroencephalographies. Christa Krüger also teamed up with Lizelle Fletcher to conduct a study on child maltreatment and the abuser-abused relational tie and dissociative disorders (2017). These authors found that childhood emotional neglect by biological parents or siblings and subsequent emotional abuse by intimate partners predicted dissociative disorders. There are a number of further publications which are co-authored by Krüger, including those focused on treatment of posttraumatic and dissociative disorders, which includes South African data (Dorahy, Lewis-Fernandez, Krüger, Brand, Şar, Ewing et al., 2017), as does her study with Van Staden, which focuses on conversion as a dissociative symptom (2003), and her study with Pretorius, Smith, Le Roux, Van der Linde, Groeneveld and Bartel which demonstrates that mild hypoxia is associated with quantitative EEG changes, but not with dissociative symptoms (2006). Other studies include those exploring the myths associated with dissociative identity disorder (DID) (Brand, Şar, Stavroupolos, Krüger, Kozekwa, Martinez-Taboas et al., 2016), as well as an empirical review of the DID literature (Dorahy, Brand, Şar, Krüger, Stavroupolos, Martinez- Taboas et al., 2014), but these articles do not include South African data. Christa Krüger also teams up with Vedat Şar and Martin Dorahy to describe DID from a biopsychosocial perspective, but they draw on international, rather than South African literature and data, in their theorisation. Finally, Krüger and Mace (2002) present the psychometric validation of the State Scale of Dissociation. Among other publications by Krüger are a number of co-authored articles on child abuse, and letters forming part of an international dialogue around dissociation.
Dan Stein, a South African psychiatrist, joined a host of international authors to describe dissociation in PTSD, as measured by the World Mental Health Surveys, but South Africa was not included in the survey (Stein, Koenen, Friedman, Hill, McLaughlin, Petukhova et al., 2012). Soraya Seedat, another South African psychiatrist, has published a great deal on PTSD, but less specifically focusing on dissociation. An important study by Nöthling, Lammers, Martin & Seedat (2015) demonstrates that traumatic dissociation at two weeks post-rape significantly predicts PTSD and depression in South African rape survivors (and not early childhood trauma or prior tendency to dissociate), and they conclude that the early identification and management of dissociation may reduce the risk of developing PTSD. Lochner, Seedat, Hemmings, Kinnear, Corfield, Niehaus et al. (2004) report substantially higher levels of dissociative experiences in South African patients with obsessive compulsive disorder and trichotillomania, although high dissociators could also be distinguished from lower dissociators by certain demographic characteristics (e.g., lower age) and comorbid profile (e.g., the presence of impulse dyscontrol disorders). Another study included participants from Cape Town, South Africa, and focused on trait anxiety, suicide risk and post-traumatic cognitions as key predictors of acute stress disorder (including dissociation) (Suliman, Truman, Stein & Seedat, 2013). Seedat and colleagues further report on the genetic contributions to dissociation in South African patients with obsessive compulsive disorder (Lochner, Seedat, Hemmings, Moolman-Smook, Kidd & Stein, 2007). Seedat’s work has also included research focused on women as a vulnerable group, although not particularly focused on South Africa (Seedat, Stein & Carey, 2005), and a dissociation prevalence study in a community sample in Memphis, Tennessee (Seedat, Stein & Ford, 2003).
One South African study focuses on the relationship between dissociation and attachment in performing artists, and demonstrates despite pervasive histories of trauma, and high levels of absorption and imagination, performing artists had relatively low levels of pathological dissociation, and that the majority were stable, coherent, secure and autonomous in terms of attachment (as measured by the Adult Attachment Interview) (Thomson & Jaque, 2012). Thomson and Jaque (2011) also demonstrated that higher fantasy proneness among professional actors (including South Africans), rather than previous trauma, was associated with the disorienting effects of dissociation in this group. Another study focused on the assessment of the psychometric properties of the Child Posttraumatic Stress Disorder Checklist, with one factor emerging as anger-dissociation (Frank-Schultz, Naidoo, Cloete & Seedat, 2012). Emerging from this brief review of the South African literature, it is clear that Soraya Seedat and Christa Krüger, both university affiliated psychiatrists, are the local leaders in this field.
In my own work, I have focused on post-traumatic shame and dissociation, DID, and spirituality and dissociation. In a study co-authored by Leslie Swartz, we emphasise that chronic trauma, shame and dissociation, and the relation between them, are acutely understudied, both locally and internationally (2015). We conducted a qualitative study exploring the experiences of chronic trauma, shame and psychopathology in single interviews with 19 South African survivors of intimate partner violence. We found that the participating women presented with both a concealed and shameful authentic self, and a socially conforming projected false self, two polarised parts of the psyche. Our analysis suggests that shame and dissociative splitting of this nature are part of the same psychological process. Specifically, we argue that a persistent pattern of negative self-evaluations associated with the shameful authentic self – and the compensatory function of the projected false self – is the process which underlies a shame-prone emotional style resulting from repeated exposure to trauma. We conclude that chronically traumatised survivors are likely to have shame-based self-esteems and use dissociative splitting as a defence to protect the chronically injured psyche.
Valerie Sinason and I then edited a volume on DID, centred around the memoir of a South African ritual abuse survivor named Anna. The original intention was to publish Anna’s haunting memoir as Part I of the book, but Anna’s family and perpetrators are still alive and a danger to her, and in consultation with my own University’s legal department, it was decided that publishing Anna’s memoir was too risky. So, the first part of the book was reconceptualised, and dedicated to all survivors like Anna, who have been silenced. Part II of the book contains detailed commentary on DID by leading authors in the field, such as Onno van der Hart (history of DID), Eli Somer (cross-temporal and cross-cultural perspectives), Christa Krüger (variations in identity alterations – A South African qualitative study), Lina Hartocollis (DID, culture and memory), Vedat Şar (psychiatric comorbidity), Phil Mollon (DID and shame), Alison Miller (ritual abuse and mind control) and Richard Kluft (treatment). However, only myself and Christa Krüger are South African researchers, and only Christa Krüger presented the findings from a local study, which show that identity alterations among South African participants are rooted in possession experiences from an external origin, shifts which occur as a result of transitioning between singularity and multiplicity, and finally, alterations that occur as a result of inner identity confusion.
Dissociation is often considered a spiritual experience in non-Western contexts, and this is highly relevant for South Africa. In fact, Krüger, Sokudela, Motlana, Mogeboge and Dikobe (2007), in their exploration of an expanded perspective on dissociation, present a preliminary contextual model of dissociation which includes interpersonal, socio-cultural, and spiritual contexts, appropriate to the pluralistic South African context, and conclude that in our country, dissociation is not only a pathological intrapsychic phenomenon, but a normative means of responding to conflicting messages at interpersonal, cultural or societal levels.
It is worth mentioning the important work of the South African-born Ingo Lambrecht here. He has devoted his research career to exploring the trance states of South African traditional healers, or “sangomas”. In his seminal book, Lambrecht (2014) argues that the trance states accessed by traditional healers are dissociative states, but that they serve different functions to those in Western cultural contexts. These dissociative states do not only serve to defend against or manage emotional dysregulation, but also serve to access different states of consciousness in an effort to prepare sangomas for healing and serving their communities. His work shifts the focus from more pathological perspectives on dissociation, and reconceptualises it as the product of expert indigenous knowledges that have at times a more sophisticated understanding of consciousness (Lampbrecht, personal communication, 19 November 2018).
A key issue here in the distinction between pathological and non-pathological dissociation is that trance and possession states are accessed spontaneously, and that they are culturally and religiously accepted and sanctioned, whereas pathological dissociation (as diagnosed in Western contexts) occurs outside of cultural or religious norms, and is considered as a form of maladjustment (Lampbrecht, 2014). Shamanic dissociative trance is volitional, initiated, ritualised and culturally sanctioned, and as in the case of “ukuthwasa” possession in South Africa, external spirits are welcomed, and through acceptance, training and medicines, these spirits become manageable, integrated and mastered (Lampbrecht, 2014). This is how the recipient of these spirits embarks on his/ her journey as a healer. Conversely, in a Western diagnostic context, DID is secular in nature, intrusions and conflict are internal (not externally derived spirits) between different parts of the psyche, and the accompanying distress is not culturally accepted or sanctioned (Lampbrecht, 2014). DID and possession states share an alteration in identity, and the presence of amnesia (Lampbrecht, 2014). But possession trance comes with physical contortions, blasphemy and special indigenous knowledge (Lampbrecht, 2014). There are also significant differences in aetiology: while DID is determined by sexual or physical abuse in childhood, this is not usually the case for possession trance states (Lampbrecht, 2014). In addition, DID has a chronic onset while possession trance states have an acute onset (Lampbrecht, 2014). Finally, as noted, in DID the different identities are considered internal, while in possession trance they are considered mythological or ancestral (external) figures (Lampbrecht, 2014). Lampbrecht (2014) warns against imposing Western diagnostic categories on possession trance states such as ukuthwasa, and in so doing, denying the meaning, power and effectiveness that accompany such states. However, he argues that it may be simplistic to claim that one form of dissociation is pathological and the other is not; it is not a simple dichotomy. There remains a great deal of overlap in their appearance and expression.
In one of our studies exploring the relationship between trauma, dissociation and spirituality (more about this below), the traditional healer and psychiatric outpatient sub-samples were directly exposed to significantly more traumatic events than other cultural/spiritual groups. The traditional healer group alone witnessed significantly more traumatic events than other groups. These findings are likely to reflect the vulnerabilities inherent to this group’s context – the traditional healers were recruited from a high-violence informal settlement. What this finding suggests is that traditional healers tend to live in areas which make them vulnerable to continuous traumatic stress, and that the dissociative trance states which they access, might in fact be both trauma-related and spiritual in nature, so serving dual functions. In other words, the propensity or tendency to dissociate may stem from exposure to trauma, which is then enacted in circumstances when dissociative possession or trance states are demanded.
In two studies, myself and my colleagues explored the relationships between trauma, dissociation and spirituality in a multi-cultural and diverse devotional sample. The sample consisted of Muslims, Christians, traditional and spiritual healers as well as psychiatric outpatients. The results of the first study point to the high levels of trauma exposure and associated levels of post-traumatic responding (both PTSD and dissociation) in different cultural and spiritual communities in South Africa, particularly among groups made vulnerable by economically disadvantaged environments, female gender and co-morbid psychiatric diagnoses. It is worth emphasising here that the psychiatric outpatients presented with significantly higher levels of both more broadly-defined dissociation, as well as more pathological dissociation, as measured by the DES (Dissociative Experiences Scale) taxon, than other groups, again pointing to the complex, comorbid post-traumatic pathological picture these patients may be presenting with. Despite this, none of the psychiatric outpatients were being treated for dissociation. Mkize (2008) notes that a substantial number of psychiatric patients presenting for non-trauma related psychopathology may demonstrate symptoms of PTSD (and dissociation). Assessment for PTSD and dissociation may be overlooked when dealing with psychiatric patients, even when these symptoms are present, because these patients do not specifically present on the basis of trauma exposure (Mkize, 2008). We recommend that in vulnerable populations such as these, PTSD and dissociation screening and diagnosis should become routine practice.
In the second study, we found that direct exposure to trauma predicted pathological dissociation, and both direct exposure to trauma and witnessing trauma predicted post traumatic symptoms. An unexpected finding emerging from this study was that direct exposure to trauma did not have a significant interaction with spirituality (we expected that more traumatised participants may turn to their spiritual beliefs for comfort and solace). However, depersonalisation and derealisation (aspects of dissociation) were predicted by the interaction between direct exposure to trauma and spirituality, demonstrating the importance of the joint effects of trauma and spirituality on dissociative processes. Only witnessing trauma demonstrated an interaction with spirituality, and the direction of effects was counter-intuitive: an increase in indirect exposure was associated with a reduction in spirituality.. Finally, direct and indirect exposure to trauma predicted dissociation in the religious sample. Spirituality significantly predicted dimensions of dissociation in psychiatric out-patients, suggesting that amongst this vulnerable group, a spiritual orientation may enhance dissociative responding and vice versa. A complex finding to untangle is the interaction between spirituality and dissociation and its prediction of PTSD in the religious group. What this finding suggests is that PTSD symptomatology is complexly determined by non-pathological and pathological dissociation. This aside, overall, the study provides evidence that dissociation is a trauma-related, pathological response pattern, not solely a spiritual (possession or trance) expression of devotion and connection to the divine in this South African sample. It also emphasises the importance of both direct and indirect exposure in dissociative and PTSD symptomatology. We suggest that future research should focus on deciphering the counter-intuitive direction of predictive effects between witnessing trauma and spirituality, and understanding the role of depersonalisation and derealisation in spiritual orientation and practice. Furthermore, efforts need to be dedicated to understanding the different roles of spirituality and dissociation in psychiatric and religious samples.
It is interesting that despite the high levels of trauma exposure and associated psychopathology in South Africans, training in dissociative disorders tends to remain DSM-5 based, with limited elaboration in terms of aetiology, local prevalence or cultural factors (Christa Krüger, Leslie Swartz, Sia Maw, personal communication). This lack is not only in relation to the research and training of health and mental health professionals in dissociation; this lack also extends to treatment, which is particularly problematic considering the likely high prevalence of dissociative disorders in contexts characterised by continuous exposure to trauma. As Joubert (2018), a South African trauma therapist, notes: “In my opinion, trauma work in South Africa is focused on debriefing, prevention and treatment of Post- Traumatic Stress Disorder rather than Dissociative Disorders. The development and progress in the areas of acknowledging, researching, diagnosing and treating dissociation and dissociative disorders are slow”. (http://news.isst-d.org/trauma-and-dissociation-work-in-south-africa)