In this chapter we discuss a number of aspects related to how women experience and engage with life stressors, including traumatic events. We seek to answer some of the questions concerning whether, how, and why women may experience stress differently from men.

Many of the chapters in this volume address a common theme: the need for a new kind of psychoanalytic theory and practice in South Africa which is relevant to its unique problems. The authors are attempting to develop a new form of psychoanalytically oriented psychotherapy which is inflected by, appropriate for and relevant to post-colonial South Africans. They are trying to develop a new hybrid theoretical framework which interrogates the assumptions of current psychoanalytic theory and expands its scope to include non-Western collectivist notions of self and community. Taken together, the chapters are a clarion call for a radical transformation of psychoanalytic praxis, an invitation for the heretofore invisible African, non-Western third to be acknowledged and welcomed into the analytic consulting room. These chapters are part of a new wave in psychoanalytic thinking which interrogates the implicit, hidden assumptions about class, gender, race, sexual orientation, culture and Western standards which are embedded in psychoanalytic theories (see Cushman, 2012; Dimen, 2011; Layton et al., 2006; Lobban, 2011). In our opinion psychoanalysis needs an infusion of such thinking if it is to remain a viable option for people from a variety of classes and cultures.

Addressing the decline of psychoanalysis in the United States, Paul Stepansky (2009) noted in Psychoanalysis at the Margins that it is vital that the field shed its elitism and make a commitment to technical pluralism and to encouraging psychoanalysts to develop applications that demonstrate that psychoanalysis has something useful to offer to society. As Stepansky noted, psychoanalysis has often cloaked itself in elitism and snobbery and in doing so has reinforced the perception that it is only a bourgeois therapy for bourgeois problems. This is unfortunate, as psychoanalysis had a long history of social activism, particularly in its earliest days, that has continued into the present (Altman, 1995; Danto, 2005; Moskowitz, 1996; O'Loughlin, 2010, 2012; Watkins & Shulman, 2008). Particularly now, with increasing pressure from market-based and evidence-based reforms, it is essential that psychoanalysis make the case for the utility and even efficiency of psychoanalytic and psychodynamic approaches to addressing particular societal problems.

With this book we hope to broaden knowledge about how psychodynamic psychotherapy, as well as psychoanalytic concepts and theories are practised and applied in the context of contemporary South Africa. The chapters include a wide range of psychodynamic work undertaken by clinical psychologists working in university settings, state hospitals, community projects, private practice and research. The aim is to provide the reader with an experience of the current debates, clinical issues, therapeutic practice and nature of research that is representative of the work being done in South Africa.

There are a handful of qualified psychoanalysts practising in South Africa at present. Although the South African Psychoanalytic Association was accredited as an official International Psychoanalytical Association study group in 2009, with the ultimate aim of training psychoanalysts in accordance with international standards, only a very few privileged South Africans will be able to pursue such training or afford to undergo the experience of psychoanalysis. The vast majority of South Africans will only have access to briefer forms of psychotherapy, some of which is psychodynamically informed. Most of the psychoanalytically oriented psychotherapy conducted in South Africa is done by clinical psychologists who have been trained at a university offering a psychodynamically oriented Master's degree in Clinical Psychology.

It is within this context of psychodynamic applications that the contributors to this book have written about their work and experience. The approaches described draw on several theoretical models, reflecting the pluralism in the field today. The book is a collective effort by experienced therapists, clinicians, trainers, teachers, clinical supervisors, consultants and researchers working in the field of diversity as it applies to the South African context.

The work described in this volume is situated within the context of post-apartheid South Africa, with all the complexities, hopes, dreams and even disillusionments that have emerged in our fledgling and fragile democracy. With this sociopolitical history in mind, it is important for clinicians to understand that issues of race, disparity, inequality, complicity, reparation, reconciliation, cultural diversity, difference and trauma permeate our practice of psychodynamic interventions. These issues require personal reflection, academic debate, theoretical interrogation and sensitive adaptation in clinical practice.

The psychoanalytic view of trauma argues that until traumatic experiences and their personal meaning are fully recognised, understood and ‘owned’ by the survivor, these experiences will continue to manifest themselves in symptoms of distress and unconscious reenactments of the original traumatic situation. Perhaps this also provides a useful analogy for a traumatised society. Until we have a fuller understanding of the types of trauma that South Africans are exposed to, and the full range of the psychological impact of and meaning attached to such experiences, traumatisation in South African society is likely to be repeated from one generation to the next. An illustration of this possible kind of effect is the fact that one of the findings of a series of panel hearings on violence in Western Cape schools, held by the South African Human Rights Commission in 2006, was that children as young as seven frequently engage in games called ‘rape me rape me’ and ‘hit me hit me’ in the playground, demonstrating how endemic and normalised violence has become for the very young members of our society.

Given what we know about the prevalence rates of different forms of direct and indirect trauma exposure in South African society, it should be no surprise that trauma is a common, even normal, part of the lives of many South Africans of all ages, including young children. But in order to really understand the psychological impact of this exposure, to be truly mindful of what it means to live in a context of chronic danger, the meaning and functions of behaviours such as playground games about violence need to be carefully explored. A layered psychological understanding might suggest a range of different possible meanings and functions of such playground enactments, including that they are a form of traumatic re-experiencing, an active attempt at mastery over situations that make children feel anxious, a way of trying to understand things they commonly see and hear about in their homes and community, or a form of identification with adults (developmentally parallel to the more benign games of ‘house house’ or ‘doctor doctor’ that many young children engage in to ‘practice’ adult roles).

In general, human beings have a remarkable capacity to adapt to extreme stress from the environment. The majority of survivors of potentially traumatic events experience a brief period of disequilibrium, but do not develop lasting difficulties. However, a substantial minority go on to experience severe and ongoing symptoms that cause much distress and substantially restrict their ability to function in the world. When trauma responses reach this level, they may be classified as a psychiatric disorder. Posttraumatic Stress Disorder (PTSD) is the most widely publicised trauma-related psychiatric disorder and it will therefore be a major focus of this chapter, but there are several others that are also commonly associated with traumatic events. In addition, researchers have recently attempted to describe the psychological and psychiatric effects of prolonged abuse at the hands of another person, and the ways in which these differ from the effects of single traumas. Despite significant advances in our understanding of trauma-related syndromes, in this chapter we will also see that relatively little is known about the effects of exposure to continuous community violence, a context that many South Africans currently live in. Finally, this chapter will review existing South African research on the psychiatric impact of trauma exposure in South Africa, and consider some of the gaps in our local knowledge that require further attention.

Posttraumatic Stress Disorder

Normal trauma reactions versus PTSD

After a traumatic event, most people will experience some degree of distress as they try to adapt to what has happened. Common reactions include feelings of anxiety and mild depression, having distressing thoughts and memories of the traumatic event, difficulty sleeping, and feeling hyper-alert to any signs of danger. In order to manage these symptoms, many trauma survivors may wish to avoid talking about what happened, may withdraw from contact with other people, and may feel emotionally numb when they think about the trauma. These reactions can last for a few days, weeks or even months after the traumatic event and then gradually fade, without severely impacting on the survivor's ability to continue with their normal daily functioning.