1 The Other Side of the MountainSarah Crawford-Browne Primary Health Care Directorate University of Cape Town

2 By Discott - Own work, CC BY-SA 4. 0, https://commons. wikimediaPhoto by Discott - Own work, CC BY-SA 4.0,

3 The psychological processes of continuous traumatic stress that facilitate adaptation to ongoing violence How do the participants’ construct meaning of their context & of their experiences of violence? How do these processes of meaning making affect their adaptations to their experiences of violence & their context?

4 Continuous traumatic stressTerm developed in Apartheid South Africa - Straker & the Sanctuaries team (1986) Kaminer and Eagle (2014) identified a presentation related to living without protection, in a violent context, where people anticipated violence, and struggled to identify threat Frankl (Austria, WW II); Martín-Baró (El Salvador); Becker, Lira, Weinstein, & Salmovich (Chile); Bell, Mendéz, Martinez, Palma, & Bosch (Columbia); Cabrera (Nicaragua); Monteil (Philippines); Diamond, Lipsitz, Fajerman, Rozenblat, & Hoffman (Israel); Giacaman (Palestine); Somasundaram (Sri Lanka); Healey, Murphy (Northern Ireland)

5 The context https://www.youtube.com/watch?v=h0iqqj1PjyQ

6 The study Constructivist psychology as conceptual framework – post modern, ecological, anticipatory schema Semi-structured interviews with 21 adult women Analysed using constructivist grounded theory Shared meaning constructions of the context, their experiences and their lives

7 Findings I. Meanings constructed II. Meta-constructions III. Patterns of adaptation

8 I. Meanings constructed“It does not even affect you any more” – being habituated to the violence (17) “Hanover Park is what you make of it” – hoping that it is possible to thrive (16) “Hanover Park is now the coffin”- recognising the danger (universal) Dynamic triad of shared meanings about the context

9 Meanings constructed of the context - cognitive / emotional constructionsRecognising the danger - the environment holds the potential for real, frequently occurring, life- threatening violence for herself & her family Being habituated to the violence – the contextual violence was in their capacity to manage or accept because of prior experience Hoping that it’s possible to thrive – holding the belief that people had the capacity to manage & respond to the adversity presented within the context

10 Recognising the dangerSometimes when I have to come out of the house, you can’t really actually just walk freely, especially when you know that they just come and the shooting starts, you can’t just walk freely in and out, in the area where you live. It’s like, a small group of people keeping the majority hostage. (Praveen)

11 Shared subthemes of recognising danger:“There’s no way for you to hide” - living in a condition of diffuse threat “It’s like a cooking pot” - expecting malevolence “It’s for respect” - relating to gangsters “Children must run because they are shooting” - worrying about children and family “Always being on edge” - feeling fearful of anticipated danger

12 Being habituated to the violenceP: But sometimes you know, even that also because sometimes when they shoot around you, you don't know when the bullets is coming through the windows. Like they, where we stay, that side, now they used shoot over the field and the people on the end, in the Court on the end, they always used to get the bullets at number two and number three, that houses there, they always used to get the bullets, so you weren't even safe in your own house as well then. R: So if you hear shooting when you are home, what do you do? P: I just tell the children, just lie flat because you don't know where the shooting is and where they come from. You just tell them to ... we just always see that the children is in the house. R: And you've got to lie flat? P: Ja. R: Do you feel scared? P: At the moment now, it's just part of life really. (Joonie)

13 Hoping that it’s possible to thriveYes. Actually, there’s nothing wrong, it’s the way you make yourself feel in a place in Hanover Park, like I left here [the interview] Wednesday and then Thursday and Friday they were shooting again but it’s the way you make yourself feel here. Like I’m not into the gangsters, so it won’t make me, “Ag, I’m going to pull out” or whatever, so, it’s what you make of it. (Eiliyah)

14 The meanings of personal experiences of violence, and of lifeCentral focus on the present Deeply traumatic loss of partners & friends in violence Domestic violence skewed experiences The chronic stress of poverty, ill-health, food insecurity, and familial substance abuse frequently dominated Faith in the Almighty and the value of family important balances

15 II. Meta-constructions of the contextOscillating between danger, habituation & optimism based on constructs of context Meta-constructions “construal of a construction” Sociality, introspection, reflection, remembering, future projection Creates gaze across life-narrative (Sewell & Williams, 2002)

16 “At times, being ok with it… at times I feel uneasy” Shifting awareness of threat Being habituated to the violence Hoping that it is possible to thrive Recognising the danger “I won’t allow the guns to make me scared” Constructing psychological safety “I don’t have friends” - Experiencing social rupture

17 Meta-constructions of contextShifting awareness of threat – participants’ fluctuation between conscious cognitive attention to, & being cognitively unaware of threat Constructing psychological safety - reconstructing the social environment as safe enough, or safer than the participant’s initial construction, & perhaps safer than the reality Experiencing rupture of relationships - responding to the threatening environment by withdrawing from people due to the fear of gossip, being vulnerable, or hurt - leading to loneliness and alienation

18 Shifting awareness of threatR: Do you find it a safe place to live? P: Oh, not at all. Not at all, but I think its just a thing of, at times, even when its shooting and a lot of things going on, I find myself, at times, being ok with it, just, you know, living with it, because I have to live with it and at times I feel uneasy. R: So it changes at different times. P: Ja, it changes all the time. It’s ceasefire, there is no shooting going on R: And when there is shooting, do you feel that you are more uneasy or is it also up and down? P: It’s also up and down, ja, I will say its up and down. (Praveen)

19 R: But then there was shooting around your window … in our last interview you were saying there was shooting like the window and hit, went on top and went -. P: I was scared then, I was scared because I was, your child is laying in that room, I had to act fast and that but like I said S, that is things that happen and growing up in Hanover Park, it only makes you tougher and a stronger person. It doesn’t matter. R: Does it happen a lot? P: The what now? R: No, it’s quiet now. It’s much quieter now but there was like a month continuing gangsterism for that month only but it affected us yes, it affected the children going to school, it affected the Matric’s during the exams and that but I say … (Joonie)

20 Constructing psychological safetyI feel I belong here. I am not actually very talkative. I don’t talk… I am a community worker, so hallo and goodbye and to help you out and that kind of thing but I feel, I am not going to pull out of Hanover Park, I will not let the guns make me scared, no because point one, our hands… our lives are in God’s hands, not in their hands. So why must we fear… is just that we shouldn’t tempt the devil. Be on time in your house. Look who Is in your house, look in front of your door, don’t let them be in front of your door… if you make it clean in front of your door, then the next person must also make it clean and the others must also, then there will be no gangsters in your area and that is what happens here (Lena).

21 Experiencing the rupture of social relationshipsP: No Sarah, I don’t … not friends exactly … I like to go to my mother and sitting at my sister’s… I don’t … no friends. R: And so when things get too much … what do you do? P: Then I just go to my mother. Just go there, talk to my mother, talk to my mommy’s sister in Mitchell’s Plain, go to her … then I feel better but not with other people. R: Yes. P: Like friends … no no no. R: You’d rather not. P: They’re going to tell this one and that one and that one and everybody knows. R: You don’t want everybody to know? P: No. When you walk in the road, then they tch tch tch … you know how’s people Sarah. (Tasneem)

22 Meta-constructing personal experiences within life narrativeDistancing Preoccupation with a past experience or current threat Merging of the emotions of experiences Integration

23 III. Patterns of adaptationConscious Agent Hell no! high agency low awareness Life is hell! high awareness low agency Costly resilience low awareness low agency

24 Continuous traumatic stress…Four patterns of adaptation to living in contexts of ongoing danger emerged. These were shaped by the meta-construction processes of constructing meaning of their context Through shifting awareness, constructing psychological safety, and managing ruptured relationship And of personal experiences of violence through being preoccupied, distancing, merging or integrating within their life narratives

25 It takes a community to raise research…I thank… The women in Hanover Park who spoke with me Ass. Prof Debra Kaminer, my PhD supervisor Hanover Park Community Health Centre team Faculty of Health Sciences UCT – Fellowship for Health and Human Rights Harry Crossley Fund My clinical colleagues who have shared this question over the years