Ethics statement

The University of KwaZulu-Natal Biomedical Research Ethics Committee gave permission to conduct the study (BREC/00000089/2019). All participants were screened for capacity to consent by the treating clinician before referral and again by the principal investigator (VN). All participants provided written informed consent.

Data collection

We collected data as part of a process towards culturally adapting an intervention for PTSD among patients with serious mental illness. The adapted intervention was to be piloted on patients in an existing cohort enrolled in a larger study on HIV among first-episode psychosis (FEP) patients [19]. We used a qualitative narrative research study design to explore the lived experiences of trauma among adult patients with early psychosis who were receiving treatment at any of the four hospitals.

Study sample and recruitment

Patients were invited to participate in this study if they 1) had been diagnosed with a psychotic disorder within the last five years, 2) self-reported a history of exposure to at least one traumatic event in their lifetime, 3) were between ages 18–45 years, 4) had a level of education of grade 7 or higher, and 5) were able to give informed consent. Trauma histories were assessed by the researcher asking each participant whether they have had “difficult life experiences” or “traumatic events” in the past. Individuals who were 1) unable to give consent and/or 2) were actively experiencing psychotic symptoms and as a result assessed to be unwell by the treating physician at the time of recruitment were excluded from the study.

The principal investigator liaised with the treating physicians and screened clinical records of patients receiving in- or outpatient care to determine eligibility. A diagnosis of a psychotic disorder was initially made by the treating physician, using the DSM-5 criteria [20]. The principal investigator confirmed this diagnosis by reviewing the clinical records. A diagnosis of a psychotic disorder was confirmed if there was documentation of two or more of the following symptoms: delusions, hallucinations, disorganised speech, disorganised or catatonic behaviour, and negative symptoms including but not limited to flat affect and avolition. These symptoms had to have been associated with occupational or functional dysfunction, present for at least one month if untreated or a shorter duration if treated. Additionally, the symptoms could not be due to a direct physiological effect of substances or a general medical condition. Those who were eligible were approached for enrolment. Recruitment occurred until data saturation was reached and no new information was recorded. A total of 23 patients were approached, of which four were excluded because they did not report a history of trauma (n = 3), or declined to speak about their traumatic life experiences (n = 1), resulting in a total sample of 19 participants.

Study procedure

Individual in-depth interviews were conducted in English, isiZulu, or a combination of both languages, based on the participant’s preference to allow the participants to describe their experiences fully using culturally-specific expressions. All interviews were conducted by the principal investigator (VN), a clinician with experience in the field of psychiatry and trained on qualitative research techniques. The transcripts are available in the supporting information section (S1 Data). VN was also trained on collecting data on trauma experiences by an established trauma researcher (LN) to ensure safety of participants during data collection, particularly around ways to manage participant discomfort and distress. Participants who were interviewed had no prior contact or provider-patient relationship with any of the investigators and this minimized conflict of interest and interviewer bias. Interviews were conducted face-to-face in the hospital setting and psychological first-aid was provided to participants when needed. Participants noted to be distressed were referred back to the treating physician for further assessment and management.

Data was collected between 23 January and 20 March 2020. All interviews were audio- recorded and transcribed by a bilingual research assistant into English. The principal investigator randomly selected transcripts and verified the data for accuracy. Transcripts were anonymised and participant names were removed and replaced with pseudonyms prior to data analysis. For protection of privacy and confidentiality, participants’ real names were not used. Common Zulu names were selected instead for pseudonyms.

Instruments

A semi-structured interview questionnaire was developed to guide the interviews. The interview guide included questions such as, “what difficult experiences have you experienced in your life?”, “what was most traumatic for you?”, “how do you think the events have impacted you in your life?” Demographic data and information on clinical diagnosis were also obtained from the participants and confirmed on clinical records.

Data analysis

Data was analysed using interpretive phenomenological analysis (IPA) [21]. The three theoretical frameworks underpinning IPA are phenomenology (the subject’s lived experiences), hermeneutics (the subject’s interpretation of their experiences and the researcher’s interpretation of the subject’s interpretation) and symbolic interactionism (how meanings are constructed within a social and personal world) [21, 22]. In IPA, participants are considered to be experts of the phenomenon under study (e.g., psychosis, trauma) and the researcher examines the “insider’s perspective” of the phenomenon. The researcher examines how participants make meaning of their lived experience, while also simultaneously interprets the personal world of the participant by paying attention to what the participants may be less aware of, or are not saying in their narrative [23].

In our study, we coded for the descriptions of the traumatic life experiences and their impact (phenomenon) directly from participants’ narratives. We also paid attention to any unintended information provided by participants about adverse or stressful experiences that the participants had not interpreted as traumatic [23]. Any description of events that the participants described as traumatic, distressing, or having a lasting negative impact on their life (e.g., having memories of the traumatic event that cause disruption in their daily functioning) were coded as “traumatic life events.” Negative life experiences that were part of the participants’ narrative but were not made explicit by the participants as traumatic were also coded under this code. The same approach was used to code data describing how the traumatic life events impacted the participants’ lives. We focused on the symbolic interactionism process to understand how participants made sense of their traumatic life experiences within their contexts as individuals living with psychosis.

Nvivo v.12 was used for data analysis which was led by the lead author, VN, and MBD. Raw data was first coded using inductive coding [24]. A codebook was developed after jointly coding five transcripts and until consensus was reached and no new codes were created. All transcripts were coded using the final codebook including the initial five used for codebook development. VN and MBD discussed divergent codes and themes until an agreement was reached to improve the reliability of the results. Another member of the research team (NGW) also randomly selected transcripts to check the coding for consistency using the final code book.

Trustworthiness

Constructs of credibility, dependability, transferability and confirmability were used to ensure scientific rigor [25]. The lead author (VN) reviewed results with other members of the study team and her clinical and research supervisors (BC and LN). This was further facilitated through analyst triangulation by the first and second authors (VN and MBD). Transparency and auditability were facilitated by qualitative data analysis software program. Detailed in-text quotations in the presentation of results are used to enhance transferability.

Reflexivity

The principal investigator and lead author (VN) identifies as an African female researcher living in a South African context. Given that most participants in this study identified as African and shared a similar cultural context to VN, she was intentional about including other races to achieve a heterogeneous sample that was consistent with the racial distribution of the population of KwaZulu-Natal. The other members of the research team came from diverse cultural and contextual backgrounds, and this added to the objectivity of the findings in the study. During interviews, VN found herself immersed in the patient experiences as some of them, for example, corporal punishment, had been a part of the culture and norm growing up. Although she went into the research in order to understand, she realised that she had not completely divorced herself from the clinician part of her identity, and the misconception that clinicians have a better understanding about clinical phenomena and diseases than patients. It had come as a surprise to her to realise that patients were able to make the connection between psychotic experiences and past trauma experiences, exposing her bias about assumed knowledge of participants.

Experiences of traumatic life events

Three major themes emerged that described participants’ traumatic life experiences: 1) experiences related to parent-child relationship disruption during childhood and adolescence, 2) bullying and violence from peers and community members, and 3) experiences of psychosis.

Parent-child relationship disruption

Disruption in the parent-child relationship between participants and their biological parents or parental figures occurred for almost all participants in several ways. For some participants, their parents or parental figures were physically absent due to death, while others were separated from their parents due to other adversities, like poverty or financial hardship. Participants with unemployed parents, for example, were sent away to live in other households with better financial resources. Some participants reported that they lacked protective, nurturing caregivers and safe environments in their childhood and adolescence, sharing narratives about traumatic events including residential instability, abuse and neglect. These findings further generated the following three sub-themes: residential instability, financial hardship, and child abuse and neglect.

Residential instability. Most participants reported not having stable housing during their childhood and adolescence. Reasons for being removed from the home included death of a caregiver or parent, or for engaging in/being wrongfully accused of engaging in minor transgressions. Participants described that they often moved from one unfavourable living arrangement to the next, and faced new challenges and stressors each time they transitioned to a new environment.

I lived there; I grew up there [at participant’s aunt’s home]. My mother preferred I went there than other places… I lived there for about four years… Then I came back to live with my mother. Then I was chased out by my uncle [who lived with my mother], I was probably 13. He kicked me out and told me to go away, he said I was rude. Then I left… I lived in… [name of township] with some boy I was dating. He rented a room for me.

Sane

Bheki spoke about losing a stable home, both physically and figuratively, after losing his parents at a young age.

My mum passed away when I was eight and my dad when I was 12. My dad passing away, let me say, I never thought much about this ever since he passed away. But what I realized was that the only thing that changed was the fact that I lost my home yeah. So, I became, I could say, homeless, I became a person who never had a permanent home, you know.

Neli, who also lost her parents at age seven, shared that she and her siblings were frequently moved from one household to another. She recalled that she did not have a stable caregiver who would protect them and provide a stable nurturing environment for them to live and thrive as children.

We’d get separated, taken in by aunts and uncles. One would live somewhere and have the experience of how things were done in that home. When you’d hardly gotten used to it, then you’re removed and placed elsewhere to live. They were changing us around all the time like that. It was hurtful because there wasn’t anyone to speak for us anymore. No one to intervene for us in all this experience.

Financial hardship. Another common traumatic experience discussed by the participants was financial hardship, which often began in childhood. Parent-child relationships were often disrupted due to the caregivers’ lack of financial resources to raise a family. For example, for households where the caregivers were unemployed, they often delegated child care to others (e.g., relatives, family friends, neighbours). The extent of financial hardship was sometimes very severe and affected participants’ access to basic needs, such as food and schooling. Sizwe, who was unable to go to school after his parents’ death, recalled the challenges of having to support himself.

After my aunt kicked me out, I went to live by myself. Then I looked for a school but then I couldn’t get in because they required a school fee of R1000 (7USD). …When I think about it, the most traumatic event for me was that I couldn’t finish school. I see myself as a failure, as a loser because I did not finish school… I was working hard jobs that were not paying much. I was also living alone and sometimes I’d run out of food. And that would force me to sleep without eating for several days.

Child abuse and neglect. Most participants also reported experiencing various forms of interpersonal trauma, including child abuse (e.g., physical, sexual, and emotional abuse and neglect) by their caregivers. Experiences of physical abuse occurred in the form of frequent corporal punishment for these participants.

[My caregivers] didn’t have time to relax with me, or talk to me as a child. I would get a strong beating… They used a stick. I had bruises, I had bruises in my arm. I would go to school with bruises. And the way they were, they would influence my teachers to beat me again, you know… And sometimes I confessed that I want to go to my father’s side of the family, and I got a beating for that too.

Londi

Shane, a 21-year old man who received corporal punishment from his father as a young boy, recalled, “growing up, my father used to discipline me a lot. I would get a beating with a belt or with a whip or anything, even like metal pipes. I used to catch a lot of beatings growing up.” Another participant shared that receiving physical abuse, which at times resulted in serious injury, was a regular occurrence for her and her siblings growing up.

…when we got beaten up, we were beaten using a water pipe. [One of my siblings] had broken hands [after a beating], as it is, she has the experience of not being able to use them properly. [Another sibling] was beaten up by uncle [name] until his teeth came out.

Neli

Sizwe also described the ways in which he received verbal and emotional abuse by his uncle, as follows—

…sometimes, my uncle sent me to the tavern for beers in the middle of the night. That man didn’t like me. He always shouted at me for lies, and lied about me… I used to get shouted at. I lived under that pressure all the time, he’d place mistakes on me that weren’t mine.

Participants who lived with relatives or in non-kin households with many children were often ostracised or neglected, particularly if their biological parents were not living with them. Preferential treatment was also often given to children whose biological parents provided financial resources to support the household. Sibusiso described the neglect and abuse he received from the caregivers he lived with. He was denied basic needs offered to the other children in the same household, such as a bath with warm water.

I went to school, and [my caregivers] wouldn’t even buy me uniform and I was begging people… I was the only one getting beaten, they had many children but only I got a beating. If I’d gone to play only I would get beaten. Only I would be left to bathe with cold water.

Participants also discussed experiences of child neglect by their parents/caregivers (e.g., neglect of their physical safety or emotional needs) and other poor caregiver-child relationships that lacked warmth or nurturance. Neli described the neglect she received from her parents when she was injured, as follows—

I’ve had the experience that when I was a child, I got injured… by a window and it left a scar. Then I got burnt even on the body, burnt by water. I was living with my parents; I could say that they were negligent to me. Thereafter the parents passed away. When the parents passed away, we lived with granny. And when living with granny we had to live with aunt, and aunty didn’t treat us well, she treated us badly.

Other participants were sexually abused, often by their caregivers or people they knew who were in a position of authority. Sexual abuse also co-occurred with other forms of abuse, such as neglect or child labour. Participants’ family members often turned a blind eye to the sexual abuse and in such cases, participants were left to tolerate the abuse alone. For some participants, their family members silenced them through fear and threats. Sane recounted her experience of being sexually abused by her uncle who was also her caregiver. The uncle was also the primary breadwinner of the family who provided her basic needs.

[My aunt’s] man used to sleep with me forcefully… He slept with me and said I must keep quiet because I used to work and live there and did cleaning and everything. He was the one who bought me clothes and everything, he bought me clothes and my aunt would be furious and say I receive everything from her man… I never told my mother because she said [that] they [would] say I’m involved with him. I won’t tell my aunt, and I won’t tell my sisters too, because it’ll be as if I came to ruin. My aunt once swore at me and said I ‘make things happen’[seduce], at the beginning, when I tried to speak up. … And he was not doing it to me only. Everyone who came [to the house while] my aunt was working… the uncle would sleep with them.

Violence

Some participants reported that they experienced violence, including bullying, ostracism, and discrimination, from their peers or community members. Simangele was bullied for having a stutter and further punished for reporting the peer to adults for his actions.

…The issue of being bullied and I have tongues, they call it stuttering. I call it tongues because if you say its stuttering, it hurts… They’re picking on me and I tell them I don’t like it… You get laughed at by everyone. And in a painful way, not laughing normally, they loud laugh, and they even come up to the face laughing. When you go home to report that person because they’re older, instead of [the perpetrator] being fetched from his home and told never to do it again, I’m the one who will get a beating.

Similarly, Zara spoke about being bullied in school for doing well academically—

I was always teased in school and sometimes they used to call me stupid. And they used to, like, make fun of me. And I used to do well at school used to get trophies and gifts and stuff, but they used to be a bit jealous. So yes, that’s their way of getting back to me, teasing me all the time.

Sibusiso described the police brutality he experienced for not being able to afford clean clothes. He recalled, “…there have been times when I… when I’d been beat up by police, beat up by security. Uh… a lot of securities… they beat me up and people [in the community] too…” Another participant, Mpendulo, was forced to receive treatment. He reported that, when he was an adult, he was taken to a traditional healer against his will by his family for experiencing mental health symptoms. He was restrained to cure a mental illness that, at the time, he did not perceive himself to have.

[My family] said we should get inside the car, and I got in the car. And it was obvious we were headed somewhere. We went—I didn’t know where we were going. My wife was not being told anything, nothing was said. And we parked at some traditional healer. I was taken and put on chains until my tummy would swell.

Experience of psychosis and receiving the diagnosis of schizophrenia

Some participants discussed that the experience of psychosis itself—the symptoms and being treated for them—was traumatizing to them. Perceptual disturbances, or hallucinations, and delusions were highlighted as traumatic experiences for these participants. A participant with an olfactory hallucination of his body odour described the following:

It’s the odour. It’s just a smell from my body. I bathe, brush my teeth, but I just have a smell. I am just aware of it. It’s just the same smell that bothers me because I seem as if I’m not like other people. I think people will see me as someone who doesn’t love myself if I’m going to come up smelling…

Thando

Bheki identified that his most traumatic experience was receiving the diagnosis of schizophrenia from his mental health provider. He recalled the reaction he had when he first heard about the diagnosis he was given:

I never thought I [would] ever be diagnosed with such an illness. I never thought [that], actually, I [would] ever take treatment for my brain. Yeah, so, I always think, “what did I do?” and so, that’s a traumatic problem for me… “what happened?”, “where did I fall off?”, “what went wrong?”

Post-traumatic experiences

Participants also described mental health symptoms that were characteristic of post-traumatic stress symptoms based on the criteria set forth by the Diagnostic and Statistical Manual [20]. These symptoms included flashbacks of trauma memories and avoiding thoughts about the traumatic experience or event [26]. Psychological distress and negative moods often followed flashbacks for Londi. She described how the heightened level of fear due to her trauma remained long into her adulthood, impacting her day-to-day life.

It’s like something that plays on television but it’s in your mind. You have those flashbacks when you were a kid being hit by… hit by your grandmother. Getting beaten. You have those memories, and also that the memory that your mother died. All these things come back together and cause my mood to be… to be bad… At some point, when I’m in a… when I’m in panic attacks, it comes back. But sometimes it’s those traumatic experiences… when they come back, they overwhelm me… And these memories come back and haunt me… You know when I think about it… it’s causing me a memory of hate.

Londi

Participants also shared that they engaged in maladaptive (e.g., substance use, withdrawal) and adaptive (e.g., physical activity) coping strategies to help them avoid thinking about their traumatic life events.

I just don’t want to go anywhere because I’m afraid. You know, it feels like I can stay alone, do a lot of things alone, and social withdrawal and stuff… I would just become numb and I feel like going away and hidin’… I feel like going away when I experience a lot of shouting… Like, I’m always working out gym-ing. I’m always busy, so when I’m busy, I don’t get time to think about this, and when I come back from the gym I’m always tired I don’t have time to think about this. But when I stop gym-ing and stop doing these activities, you know, I stay alone a lot. And these memories come back and haunt me.

Londi

Shane’s experience of childhood abuse led him to turn to substance use as a means of escaping distressing emotions.

All I know [is that] I cried, and in my mind, I just said, “I hate this man” and, like, “why am I suffering?” and stuff. In the long run, when it came to high school, I realise that there are things I could do to escape. Like, for example, alcohol and drugs and stuff, so that’s when I started indulging in those things.

Shane

Cognitive impairment was another mental health symptom reported by participants. Sizwe, who was repeatedly exposed to domestic violence through witnessing her sister getting assaulted by her husband, reported how intrusive memories of the trauma impacted his learning at school. He recalled, “at school I couldn’t concentrate because I heard her voice because I’d wake up in the night and she’s calling me painfully. Because from her voice you could tell she needed help.” Another participant, Nolwazi, was abandoned by a boyfriend when she fell pregnant and later discovered he had infected her with HIV. She could only give vague and general descriptions of the event that occurred 17 years earlier, unable to provide details as she had forgotten what happened.

Making sense of the traumatic experiences

Two themes emerged that described how participants made sense of their past traumatic experiences. Participants described loss, post-traumatic stress symptoms, and the inter-relatedness of their experience of psychosis and trauma.

Loss

The two main experiences of loss reported by participants were, 1) the loss of a sense of self or self-identity, and 2) the loss of a position in society or social identity. These losses were felt as a consequence of both the trauma experiences and having a diagnosis of a psychotic disorder. For participants who reported that their first psychotic episode or receiving the diagnosis was traumatic, recounted how their condition significantly impacted their sense of self. Some described it as losing touch with their inner self, or their identity, and they no longer knew who they were and did not feel in control of their behaviour. Participants described a loss associated with who they thought they could be in the future.

Yeah, so, [being diagnosed with schizophrenia] has been the worst part for me… and for the world to know that I will never be myself again. I mean, like, I’ll never be able to not take treatment because I’m going to live on this treatment for… I’ll be taking the treatment for as long as I live. That’s the traumatic part… the fact that I’m diagnosed with schizophrenia. I’m not like somebody who’s not.

Bheki

For Zara, her mental illness negatively impacted her self-perception and her belief about the world around her. It was challenging for her to have lost a sense of control in her life due to her psychosis and the trauma she experienced from it.

The difficult thing I found to deal with is waking up every morning and not knowing how I’m going to behave towards the next person. It has totally changed the way I think and feel about the people around me and about society and about nature and about myself. It’s totally taking over my mind that it becomes a whole negative impact.

Zara

Participants also described the loss of their identity within a community due to past personal traumatic experiences. This was the case for Sane, a 35 year-old female who had been sexually abused by her uncle. She described that the experience of losing her virginity due to sexual abuse meant losing her position within her social context, which resulted in being excluded from ceremonies like “The Reed Dance” [27], a community-wide rite of passage event that publicly celebrates and honours virgins.

…there was that “why did it happen to me?” You see, wishing that I was also normal like other kids… and I didn’t have that experience. Because another thing that was painful was when people entered the reed dance… and as a child, I couldn’t go to the reed dance because I didn’t know where my virginity had gone.

Sane

Sexual trauma also led to feelings of undue self-blame and loss of power and freedom to choose one’s identity. One participant described that their experience of being molested at a young age led to unresolved internal conflict of their sexual orientation.

I was very angry at myself. Because I said, “how could this happen to me?”… Now, years after the event, I still feel traumatized. I still feel my dignity got lost. It caused a tension, like [having a sexual identity, or sexual thoughts, is] a wrong, wrong thing. It opened a wrong door, thinking that it’s right for me… to, to fantasize about myself with another man.

Luke

Interconnectedness of psychosis and trauma

Some participants shared insights into how their childhood trauma experiences manifested as psychotic symptoms, either around the time of abuse or later in life. Bheki had a history of severe childhood physical abuse. As a child, he would engage in repetitive play, mimicking the abuse he received—a common clinical expression of re-experiencing trauma among young children [20]. He conceptualized that this childhood play behaviour was related to his trauma and also considered it a symptom of psychosis. Bheki also shared his discomfort around the diagnosis of schizophrenia, which has led him to minimally report his symptoms and behaviours to his provider.

I do remember when I was young, uhm, my mum used to hit us. My dad used to abuse us. So, I think maybe that’s where the whole thing started because that’s why I used to hit sticks you know. Like, I used to play with sticks alone. Like, I would take sticks and play with them, like, hit sticks. I would hit sticks as if, like… as if I was a crazy person. But I’ve never spoken to anybody about this. I think about it sometimes but then I don’t. Nobody knows. Even the doctors don’t know that. Because the way I look at schizophrenia, there are some things [that] can be considered as reasons why I was diagnosed, you see. But I don’t talk about it because every time I talk about it, it’ll come to be as if this person was supposed to be diagnosed with schizophrenia. But I don’t feel comfortable with being diagnosed with schizophrenia.

Londi also recalled that growing up in an environment where she remained constantly guarded against physical abuse made it more likely for her to experience paranoid delusions.

In the beginning of my sickness, I thought everybody was out to harm me, you know? So, getting beaten psychologically made me feel like most people want to harm me… when my sickness began, I felt, like, “oh, everybody is out to harm me. Somebody is going to cause me to suffer.” Only to find out that the people are not going to harm me. It’s all in my head.

For others, their experiences of past trauma and related memories were more pronounced in their psychotic symptoms. In other words, the content of the psychotic symptoms were directly related to the traumatic event they experienced, Zara, for example, spoke about her constant paranoid delusions of reference—thoughts she described to have started when she was the target of bullying in school which she iterated, “it was the teasing, and sometimes they used to call me stupid. And they used to, like, make fun of me.” Her past trauma memories of being excluded and feeling judged by her peers was described as a form of intrusive thoughts that were also not reality-based. “The day-to-day becomes weird, it becomes something weird to me. Certain times, I feel as though everyone around me has something to say all the time. They’re going to judge [me].” Simangele, a 30-year-old male was also a victim of bullying at school as a child. He was frequently targeted and ridiculed by his peers. He recalled, “they’re picking on me and I tell them I don’t like it… [but I] get laughed at by everyone… and in a painful way, not laughing normally, the loud laugh and they even come up to [my] face laughing.” This memory left a lasting impact on him and as he later began experiencing psychotic symptoms, he reported hearing sounds reminiscent of the laughter of those childhood peers who tormented him. “It began when I was still young. It still happens even now, when I am about to fall asleep, I would hear noisy things as if it’s a lot of people screaming and laughing ‘Ye-e-e-a-a-h-h’ and drum like things ‘dudududu’.”

Some participants reported the overlapping experience of psychosis and trauma symptoms. As Neli, who was sexually abused multiple times in her adolescence, perceived her stress symptoms to be part of her psychotic symptoms. She described, what appeared to be a panic attack, it felt like shadows around her were “holding” her breath.

I used to see shadows coming towards me, as if they’re going to press against me, wanting to kill me… yes, I felt like I was being pressed, as if I’m going to die. It was hard to breathe, it was hard to breathe.

Sane, who was also sexually abused by a relative, fell pregnant from an older boyfriend and had a miscarriage at the age of 14 years.

There’s just a voice that says she won’t complete school. There is a voice that just keeps saying inside my ears, that this one is going to get pregnant. And I keep praying for her over and over. And her father and grandmother become angry when I pray for her and told not to pray for her because the thing keeps telling me to pray for her. And hold her here, in the stomach because she’s had a problem; there’s my sister’s child that came for a visit and stayed there at my house… He tried to sleep with her. I caught him, and he tried again.

Sane’s auditory hallucinations, hypervigilance, and stereotypic psychotic behaviour she exhibited, resulting to her hospital admission, were related to her and her daughter’s past trauma experiences of sexual assault.