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Urban Suffering Studies Center



Outside-in e Inside-out: an approach to suffering in South Africa

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Melvyn Freeman


Melvyn Freeman

Going there

i) bread and houses

I try to think about injury in different ways
(I don't like thinking of myself as a victim).
I was raped at six, 11, at 13, at 17 and 19
I didn't know I was violated because
I had no idea what rape was.

Life is a shelter. The frail meat of humankind
cannot withstand extremes. We construct ourselves
around ourselves, making shelter.

When you build a house,
you place the window carefully,
when you grow out of a wound,
you see things through eyes
that have survived.

I look through the album of
my rapes, they were bread: a catalogue of certainty,
I gave thanks for this
daily meal of reality.
Think of the keloid memories of
Africa's male and female warriors: scars
deliberately inflicted, a short pain, a mark,
a sign of identity. I read them like Braille.

ii) night and blood

This is a letter scratched out by candlelight:
I leave it for all those who are also
confined, painfully pressed, split open.
Those who hold themselves tightly in their hands
and hope that they will not spill over
and drain away into the senseless dust.
Fear eats hope like the night eats the day
leaving only crumbs of stars. Too far away
to be of any help.

iii) crumbs of light

When they found me I was filthy,
wild and mute. They asked me: what
happened? Concern unlocked
the cage of memory, and words fell out of me
like crumbs in Gretel's forest, words
became light, words
showed me
how to get home.

I am healed now.
But I no longer
look the same.

Poem by Phillippa Yaa de Villiers


Suffering is probably best understood and expressed by poets, novelists, artists and songwriters rather than psychiatrists and psychologists. Though there is certainly overlap with mental disorder, suffering cannot be scientifically measured, defined and compared and is always a profoundly personal experience. On the other hand if we are to try to prevent and to change it, suffering cannot be left only in the realm of artistic expression and people from different disciplines and professions need to become involved in theoretically analysing and understanding the issues, in shifting the dynamics that cause suffering and in assisting those who experience it. Material and physical adversity, oppression, discrimination, displacement, poor health and educational, violence and war are just some of the factors that cause human suffering, hence altering human misery needs participation from multiple and varying sources.
Remarkably many people in the worst of conditions manage to overcome material and physical hardship and despite conditions that commonly act towards psychological disintegration they manage to maintain their mental integrity and well-being. Certain unique people even appear to thrive in highly adverse conditions and exhibit qualities of good mental health such as caring, forgiveness and humility that go far beyond "normal" expectations - even of people whose life conditions have been far more favourable. On the other hand some people in very advantageous physical and material circumstances experience extreme suffering - to the extent of taking their own lives. Hence though there are no doubt a range of adverse social factors that foster suffering, there is no direct causal relationship between external adversity and internal reaction. Personal resilience plays an important role and the extent that people are able to cope depends on a combination of biological, psychological and social factors. The aetiology and the solutions to dealing with human suffering are thus both "in" and "outside" the person and in the inter-relationships between people and their worlds.
While suffering is universal, and is arguably even integral to the human condition, when one compares regions of the world it is apparent that the distribution of adversity (for example as measured by the human develop index ) and resultant suffering is both unequal and unfair. While it is counterproductive to set up a country related hierarchy of suffering, the adverse external forces that impact negatively on people's well-being in developing countries is extreme. Most of us are not Nelson Mandelas or Mahatma Ghandis where suffering seems to have strengthened "mental health", and for the majority the psychological cost of living with past and present adversity is high.
Most conventional psychiatry and psychology tends to locate suffering within the individual and alleviation of it consequently also lies within the individual. Addressing change may involve modifying biological patterns and pathways, the way people think, individual psycho-dynamics or other means of individual behaviour change. However while personal change is important these approaches are plainly inadequate responses to human suffering in that they deal only with the effects and not the causes of suffering and because the scale of suffering in developing countries relative to the resources for dealing with it will for the foreseeable future, be inadequate. A rational response to alleviating suffering requires that the external causes of distress are tackled, and tackled with vigour. Addressing the social determinants of health, including mental health, has recently received increased attention and this is an important move forward, but far more action is needed.
It is argued in this paper though that much of the external change that is needed to prevent suffering is itself dependent on well functioning individuals and communities and hence the alleviation of suffering not only requires changing of social and economic factors that impact on people, but increasing human empowerment and agency to enable individuals and communities to be effective social and economic change agents. This requires having to deal directly with and change people's personal suffering. Hence addressing suffering must be both from "outside in" and from "inside out". An important additional question that will be addressed in this paper is whether it is possible to simultaneously tackle the "internal" and the "external" factors and relationships involved in suffering.

Key impacts on mental health and suffering in South Africa

While it is difficult to identify and isolate the most important factors that foster suffering in South Africa (or in any other country) as there are a myriad of important contributory factors and almost all the determinants are irrevocably interlinked and entwined, the following six interlinked variables stand out i.e. poverty, HIV/AIDS, dehumanisation, violence/crime, substance abuse and mental health (See Figure 1).

Figure 1

Each of these factors contributes to human suffering as a variable in itself, yet each is linked to every other and like an ecological system pressure and change at any one point impacts throughout. The dynamics of how each contributes to suffering directly but also impacts and is impacted upon by the other factors can be illustrated by a brief analyses of 3 of the variables in the above matrix i.e. poverty, HIV/AIDS and violence/crime. Of course the other 3 variables would illustrate the point just as effectively but it is not necessary to belabour the point.


Poverty can be defined as "a condition of material and social deprivation in which people fall below a socially acceptable minimum standard of living or in which they experience deprivation relative to others in a society" . In South Africa officially 23% of the potentially working population is unemployed , though it is highly likely that this figure is far higher. Global economic conditions are also set to substantially increase this percentage. The number of people living below the poverty line is estimated to be 71% for rural areas . Living in poverty is a risk factor for a number of physical health conditions such as tuberculosis, malnutrition, HIV/AIDS, infectious and respiratory diseases, but is also devastating to people from a psychological or "mental" point of view. Various studies have shown that there are higher proportions of people with mental disorder amongst people living in poverty than in more favourable economic conditions and from a common sense perspective it would be difficult to comprehend were this otherwise. A short illustration of a typical example of a family living in poverty and the psychological stressors they are under portrays well the cyclical nature of this nexus.
Anele (not her real name), a women living in a shack in an informal settlement with 4 children lives amid crime and violence and is herself a victim of domestic violence, past rape and robbery. She lives with these scars on a daily basis. She further lives the indignity of being clothed in rags and has to face adverse weather without proper housing protection. As a mother she faces the physical as well as the psychological strain of being unable to feed and provide adequate shelter for her children. Even though she is unable to change her situation she berates and blames herself for her childrens' privation. As her identify as a women is inseparable from her identity as mother she perceives her maternal inadequacy and her worth as a person as the same. Her adequacy as a person feels threatened. Other people in and outside the community in which she lives also irrationally blame her. Her self-blame and external condemnation occurs despite the fact that Anele, like so many other women in poverty, gives what food that is available to her children and deprives herself. The psychological guilt she feels has little to do with the practical realities, but the personal pain is not illusional. Anele has not tested for HIV but fears that she may be positive. She will not test because she fears that she will not cope with a positive result and is concerned with retribution from her husband should she be positive, however she worries daily about her status and what would happen to her children should she die.
The spiral of suffering continues as in addition to the self-blame which she takes out on herself and sometimes aggressively on her children, Anele's mental condition is aggravated by physical weakness caused by her lack of food intake. The resulting lethargy means that in addition to the physical consequences of lack of food and shelter for her children, Anele fails to give adequate emotional sustenance and support to them. Her weak physical state also deprives her of making use of the slim opportunities that do come her way for obtaining some income (such as occasional domestic work). Her state of lethargy also increases the risk of behavioural problems for the children. Because her children feel uncared for at home they leave school finding closeness, a sense of belonging and protection within gangs and in other antisocial activities. This downward spiral continues with violence begetting more violence, increased substance abuse, trauma increasing and any chance that there may have been in turning poverty into prosperity decreasing with each turn. Lack of mental health services to assist Anele or her children further weakens any chance of reversing the downward trend.
Mandla, the father of the children believes it is his task to provide materially for the family, but he is unemployed. As a result he feels that his dignity and personal power are undermined. What little money he acquires is uses to buy alcohol and other substances and on forgetting about his problems. In his drunken state and with the underlying powerlessness that he feels Mandla becomes violent and abuses Anele and the children; stability in the home decreases due to this and his unavailability to the children. Mandla finds emotional solace with a prostitute and becomes HIV positive. He does not inform Anele about this. Eventually he feels so bad about the lack of money coming into the family, he decides to rob a house. He rationalises that he will die from the HIV in any case and that his deprivation results from past political injustices, so what if he is caught. Unfortunately he finds the family at home during the robbery and without remorse uses the owner's gun to kill him. Mandla, the potential bread winner for the family, is caught and jailed. His own dehumanisation has allowed him in the act of violence to also dehumanise his victim. But again in this vicious cycle he has further dehumanised himself. The conditions in the prison and the attitudes of the warders completes his ever deteriorating belief in himself as an empathic, dignified and caring human being.
Closely linked with poverty in South Africa is the dehumanisation and personal sense of disempowerment left by Apartheid. Apartheid robbed people of their human dignity and for many people belief in themselves as individuals capable of achieving self-reliance and self-determination was severely undermined - and even 15 years after Apartheid for many people this has not changed. This has left many people unable to overcome poverty even where opportunities become available for them to change their situation. As a result the misery and wretchedness of existence and feeling of hopelessness and helplessness continues for them even though they live in a political democracy. While certainly opportunities are still limited for people to change their lives they are "prisoners" of both their external and their internal words.
Poverty is a known risk factor for poor mental health but mental health is also a risk factor for poverty. People with mental disorder often find themselves out of work, isolated from families and friends and descend into poverty. Moreover high rates of poor mental health amongst the poor is as much a consequence of poor services in these areas as the stresses of poverty. Lack of access to treatment through physical proximity to services or economic factors often means that poor people fail to be treated . There is thus (another) clear "vicious cycle" between poverty and poor mental health. A recent study in poverty stricken areas of Johannesburg found that almost 40% of respondents had symptoms of common mental disorder . Education and formal employment were found to be protective factors.


In 2006, HIV seroprevalence in public sector antenatal clinic attendees (DOH, 2007) was 28.6% . This means that more than one in four pregnant women was HIV-positive. One in nine (11.4%) South Africans over the age of two years were estimated to be HIV positive at the end of 2007 . Although fewer than 3 in 100 South Africans aged 10-14 years are infected with HIV, at current infection rates more than 20% will be infected by the time they turn 25 years old. The 2005 Human Development Report identified AIDS as the factor inflicting the single greatest reversal in human development history (UNDP, 2005).

Many people suffer as a consequence of HIV. It is not only the individual infected but also his or her children, family, caregivers and society as a whole who experience the negative consequences. AIDS affects poverty and inequality, economic growth, the availability of a workforce, health services, life expectancy, education and just about every aspect of macro and micro existence . Every income earner is likely to acquire one additional dependent over the next 10 years due to the epidemic. But families in the poorest quartile will acquire an additional eight people who will become dependent on their income as a result of AIDS .

The evidence is clear that HIV spreads fastest in conditions on poverty and that violence (especially against women) is an important driver of the epidemic . We know too that intoxicated people are more likely to be involved in risky sexual behaviour and indeed that many people abuse substances once they hear they are positive to drown the emotional hurt and fear .
The inter-relationship between HIV/AIDS and mental health is complex. Mental health status is a risk factor for contracting HIV/AIDS, affects the course of the disease and is also a consequence of it . As figure 2 illustrates, poor mental health, be this schizophrenia, depression or other disorder, often leads to individuals engaging in sexual risk behaviour. Moreover how one behaves when infected with the virus impacts on the course of the disease. In addition the HI virus attacks the brain and without treatment may lead to dementia and even psychosis in the latter stages. A positive status is almost always an emotional shock to the infected individual and ongoing living with HIV can be extremely stressful and psychologically draining. This is exacerbated by stigma and discrimination. Where a person is seen to have both HIV and mental disorder they suffer "double stigma".

This example again illustrates that all the variables in our matrix combine to both fuel the spread of HIV and are consequences of it. As many as 45% of people living with HIV in South Africa also have a diagnosable mental disorder . It has been seen that this is both because poor mental health leads to risky behaviour that results in people becoming infected with HIV and because having HIV leads to poorer mental health.

Crime and violence

Crime and violence are major causes of human suffering in South Africa. Around one third of all officially recorded crime is violent. The death rate due to violence is around 6 times higher than the global average . Men are particularly vulnerable to violent related mortality (6 times higher than women). However rates of domestic violence (against women) are also amongst the highest in the world with 1 in every 4-6 women beaten by their intimate partner. Moreover rapes are particularly high with 55 000 people reporting rape in 2006. However it is estimated that 450 000 rapes go unreported i.e. in South Africa there are 1 300 rapes every day (Population 48 million).
The pain and suffering caused by crime and violence is not easily measurable. With crime rates such as these already mentioned and where in addition there are 1000 per 100 000 population of assaults a year, 27 per 100 000 car hijackings and 560 per 100 000 burglaries of residences, citizens live in fear that they may be the next victim. This inhibits the free expression of people's humanness and ability to lead free and fulfilled lives.
Substance abuse is a major driver of crime. A study carried out in Cape Town, Durban and Johannesburg on arrestees 15% indicated that they were under the influence of alcohol at the time the alleged offence took place. Regarding violent offences, arrestees indicated that they were under the influence of alcohol for 25% of weapons related offences, 22% of rapes, 17% of murders, 14% of assault cases and 10% of robberies. Levels of alcohol-related crime were particularly high for family violence offences at 49%. When asked why they consumed alcohol or other drugs in relation to crimes, many arrestees indicated they consumed these substances in order to give them courage to commit the crimes .
The relation between crime and violence and mental health is evident particularly in the nature of criminal acts. For example if it were poverty alone that was driving crime, one would expect most crimes to not involve violence and certainly not gratuitous violence. Yet there are numerous examples of criminal acts where a victim is assaulted and even murdered for no apparent reason - suggesting that the violence was committed by people with a "traumatized" - or otherwise "disturbed" - mind . Hoffman suggests that it is often alienation and need for recognition that drive "violations" between people . The historical and ongoing dehumanization of individuals reinforces violent actions that has resulted in a culture of fear and self-protection rather than mutual assistance.

The need to address both the causes and effects of suffering

Human well-being requires less poverty, less HIV/AIDS, less dehumanization, less substance abuse, less crime and violence and ...more mental health. Perhaps one can even go as far as to say that given the impacts of economic and social issues on mental health that those seriously concerned with human suffering and promoting mental health have an obligation to not only understand the structural (economic and social) and other factors that negatively impact on mental health (such as violence, substance abuse, HIV, dehumanisation), but to be active agents of changing these forces.
An important question therefore is whether all people who are seriously concerned with suffering and its mental health implications can and should be involved in addressing the causes rather than the consequences of poor mental health. The question is particularly important as mental health is so obviously an outcome of social and economic variables. For example if it is accepted that poverty alleviation or the reduction of HIV/AIDS will have more impact on mental health than psychiatric or psychological interventions - and a strong case can be made for such a position - does this mean that mental health professionals should stop curative work to address the causes? For public mental health professionals serious about the dictum that prevention is better than cure this is indeed a tempting alternative, however it is also a rather rash response for three reasons. Firstly unless mental health professionals have the skills in good poverty alleviation intervention, their efforts in this regard are likely to bare little fruit, neither impacting on poverty nor mental health. Secondly there is a strong argument to be made that addressing mental health and human suffering requires intervention with both the causes and the effects of ill-health. While certainly there has been a significant overemphasis on curative rather than preventive responses to ill-health, including mental health, alleviating physical and mental suffering is an important humanitarian intervention. Moreover many peoples' suffering is likely to get worse without intervention, thus cure seldom excludes a secondary or tertiary preventive aspect. Thirdly, and most importantly for this paper, if we are correct in the belief (and I think we are) that poor mental health is a significant contributor to major social ills such as violence, poverty, substance abuse, dehumanisation and HIV, then mental health professionals can play an important social role through helping individuals impact on the forces that negatively affect their lives.

Good mental health as a critical factor in social and political development

People living with mental disorders and many others who suffer personally but who may not reach diagnosable thresholds for mental disorder, are very often unable to contribute to personal, family and community well-being and instead of adding to local growth and development and potentially alleviating poverty through their energies and endeavours, become a burden to others - be this family members, the community or the State. Interventions that assist individuals are thus critical not only because alleviating personal suffering is a good in itself (which it is), but also because people with untreated mental disorder so often add to the poverty, increase the proportion of people with HIV/AIDS, add to substance abuse, increase dehumanization and may be both perpetrators and victims of crime and violence. The well-being of individuals is hence inextricable from the well-being of communities and societies as poor well-being is a cause of adversity as well as being a consequence of it. As poor mental health is a contributor to major social ills such as violence, poverty, substance abuse, dehumanisation and HIV (even if a small contributor) mental health professionals can play an important role, through helping people with poor mental health, to not only assist in improving mental health (which is an important end in itself) but also to be instrumental in helping to shift some level of social ill. Good mental health is therefore a necessary component of optimal social and economic development. In the same way that physically healthy individuals are key to local, national and international prosperity, mental health and the alleviation of internal suffering too, is essential
Good mental health may indeed be a critical factor in social and political development.

Models of personal empowerment

The above stance appears to suggest that, costs being equal, any intervention that alleviates symptoms of mental disorder or suffering are equally acceptable as it makes the personal life of the individual more tolerable (and probably also their family) and in addition is likely to assist the society through the individual making a higher social and economic contribution to that society. However most mental health interventions do not aim to help the person to understand the complex causes of their mental suffering and/or to increase their personal agency and empowerment, but set their target "merely" at symptom alleviation. Cognitive behaviour therapy and psychotropic medication are good examples of this. However while such therapies undoubtedly have an important role, and while evidence shows that these interventions are often the most effective for alleviation of psychiatric symptoms , this is often a missed opportunity for deeper personal empowerment and consequently also for greater social and economic change. The potential of an intervention to not merely alleviate symptoms but to empower an individual through gaining a greater understanding of themselves and the impacts on them that result from the world around them is lost. Any opportunity of using peoples' suffering to help them to understand their suffering and hence to change those factors that gave rise to their symptoms in the first place is lost.
For example a women may be depressed because she is being beaten at home by her husband. Treatment may make her feel better without ever empowering her personally to make important decisions about her life and will have very little impact socially/politically. A different "therapy" may help the women understand her suffering in terms of gender oppression more generally and may help her to take decisive decisions around her personal life. It may also even result in her becoming part of social activist movements that fights against women abuse or even against gender discrimination. In such a model suffering may not just be seen as something that needs to be alleviated, but as a turning point for change. For many people life develops meaning (sometimes for the first time) when they not only experience some control over their own lives but when they feel they can assist others who are suffering from the same causes as their suffering.

Working with communities to change

In this section the possibility of working with people in communities in order to try to change their situation, including addressing the causes of their suffering, is discussed. The discipline of (critical) community psychology is explored as an alternative to approaches that look only at changing the individual and/or allowing the person to adapt to their oppressive situation rather than trying to change it. The discipline of community psychology was founded primarily because there were not, and were never likely to be, sufficient human and financial resources to give each person in need, individual attention and because it was realized that many mental health problems could be best solved by making changes at a community rather than an individual level. The discipline is concerned with looking at the causes of problems rather than only the effects. Community psychology is different from community psychiatry which tends to primarily concentrate of providing psychiatric services at a community level. Community psychology, on the other hand "focuses on social issues, social institutions and other settings that influence groups and organizations. The goal is to optimise the wellbeing of communities and individuals with innovative and alternative interventions designed in collaboration with affected communities" . While there are a number of different models of community psychology with different theoretical underpinnings as well as different objectives, an important goal of for example the social action model of community psychology is the joint emancipation and empowerment of peoples' minds with achieving change to the oppressive structures that cause human suffering.
Community psychology focuses on the relationship or interaction between an individual and his or her environment or social context. According to Lazarus core values and assumptions of community psychology are that the discipline focuses on the dynamics of oppression . It also concentrates on allowing a person to gain a personal sense of control over one's own life as well as over the political factors that influence one's life. However rather than working with individuals to do this, the discipline works with whole communities (which could be communities in "space" rather than "place") and assists the group to gain a "psychological sense of community". This collective action gives the individuals within it a feeling of solidarity as well as increases the capacity of communities to bring about change.
Burton and Kagan, based on what has come to be known as Liberation Psychology developed mainly in Latin America, identify 5 central elements of a critical community or liberatory psychology .
i. Conscientization. This concept, developed by Paulo Frere, suggests that psychological as well as material liberation occurs in the interaction between 2 types of agents, external catalytic agents (organic intellectuals, activists, committed professionals) and the oppressed people themselves. The person is changed through an active dialogue in which people grasp the mechanisms of oppression and dehumanisation. People increase in confidence as they understand the sources of their marginalization and organizing together to do something about it.
ii. Realismo Critico and de-ideologisation. To attain "liberation" (internal and external) it is necessary for people to "de-ideologise" reality. People are presented with a reality that suits certain people in the society but usually not the worst off. People need to go through a process of "peeling off" the ideology that covers the reality.
iii. A social-societal orientation. Much of psychology is individualist in nature. While portrayed as the "truth", this is a unique historical and cultural representation. Power and liberation is achieved through a more social orientation and understanding.
iv. Preferential option for the oppressed majorities. People's real problems , not those that pre-occupy people elsewhere, need to be addressed. Fulfilment of people's needs depends on their liberation from the social structures that keep them oppressed.
v. Methodological eclecticism. Information should be collected from a range of methods including surveys, official statistics, content analysis, social representations, interviews, textual analysis, drama and so on. Ideological critique should also form part of the methodology.

Counteracting suffering means going beyond the individual and the symptoms they exhibit into understanding how the social system is structured and how it works. Social phenomena "enter into the construction and functioning of human actors, their ideas, desires, prejudices, feelings, preferences, habits, customs and culture" (pg 25). Thus understanding a person means understanding the social forces that form him or her. Knowledge then of the personal and interpersonal dynamics of human behaviour and of the forces that form peoples thinking and behaviour assist the facilitator to allow the community to find solutions that both empower it and that lead to the resolution of forces that oppress it (including mentally oppress it)


Addressing human suffering must involve changing the forces "outside" the person as well as "inside" the person. The "outside" changes will bring "inside" change while the "inside" changes will help bring "outside" change. Both ways are important to shifting the wretched lives of the many people living in poverty, who are disempowered, who abuse substances, who live with mental disorder and who are infected with or affected by HIV/AIDS.
The community psychology approach attempts to combine these processes. Using this approach and based on peoples' real concerns, people are empowered to feel that they can bring about changes to problems that affect their lives and are helped through dialogical relationships to make real concrete shifts. In this process the individual gains a sense of their own well-being and personal power but they are also able to change conditions that contributed to their disempowerment in the first place.
There is far too much preventable human suffering in the world. We all have choices to engage with it and to try to change it, or to be part of the problem. This paper began with reference to the poets, novelists and songwriters and ends with a quote from one of the most poignant, Albert Camus
" that he should not be one of those who hold their peace but should bear witness in favour of those plague-stricken people; so that some memorial of the injustice and outrage done them might endure: and to state quite simply what we learn in time of pestilence: that there are more things to admire in men that to despise. It could only be the record of what had had to be done,...despite their personal afflictions, by all who, while unable to be saints, strive their utmost to be healers." The Plague


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The study centre wishes to study the phenomenon of urban suffering, in other words the suffering that is specific to the great metropolises. Urban Suffering is a category that describes the meeting of individual suffering with the social fabric that they inhabit. The description, the understanding and the transformation of the psychological and social dynamics that develop from the meeting of ...

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The Urban Suffering Studies Center - SOUQ - arises from Milan, a place of complexity and economic and social contradictions belonged to global world.Tightly linked to Casa della Carità Foundation, which provides assistance and care to unserved populations in Milan (such as immigrants legal and illegal, homeless, vulnerable minorities), the Urban Suffering Studies Center puts attention on ...


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