Over the last few decades, several trauma-focused psychotherapies have accrued substantial evidence to effectively treat posttraumatic stress disorder (PTSD). Further development in the field of traumatic stress research has been the evaluation of empirically supported treatments (ESTs) such as prolonged exposure therapy (PE) and cognitive processing therapy (CPT), among others, in low- and middle-income countries (LMICs) (see Kaysen et al. 2020; Rossouw et al., 2020). Yet even with the availability of several efficacious trauma therapies for PTSD, the uptake and implementation of these treatments remain relatively sparse in LMICs such as South Africa.
The Case of South Africa
South Africa, which is a resource-constrained context, has a longstanding history of violence and traumatisation that started in the mid-1600s with colonialism and recently ended with racial apartheid in the early 1990s. The former apartheid government initiated widespread practices of structural and physical violence, psychological destruction of the person, and facilitated widespread community violence and torture. Today as a postcolonial society, it can be argued that South African society is still processing, to some extent, the psychological sequelae of a traumatic history (Hamber, 2009).
As a result, the conceptualisation and treatment of traumatic stress in South Africa has been approached from various perspectives, namely a sociopolitical and activist approach, and recently from a more public mental health framework. Furthermore, due to the problematic history of psychology in South Africa as a conduit for the apartheid government, so-called mainstream approaches such as psychotherapy were not accessible to persons of colour, which created a distorted view of psychology among the majority of South Africans. Against this backdrop, the assessment and treatment of PTSD in a contemporary South Africa requires clinicians to be cognizant of how contextual factors, such as the sociopolitical history, and present-day issues, such as poverty and limited socioeconomic resources, can impact the treatment of PTSD in South Africa (Booysen & Kagee, 2020a).
Treating for PTSD in South Africa
Mental health services in South Africa are plagued by several challenges ranging from a lack of mental health policy implementation, a high treatment gap, limited trained mental health professionals and limited access to evidence-based mental health care at a primary care level (Department of Health, 2013). Yet the last decade has brought about a shift towards a more evidence-based approach to mental health care in South Africa. A survey on clinicians’ (N = 60) attitudes toward the adoption of evidence-based interventions for PTSD found that overall participants had favourable attitudes toward implementing such evidence-based interventions (Padmanabhanunni & Sui, 2017).
Further development in evidence-based approaches have been supported by various levels of intervention research on the effectiveness of ESTs, such as PE (see Booysen & Kagee, 2020b; Rossouw et al., 2018), and trauma-focused cognitive behavioural therapy (Trauma Focused-Cognitive Behavioural Therapy) for adolescents in South Africa (Kaminer et al. unpublished manuscript). Rossouw and colleagues (2018) conducted the first ever comparative randomized controlled trial (RCT) on Prolonged Exposure for adolescents (PE-A) versus supportive counselling (SC) (N = 63) administered by nurses in a school context in South Africa. Observed improvement in PTSD symptom severity in the PE-A group was significantly greater than in the SC group. Furthermore, improvement in the PE-A group was observed to be greater from pre- to post-treatment assessment (p < 0.05), as well as at the 12- (p < 0.05), and 24-month follow-up study (Rossouw et al., 2020).
In addition, an idiographic intervention study by Booysen and Kagee (2020b) found that the implementation of PE for PTSD in a context of ongoing adversity, such as poverty and gang violence, could still reduce symptoms of PTSD, depression, and anxiety and maintain treatment gains at three-month follow-up. The authors also emphasised the role of contextual factors when implementing manualised treatments such as PE for PTSD and highlighted some of challenges encountered during treatment so as to provide clinicians a reference point. Overall, these findings go beyond the effectiveness of PE for PTSD but also provide further encouragement to continue evaluating and implementing ESTs such as PE for PTSD in South Africa.
Considerations
In South Africa, clinical researchers have only recently started conducting large-scale RCTs to study the uptake and implementation of effective treatments, such as PE and TF-CBT, in South Africa. Yet there are considerable challenges that will require continuous attention. First, considering the history of trauma in South Africa, clinicians need to be cognizant of how sociopolitical and economic factors can affect the process and outcome of trauma-focused interventions. Second, poor governance and the inadequate implementation of mental health care policies is a major obstacle to the growth of human resources (trained professionals) and infrastructure to improve access to mental health care. Third, social determinants such as poverty, community violence and inadequate social service delivery, among others, perpetuate contexts of ongoing traumatic stress.
Lastly, the field of traumatic stress has enjoyed a great deal of development. As a result, these developments and scientific progress must be disseminated to the majority world, in countries like South Africa and similar nations. Thus, irrespective of the social challenges, clinicians and researchers need to embrace the progress that has been made and find ways of ascertaining how these developments can be implemented in different contexts. It would be remiss to not consider the potential benefits of existing ESTs such as PE in countries such as South Africa. Therefore, continuous and adequate evaluation and implementation of treatments, such as PE, must continue to not only ascertain effectiveness, but also feasibility and acceptability for the treatment of PTSD.
About the Author
Duane D. Booysen is a PhD candidate at Stellenbosch University and a lecturer at Rhodes University in South Africa. His primary research focus is on the dissemination and implementation of empirically supported trauma-focused treatments for PTSD in low- and middle-income countries. Duane is also a part of the membership committee of ISTSS.
References
Booysen, D. D., & Kagee, A. (2020a). The feasibility of prolonged exposure therapy for PTSD in low- and middle-income countries: A review. European Journal of Psychotraumatology, 11(1), 1753941. https://doi.org/10.1080/20008198.2020.1753941
Booysen, D. D., & Kagee, A. (2020b). Implementing prolonged exposure therapy for PTSD in a context of ongoing adversity: A clinical case Study. Clinical Case Studies, 19(4), 258–269. https://doi.org/10.1177/1534650120925918
Department of Health. (2013). National Mental Health Policy Framework and Strategic Plan 2013–2020. Pretoria, South Africa: National Department of Health.
Hamber, B. (2009). Transforming Societies after Political Violence: Truth, Reconciliation, and Mental Health. (D. J. Christie, Ed.). Springer US.
Kaysen, D., Stappenbeck, C. A., Carroll, H., Fukunaga, R., Robinette, K., Dworkin, E. R., Murray, S. M., Tol, W. A., Annan, J., Bolton, P., & Bass, J. (2020). Impact of setting insecurity on Cognitive Processing Therapy implementation and outcomes in eastern Democratic Republic of the Congo. European Journal of Psychotraumatology, 11(1), 1735162. https://doi.org/10.1080/20008198.2020.1735162
Kaminer, D. (n.d.) A randomised controlled trial of TF-CBT in South African adolescents. Unpublished manuscript. National Research Foundation (NRF) grant no. 93568.
Padmanabhanunni, A., & Sui, X.-C. (2017). Mental healthcare providers’ attitudes towards the adoption of evidence-based practice in the treatment of post-traumatic stress disorder in South Africa. South African Journal of Psychology, 47(2), 198–208. https://doi.org/10.1177/0081246316673244
Rossouw, J., Yadin, E., Alexander, D., & Seedat, S. (2018). Prolonged exposure therapy and supportive counselling for post-traumatic stress disorder in adolescents: Task-shifting randomised controlled trial. British Journal of Psychiatry, 213(4), 587–594. https://doi.org/10.1192/bjp.2018.130
Rossouw, J., Yadin, E., Alexander, D., & Seedat, S. (2020). Long-term follow-up of a randomised controlled trial of prolonged exposure therapy and supportive counselling for post-traumatic stress disorder in adolescents: A task-shifted intervention. Psychological Medicine, 1–9. https://doi.org/10.1017/S0033291720002731