Social acknowledgment and its relation to PTSD and aggression in a victim-offender sample in South Africa : new perspectives on a major public health problem

Abstract

Violence, declared as a public health problem, is one of the major factors underlying a global mental health crisis. In communities with high rates of interpersonal violence and thus in per-sistently unsafe environments, violence exposure is associated with psychological disorders such as posttraumatic stress disorder (PTSD). Further, it is related to behavioral problems in the form of violent outbursts and the propensity to enjoy violence, i.e. appetitive aggression. This violence breeds further violence, and thus a cycle of violence develops. Substance abuse as well as social factors may have an additional impact on these adverse consequences of violent environments. In order to overcome the detrimental effects of violence exposure, the Narrative Exposure Therapy for Forensic Offender Rehabilitation (FORNET) – a short-term intervention aiming to reduce symptoms of posttraumatic stress and the propensity towards violence – has been developed. One crucial test of its practical efficacy is whether it can be successful even under continuous exposure to traumatic stress. FORNET has not been sufficiently studied in this context so far. Further, factors that are involved in the cycle of violence need to be considered with regard to their potential influence on treatment effects. The aims of this thesis were to study the cycle of violence on the example of young South African males with a background of violent victimization and perpetration of violence. Thus, I investigated how violence exposure and perpetration, severity of PTSD symptoms, and appetitive aggression are related to each other. Furthermore, I explored how substance abuse and the perceived social acknowledgment of individuals’ violent experiences contributes to the cycle of violence. Additionally, the efficacy of the FORNET was investigated with regard to changes in PTSD symptom severity, appetitive aggression and committed offenses. Finally, the influence of risk and protective factors on treatment outcomes was examined. A sample of 290 male South Africans from low-income urban areas in Cape Town, aged 14 to 40 years (M = 22.0, SD = 4.5), was recruited through a reintegration center for offenders and youth-at-risk for violence perpetration and substance abuse. In order to study the questions outlined above, participants were assessed with regard to the number of different experienced traumatic event types, the number of committed offenses, PTSD symptom severity (PTSD Symptom Scale-Interview [PSS-I]; Foa & Tolin, 2000), and the extent of appetitive aggression (Appetitive Aggression Scale [AAS]; Weierstall & Elbert, 2011). Substance abuse prior to violence perpetration and social acknowledgment (Social Acknowledgment Questionnaire [SAQ]; Maercker & Mueller, 2004) were assessed as potential risk and protective factors, respectively. Further, a subsample of the participants was involved in a treatment study investigating changes in PTSD symptoms, appetitive aggression scores and number of committed offenses by means of FORNET. The efficacy of FORNET was studied by comparing it to the cognitive-behavioral intervention “Thinking for a Change” (TFAC) and a waiting list control condition. Post-treatment social acknowledgment was considered to be a potential influential factor with regard to treatment outcome. The findings from the four conducted studies presented in this thesis showed that (1) the number of different experienced traumatic event types was positively associated with PTSD symptom severity, appetitive aggression and substance abuse; (2) the number of committed offenses was positively related to appetitive aggression; (3) PTSD symptom severity was positively associated with appetitive aggression. In terms of risk and protective factors in the cycle of violence, results further demonstrated that (1) the severity of substance abuse prior to the commission of offenses was positively related to appetitive aggression and to the number of committed offenses; (2) general disapproval, a subscale of the SAQ, was correlated with both higher PTSD symptom severity and higher levels of appetitive aggression, and a complementary muted therapeutic improvement in PTSD symptom severity and appetitive aggression after treatment. With regard to treatment approaches, FORNET significantly reduced PTSD scores at 8-months follow-up and scores were significantly lower than those of the waiting list control condition. Changes in scores for appetitive aggression and committed offenses were not significant for any of the treatment conditions nor the waiting list control condition. Further, path analyses demonstrated ongoing general disapproval from the community to be significantly related to a lower reduction in PTSD symptom severity and appetitive aggression after psychotherapeutic treatment. In sum, trauma-focused treatment can reduce the psychological symptoms of posttraumatic stress even for individuals living under continuing unsafe conditions in low-income urban communities in South Africa. Achieving optimal treatment outcome for PTSD and changes in violent behavior within a context of ongoing violence may require more than treatment of trauma-related suffering and confrontation with one’s own offenses: Results indicate that improved social acknowledgment plays a significant role in the reduction of PTSD symptom severity and appetitive aggression in a context of ongoing community and gang violence. Further, psycho-therapeutic interventions for trauma-related suffering may not be effective without first targeting social structures and second providing sustained drug abuse rehabilitation.