The International Journal of Psychosocial Rehabilitation

Substance Abuse Among Sesotho Speakers

Mosotho, Lehlohonolo. Ph.D.
Department of Psychiatry
University of the Free State, Bloemfontein, South Africa

Louw, D. A. P.   Ph.D.
Department of Psychology
University of the Free State, Bloemfontein, South Africa
Calitz, F.J.W. Ph.D.
University of the Free State, Bloemfontein, South Africa


Mosotho L, Louw AP, & Calitz FJW (2010). Substance abuse among Sesotho speakers.
International Journal of Psychosocial Rehabilitation. Vol 14(2) 67-81  


This study was supported by National Research Foundation (NRF)-South Africa.

Correspondence: Dr. L. Mosotho, University of the Free State, Department of Psychiatry, P.O. Box 339, Bloemfontein, 9300, South Africa.


Substance abuse is one of the biggest challenges facing South Africa today.  Social deviances such as poverty, crime and other social disintegrations are consequences of a high prevalence of substance abuse.  This research investigates clinical manifestations of substance abuse among Sesotho speakers.  A sample 106 participants diagnosed with substance abuse was evaluated using the Psychiatric Interview Questionnaire.  Alcohol is found to be the most widely abused substance, followed by nicotine and cannabis.  The participants presented with a wide range of cognitive, affective and hypothalamic symptoms.

Key words: Culture, substance abuse, mental health, clinical manifestations 

Substance abuse is defined as the abuse of alcohol and drugs which may be culturally determined, and it varies between socio-cultural groups (Abbott & Chase, 2008). Substance abuse is a major cause of social deviances such as crime, domestic violence, poverty, decreased productivity, family and marital disintegration, exacerbation of chronic and fatal diseases (e.g. HIV-Aids, tuberculosis, diabetes and cancer) in South Africa, according to the South African National Drug Master Plan (1999). Kraus et al. (2009) describe high levels of alcohol intake as one of the main sources of social harms and problems. The situation is aggravated by the fact that most parents do not feel free to discuss drug-related issues with their children. Substance abuse is therefore, to a large extent, a concealed psychological disorder. Excessive use of alcohol is likely to lead into risky behaviour such as practising unprotected sex which may expose individuals to the risk of contracting deadly diseases such as HIV-AIDS (Morojele, et al., 2005).
Just like in most, if not all other countries, alcohol is the most commonly abused substance in South Africa. It adversely affects millions of South Africans, many of them being innocent victims. However, South African socio-economic and political changes have made the country attractive to investors and foreign trade; for this reason, the region has been turned into a world drug centre, luring international crime syndicates. Also because of its climate and many isolated geographical areas, South Africa is one of the biggest producers of cannabis in the world.  It is thus understandable why South Africa has become a regional and international hub for trafficking various types of narcotic drugs. Another common but often neglected form of substance abuse in South Africa involves over-the-counter and prescription medication, which is highly prevalent (Myers et al., 2003).
Nevertheless, most research on substance abuse in South Africa has been in urban areas, leaving certain rural areas and cultural groups in particular, neglected.
The aim of this study was to find out how substance abuse-related disorders are clinically manifested among Sesotho speakers in Mangaung – Bloemfontein, South Africa.
Brady and Randall (1999) report that although the occurrence of substance abuse and dependence is more common among men than women, the prevalence rates show that a diagnosis of substance abuse is not gender specific. The literature has shown that substance abuse among men and women is not clearly specific as far as differences are concerned.  Men usually begin to abuse substances earlier than women do.  In the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR, 2000) and ICD- 10 (WHO, 1992) the epidemiology of specific substance abuse disorders is not clearly detailed.
Parry (1998) rightly points out that there are no reliable systems that can facilitate the thorough collection of data on substance abuse in South Africa. The available information is usually obtained from research conducted in an isolated location and from information gathered through police arrests and seizures. However, at the same time it is generally noted that substance abuse is rapidly permeating the poorer sectors of South African society (Morojele, 2000). Despite this precarious situation, Flisher and Stein (2000) report that most South African mental health professional societies do not address substance abuse as a priority issue. This point of view comes after they have observed and reviewed the conferences organized and conducted by professional societies such as the South African Society of Psychiatry, the Psychological Society of South Africa, the Epidemiological Society of Southern Africa, and the South African Association of Child and Adolescent Psychiatry and Allied Disciplines. This does not imply, however, that valuable research on substance abuse in South Africa has not been conducted. For example, Peltzer et al. (2002) state that it is difficult to estimate accurately the prevalence of substance abuse in South Africa.  This may be due to, according to the present authors, the social and geographical complexity of South Africa. It was found that the prevalence of substance abuse, especially alcohol (22,2%), tobacco (12,0%), cannabis (6,6%), opiate type drugs (6,9%) and inhalants among university students in Limpopo Province, was very similar to those found in Kenya, East Africa. The results showed that alcohol, followed by nicotine and marijuana was the most commonly abused substance.
In the Western Cape, research was conducted to investigate the incidence of alcohol intake among pregnant women attending antenatal clinics in various health establishments.  Croxford and Viljoen (1999) reported a disturbingly high rate (42,8%) of alcohol ingestion among pregnant women. About 46,0% of the participants admitted smoking, whilst combined abuse of alcohol and nicotine was 29,6%.  Still in the Western Cape, Peden and Bautz (2000) investigated the link between substance abuse and physical trauma in Cape Town.  It was found that about 60,0% of patients reporting with injuries tested positive for the presence of alcohol.  The injuries were inflicted through traffic accidents, interpersonal violence and self-inflicted injuries. Van der Spuy (2000) goes further arguing that substance abuse, in general, is one of the major causes of high rate of trauma in that 7,0% of the drivers with higher blood alcohol concentration are responsible for 29,0% of non-fatal and 47,0% of fatal driver injuries.  Intoxicated pedestrians also account for 40,0% of the national traffic death toll in South Africa. Cannabis and Mandrax accounted for 41,8% of injured patients. 
Attempting to shed light on over-the-counter and prescription medicine abuse, Myers et al. (2003) argue that over-the-counter and prescription medicine abuse should be considered a major social and health risk and burden.  It was found that benzodiazepines and analgesics are the most commonly abused drugs in Cape Town.  Women were more prone to abuse these drugs than men.
The Province of KwaZulu-Natal is no exception as far as substance abuse is concerned.  Taylor et al. (2003) studied the prevalence and associated factors of substance abuse among rural pupils in this province.  It was found that there was high rate of substance abuse among these learners. Alcohol (52,9%) was the main substance of abuse, followed by cannabis (16,9%), while 13,0% admitted to smoking more than one cigarette per day. Furthermore, Brook et al. (2006) considered personal attributes and peer substance use as the main driver of the highest percentage of the variables in the abuse of substance among young people. It seems that even health professionals are not immune to the dangers of substance abuse.  Marais et al. (2002) investigated the prevalence of alcohol abuse among medical students at the University of the Free State.  It was found that 28,3% of medical students at sixth-year level abused alcohol excessively. Bateman (2004) reviewed research projects on substance abuse among medical practitioners in South Africa. However, the studies only focused on medical professionals who suffered from substance dependency and were therefore a highly selected group. The research, nonetheless, confirms that a significant percentage of medical professionals develop substance dependency during their training years.
It is clear that alcohol is the most commonly abused substance in South Africa. Next to the already mentioned consequences of substance abuse (accidents, aggressive behaviour, etc,) the correlation between substance abuse and the development of mental disorders and violent behaviour should not be underestimated. For example, there are ongoing debates on the link between substance abuse and psychosis. The fundamental question is what precipitates what? Brink et al. (2003), upon investigating the impact of substance abuse on psychosis, reported that such abuse has a significant effect on the onset of Psychotic behaviour among patients in the Western Cape.  The finding was that a significant percentage (27%) had used or abused substances more than once a week in the three months prior to their becoming psychotic.  The conclusion was that substance abuse is very common among Psychiatric patients.
In a review article, Padayachee and Singh (2003) link intimate violent behaviour with substance abuse.  The argument is that substances, especially alcohol, play a role in the incidence of domestic violence.  However, people’s response to substance abuse differs from culture to culture.  It is argued that violence caused by substance abuse is assimilated socially rather than caused by involuntary reactions.
Culture and substance abuse
Culture is an assimilated system of beliefs, values, rules, meanings, and practices that are transmitted from one generation to the next in patterned ways (Flaskerud, 2000).  Culture therefore expresses and reflects the manner of looking at, perceiving, and experiencing the world. Swartz (2008) emphasizes that there are discrete cultural groups globally, and the issue is about the appropriateness, correctness and accessibility of adequate mental health services in a culturally diverse society such as South Africa with officially eleven ethnic groups and languages. Against this background, it is understandable that culture plays a vital role in the development of certain attitudes and behaviours towards alcohol and other drugs (Zickler, 1999; Grob, 1992).
Heath (2001) rightly points out that it is globally recognized that various cultural and ethnic groupings use a wide variety of alcohol and drugs in many different ways. Mental health professionals are often not well equipped to work with clients from cultures different from their own (Amodeo & Jones, 1997). Mental health services providers should be able to recognize, appreciate, respect and engage cultural issues of the people they are treating (Quintero et al., 2007). Moreover, Withy et al. (2007) point out that substance treatment programmes require culturally tailored-made approaches to be effective and successful. Room et al. (1996) go further, emphasizing the urgent need for the development of a cross-culturally applicable diagnostic criteria and assessment tools that can be appropriately used in different cultures.
Though some significant changes have been observed in various cultures, nonetheless, there are still some expectations based on gender regarding drinking behaviours and drunkenness, meaning that it is somehow acceptable for males to be seen drunk (Kulis et al., 2003).The most common substances of abuse worldwide are alcohol, cannabis, cocaine, ecstasy, heroin, LSD and mandrax. Pharmacologically, alcohol is considered a depressant drug.  For many, the abuse of alcohol is a multi-factorial process related to genetic, psychological and socio-cultural forces Batel (1996). Each culture has its own unique interpretation and perception of alcohol abuse. Mental illness, guilt and tolerance thresholds are manifested differently in different cultures.
In many cultures, beverages of alcohol make up significant and valued dimensions of life (Barry III, 1982).  In the main, most literature places excessive emphasis on alcohol, albeit those other hard and harmful drugs have already penetrated many communities.
Room (2001) categorizes drinking behaviour into two dimensions: “wet” and “dry” societies.  According to the nosology in dry societies, alcohol is taken apart from everyday life as a unique valuable commodity for special occasions, hence drinking is traditionally sporadic, is often used during special days or weekends, with a high proportion of drinking involving drunkenness.  But “wet” societies use alcohol as part of everyday life, and such use usually accompanies meals.  An example of alcohol that is often used in “wet” societies is red wine which is often used during meals.
Drinking behaviour in various societies has been viewed in different ways in the world.  Alcohol is a substance with psychoactive ingredients. For that reason, access to alcohol may be restricted. On the other hand, alcohol is seen as part of nutrition rather than a drug, and therefore, access to alcohol may be relatively unrestricted (Schmidt & Room, 1999).  There are also cultural variations in the regulation of quantity, duration and behavioural dimensions of drinking and drunkenness.  People across the globe may differ significantly in the degree to which particular substance-related problems are viewed as serious issues in their communities.  Other cultural aspects of drinking include the problematization of dependence, drinking-related states and experiences, the extent to which attention is paid to the potential involvement of substance in adverse situations and the reality of culture specific presentation of alcohol disturbances that are not properly captured in either the DSM-IV-TR or the ICD-10.
The continuum between normal and abnormal (pathological) drinking was explored by Bennet and Janca (1993), who focused on how people from various cultural backgrounds distinguish between normal and abnormal drinking which might be labelled harmful, abusive, heavy, dependent and pathological consumption.  It is also mentioned that people within the same culture display different ideas and experiences regarding alcohol consumption, whether these are normal or pathological.  It was found that people (sample) from Greece and Spain agreed that normal drinking was possible and was a very important aspect of their cultures.  Arizona respondents gave mixed views concerning normal drinking and pathological drinking.  The first group of respondents argued that normal drinking was not possible, hence normal drinking equalled binge drinking, while other negligible numbers of respondents believed that normal drinking was possible because it was more apparent in other cultures than among the Navajo themselves.  In Bangalore, India, it was reported that respondents generally argued that normal drinking was not possible within their cultures.
Brannock and Schandler (1990) investigated cultural and cognitive factors among groups of black, white and Hispanic adolescent drinkers.  White respondents manifested more frequent drinking behaviour than black and Hispanic groups. However, there was a significant difference between Blacks and Hispanics as far as drinking behaviour was concerned.  Whites drank more socially, and drank in response to distress, while black respondees reported less drinking among friends and peers.
In Dallas, Houston and San Antonio, a comparative study on the link between aggressive criminal activities and substance abuse among Mexican American, black and white arrestees was carried out.  The purpose was to predict the outcome of aggressive crime on the basis of substance abuse (both hard drugs and alcohol) and cultural group variables within the total male sample of 2,364 (Valdez et al., 1997).  It was found that Mexican Americans were more likely to be arrested for aggressive crimes than either African Americans or European Americans.  However, effects of both illicit drugs and alcohol were found to be similar for all ethnic groups.  This means that although hard drug abuse and aggressive behaviours receive most of the attention across the globe, alcohol itself is still the prominent substance responsible for violent behaviours across the range of ethnic groups consisting of Hispanics, Blacks and Whites.  Alcohol is evidently linked to domestic violence, especially among middle class men.
In Singapore, in the Far East, Hong & Isralowitz (1989) conducted a cross-cultural study on alcohol consumption behaviour among Singapore college students. The assumption was that Singapore Indian college students would display higher rates of drinking problem behaviour than Chinese students.  The findings were that about 70,0% of Chinese participants mentioned that they consumed alcohol in comparison to 63,0% of the Indian respondents who used the substance.  Regarding gender, 80,0% of Chinese males and 60,0% of females used alcohol.  Making a comparison, it can be stated that a slightly lower percentage of alcohol users were found in the Indian sample.  Chinese students liked beer while Indians preferred red wine.  There were differences in the effects of substance abuse among Chinese and Indian respondents in terms of having a hangover, vomiting because of drinking, driving a car under the influence of alcohol, social and occupational impairment such as missing a class because of the after effects, and causing disharmony in interpersonal relationship.  Indians displayed a tendency of more problematic behaviour than the Chinese sample.
Testing the cross-cultural applicability of Jellinek’s Progression Technique in a sample of Navajo men and women, Venner and Miller (2001) found the following as far as the progression of alcohol problems was concerned:  that in general, Navajo respondees tasted alcohol for the first time around age 16; violation of legal, social norms and rules took place in the early twenties, and the first experience of blackout occurred in the mid-twenties.  Many happenings centred around 28 years of age, events that were related to social and interpersonal relationships, while they carried on with their drinking habits despite problems.  First hospitalization, attempts to quit drinking and nutritional neglect occurred by their early thirties.  Aspects typical of dependence appeared later in the progression.  Changes in tolerance and the drinking of non-beverage alcohol such as mouthwash or hairspray were the last to be reported.  Symptomatologically, the participants (20 out of 46) experienced loss of interest in life, heavy drinking episodes lasting for at least two days.  They also reported a decrease in moral standards and vague spiritual desires, physical withdrawal symptoms such as being afraid and tremors.  Most importantly, Navajo women experienced hallucinations at the beginning of their progression.  Feeling bad about drinking, experiencing augmented tolerance and quitting for a while occurred in at least 20 ordinal positions later for the Navajo.
Once more, in the United State of America, the study was conducted among primary care patients with alcohol problems, comparing whether race made any difference between two groups of participants (African Americans and Whites) with respect to consumption, severity, consequences, readiness to change and coping behaviour.  Conigliaro et al. (2000) reported that in comparison to white patients, African-American respondents presenting with alcohol problems, and enrolled in a brief intervention programme, met all the criteria for alcohol dependence or drug dependence, but displayed the same levels of alcohol consumption compared to white patients.  There was a marked increase in drug dependence among African Americans compared to Whites who met criteria for drug dependence (43,0% versus 35,0%).  Again, it was discovered that alcohol and drug abuse were more serious among African Americans than Whites.  However, there was no difference in alcohol consumption rate between the two groups. African-American patients reported more symptoms of dependence and less consumption than white patients.  In relation to readiness to change, both groups were equally ready to change their drinking behaviour, but African Americans were more highly concerned about the consequences of alcohol on their health and life in general.
A similar study was also conducted in the USA focusing on the prevalence, incidence and stability of dependence-related problems and social consequences among Whites, Blacks and Hispanics: 1984 – 1992 (Caetano, 1997).  The findings were that Hispanic men displayed a higher incidence of frequent heavy drinking, much more than other ethnic groups and women.  Again the higher incidence and stability of dependence problems were found to be more prevalent among Hispanic men than Blacks and Whites.  Stability referred to an indicator of chronicity, while the incidence denoted the proportion of people who did not report a disturbance in 1984, but did so in 1992. The dependence-related disturbances are:  salience of drink-seeking behaviour, loss of control, withdrawal and tolerance symptoms as well as relief drinking.  In general, the results showed that Blacks displayed a higher incidence of both dependence-related and social consequences, as well as more marked stability of social consequences compared with whites.  Social consequences refer to financial difficulties, social and legal problems, health-related issues, marital dysfunction, as well as social and occupational impairment.
In California, the sub-tribes of Chumash Indians use Datura, which is a hallucinogenic substance (Grobstein & Rios, 1992).  This decoction is used in pubertal custom to celebrate the passage of the youth into adulthood.  The potion consists of the leaves, roots and stems, which are soaked in water. 
There have been several reports on wide varieties of illicit drugs such s cannabis, cocaine, Lsd, ecstasy, mandrax and heroin in South Africa. There is a new home-made drug called methcathinone popularly known as “cat”, which is a cocktail of methamphetamine mixed with other substances (Lillah, 2003). This drug is secretly prepared in the kitchen by anyone with a recipe and sold exclusively in a white powder form. It can be diluted in liquids or mixed with other substances in capsule form in order to be injected intravenously. The most dangerous part of this drug is that it is deadly addictive. Common symptoms include increased energy, euphoria, flight of the mind, feelings of invincibility. The side effects are reported to be terrible and include, tremors, insomnia, somatic symptoms, dehydration, sweating, nasal disturbances, anxiety, rapid heart rate, and loss of weight; at worst, the addicted person may present with paranoia, convulsions and various forms of hallucinations.
It was against this background that it was decided to study how substance abuse-related disorders are clinically manifested among Sesotho speakers in Mangaung, South Africa. 
The Mangaung Township in Bloemfontein, South Africa, was selected as the geographical area for the completion of the research.  For this exploratory descriptive study, the participants consisted of 106 Sesotho speakers diagnosed with substance abuse.  They were drawn from the population of patients visiting various health establishments in the area.  All patients presenting to a specific health facility who qualified, during the period when the researchers were based at the facility, were included. The time periods varied from one month to two years.  The participants were evaluated and diagnosed by a multi-professional team which typically consisted of a psychiatry doctor (registrar), clinical psychologist and a psychiatric nurse (in certain areas, social workers, occupational therapists and/or physiotherapists also formed part of the team).  The DSM-IV-TR criteria for substance abuse were used as the inclusion criteria.  The participants were between 18 and 65 years of age, and both genders were represented.  Written informed consent was obtained from each participant.
A semi-structured interview, based on the Psychiatric Interview Questionnaire (PIQ) used by the Department of Psychiatry at the University of the Free State, was used to elicit the information (Mosotho et al., 2008).  The PIQ is based on the Clinician’s Thesaurus: The Guidebook for Writing Psychological Reports (Zuckerman, 2000) and Outline of the Psychiatric History and Mental Status Examination (MacKinnon and Yudofsky, 1986).  The PIQ provides data on preliminary identification (including demographic information), main complaints, personal description, history of present illness, psychiatric review of systems, previous mental illness, past personal history, a mental-status examination consisting of:  appearance, attitude and behaviour, thought processes, perception, mood and affect, consciousness, orientation, memory, tempo, intelligence, mode of thinking, judgment and insight, as well as hypothalamic and autonomic functioning (Mosotho et al., 2008).
Qualitative methods were used to describe the experiences of the participants regarding their symptoms, as well as a way to elucidate the quantitative data.  Qualitative methods that were used consisted of two types of data collection:  the open-ended interview and clinical observation.  The interview data consist of direct quotations from participants about their experiences, feelings, emotions, opinions and knowledge, while observation data refer to detailed description of participants’ activities, behaviours, actions and full range of interpersonal interactions and organizational processes that are part of observable human experience (Patton, 1990).  Individual interviews were transcribed, and information gathered was grouped into themes.  Themes are written in the subject’s own words or transcribed as closely as possible (or a close rendition of the subject’s account).  These themes were divided into psychological symptoms, physical (somatic) symptoms, as well as behavioural and social symptoms.  Quantitatively, a descriptive statistical analysis was performed to provide indications of frequency (incidence) of identifying demographic characteristics, signs and symptoms of mental illness, and socio-cultural variables associated with substance abuse that are covered in the questionnaire.
The study was approved by the ethics committee and the council of the University of the Free State. The pilot study was conducted on 40 patients to investigate the practical feasibility of the research.  Based on the pilot study findings, minor adjustments on coding of the questionnaire were made.
Results and Discussion  
About 54,0% of the participants were aged between 18 and 35 years. The elderly (aged between 46 and 65) were most affected by substance abuse disorders.  This finding confirms what was reported by Widlitz and Marin (2002) that elderly people are also prone to develop substance addiction and dependence. However, this issue is more likely to be overlooked and ignored by health professionals. The fact remains; nonetheless, that substance abuse is common in the general population and encompasses people of all ages and all socio-economic levels (Weaver et al., 1999).  As far as gender is concerned, it was found that about 70,0% of the participants were males.  This corresponds well with international literature and research findings that substance abuse is usually higher among males than females (Kulis et al., 2003).
As far as education is concerned, it was found that relatively few participants had passed grade 12. These low educational levels are understandable. It could also be that substance abuse negatively affects an individual’s social and mental functioning.    Almost 60,0% of the subjects were single. A possible explanation could lie in the fact that most South African youth do not marry before the age of 30. Also, the fact that so many of the participants were unemployed and could therefore not provide the necessary financial security to their families, probably also played a role.  It is disturbing that a significant percentage of participants who were diagnosed with serious substance abuse disorders were students.  This result supports the findings by Marais et al. (2002) who reported a prevalence rate of more than 25,0% of alcohol abuse among medical students in the Mangaung area. The dominance of Christianity among the participants corresponds well with the distribution of religions in South Africa. Another significant finding was that more than 40,0% of the participants were involved in criminal activities.  This is in agreement with what was reported by Padayachee and Singh (2003) and Heffernan et al. (2003) who also found a relatively high incidence of various crimes among substance abusers.
Alcohol was found to be the main substance abused by the participants, followed by nicotine and cannabis respectively. About 40,0% of the participants abused more than one substance. The higher prevalence of alcohol, nicotine and cannabis relative to other hard drugs such as heroin, cocaine, crack and the like, might be attributed to accessibility and affordability of the afore-mentioned drugs in the community. Taylor et al. (2003) found a similar trend in KwaZulu-Natal Province and the Eastern coastal region of South Africa. However, this finding is in contrast with other regions and cultural groups in South Africa. Nearly 90,0% of the participants did have some form of social support system. This is in accordance with findings by other researchers that the social support system of individuals suffering from mental disorders is adequate in the developing world, leading to a better prognosis and course than is the case in developed nations (Dani & Thienshaus, 1996; Sartorius et al., 1980; Jablensky et al., 1992).
The findings concerning the primary symptoms are presented in Table 1. As it was impossible to determine the cause, it should be noted, however, that the reported symptoms could not necessarily be linked unequivocally to substance abuse, because they could have been symptomatic of another underlying mental disorder.  The inclusion criteria for classifying symptoms as primary revealed a prevalence rate of at least 20,0%. Only dividing symptoms into somatic and psychological categories would have been regarded as overlapping and superficial.  However, for practical and discussion purposes, it was decided to make the distinction between primary symptoms (20,0% and more) and secondary symptoms (less than 20,0% but more than 5,0%).The frequencies are the sum total of the symptoms reported by the participants as well as those observed by the researcher.
Table 1:  Primary Substance Abuse Symptoms expressed by Sesotho speakers 
Psychological Symptoms
Aggression                                             32,1                                                         Auditory hallucinations        73,1
Disorientation                                      23,0                                                         Visual hallucinations             55,0
Poor concentration                                77,1                                                         Hallucinosis                           27,2
Irrelevant answers                                  25,5                                                         Illusions                                 23,0
Derailment                                             24,5                                                         Inappropriate affect               27,4
Suicide ideation                                      20,0                                                         Restricted affect                    23,6
Delusions of persecution                      36,8                                                         Irritability                               50,0
Delusion of grandeur                            20,8                                                         Anxiety                                   35,0
Memory impairment                             53,0                                                         Agitation                                40,6
Poor insight                                           58,0                                                         Poor judgment                      53,0
Concrete Mode of thinking                  67,0                                                         Insomnia                               71,0
Overeating                                              21,0                                                         Poor libido                             51,0
Somatic Symptoms
Constipation                                          43,4                                                         Palpitations                            43,0
Headaches                                              50,0                                                         Excessive sweating                59,0
Dizziness                                               52,0                                                         Anxiousness                          60,4
 Table 1 shows that there was significant comorbidity and over-lapping of symptoms such as impaired concentration, poor memory, auditory and visual hallucinations, irritability, insomnia and decreased libido. These symptoms were also found in other mental disorders, especially schizophrenia and major depressive disorders among Sesotho speakers (Mosotho, et al, 2008). However, it was found that the contents of hallucinations in the participants were not clearly defined as it was the case among patients suffering from depression, anxiety and schizophrenia.
Because substance abuse and especially alcohol abuse could lead to various physical conditions, a marked deterioration in general health, malnutrition, poor personal self-care and hygiene were also observed. It was therefore somewhat surprising that participants expressed more and a wider variety of psychological than physical symptoms. Cognition was affected more severely than mood, affect and behaviour. Behavioural and social deviations such as violent and aggressive acts, violation of social and legal norms seemed to have been more frequent when a combination of substances was abused. These seemed to be alcohol and cannabis in particular. A significant number of the participants also expressed difficulties with absenteeism at work, decreased productivity, poor labour discipline as well as general impairment in social, academic, occupational and mental functioning. Moreover, they also experienced financial difficulties, consequently neglecting their family and social responsibilities.
Next to the primary symptoms, there were also secondary symptoms which could not be ignored.  The symptoms were classified as secondary as they contributed less than 20,0%, but more than 5,0%.  These symptoms varied markedly in terms of diversity and severity. Those secondary symptoms are shown in Table 2.
Table 2: Secondary symptoms of substance abuse expressed by Sesotho speakers
Tangentiality                                                                                                          Delusions of reference
Loosening of associations                                                                                    Bizarre delusions
Derailment                                                                                                             Olfactory hallucinations
Flight of ideas                                                                                                        Gustatory hallucinations
Pressure of speech                                                                                 Somatic hallucination
Poverty of speech                                                                                                   Depersonalization
Blunted affect                                                                                                         Labile affect
Walking around naked                                                                                          Dysphoric mood
Expansive mood                                                                                                   Mood swings
Elevated mood                                                                                                      Euphoria
Depression                                                                                                             Anhedonia
Alexithymia                                                                                                            Panic
Apathy                                                                                                                    Shame
Guilt feelings                                                                                                         Fainting
Acting out                                                                                                              Nerves
Bad smell                                                                                                               Boiling brain
Hot head                                                                                                     Fear
Poor personal hygiene                                                                                           Red eyes
Stress                                                                                                                      Deterioration
Poor academic performance                                                                  Loss of control
Numbness                                                                                                             Talking with heart
Decreased productivity                                                                                          Poor motivation
Lack of willpower                                                                                                  Walking around aimlessly
Family negligence                                                                                                   Itching sensations
Weakness                                                                                                               Visual disturbances
Stiffness of the neck                                                                                              Social withdrawal
Loss of weight                                                                                                       Running away from home
Short tempered                                                                                                      Intoxicated
Talkative                                                                                                                 Feeling dull
Crying                                                                                                                     Vomiting
Stealing behaviour                                                                                                 Secretive

The variety of secondary symptoms is conspicuous. However, this finding is in line with other researchers who also reported a wide range of symptoms in substances abusers (Brink et al., 2003).
The duration of the primary and secondary symptoms of substance abuse among the participants is shown in Figure 1.

Figure 1: Duration of symptoms in substance abusers

It is clear that the majority of participants experienced the symptoms for significant periods of time. In more than 60,0% of the samples, the symptoms have persisted between two and three years. This finding is disturbing because substance abuse negatively affects basically all spheres of human functioning, these being the psychological, mental, physical and social domains (see Tables 1 and 2).
As far as treatment is concerned, a relatively high percentage (66,5%) of the participants simultaneously consulted both Western-trained mental health professionals and traditional/spiritual healers for their ailments. Although it was found that in the majority of cases the Western model of treatment was the first choice, the finding confirms the significant role played by traditional medicine in South Africa (Mkhize, 2003).
 The general consensus is that substance abuse is one of the major social and health problems, not only in South Africa, but throughout the world. It was found in the present study that alcohol was the most commonly abused substance in Mangaung, followed by nicotine and cannabis respectively. This finding was in contrast with other results in South Africa where the prevalence of hard drugs such as heroin, cocaine, ecstasy and mandrax was much higher among their research participants. Sesotho speakers expressed a wide range of symptoms. The finding that the participants had suffered for a relatively extended time from the symptoms was worrying. Regarding treatment, the important role of traditional healers and medicine in the Mangaung area was confirmed.
Although the present study has revealed significant findings, these results should, however, be interpreted with caution. Firstly, the participants were almost exclusively from one area of the Free State Province, while Sesotho speakers are widely dispersed throughout the province, other parts of South Africa and Lesotho. The generalization of the results should therefore be interpreted cautiously. Another factor to be taken into consideration is that within the Sesotho-speaking population there are many sub-cultural differences. The point is that different groups of Sesotho speakers within the same geographical areas may differ significantly. Additionally, it should be taken into account that the data gathering to a large extent relied on self-report which, as is generally accepted, often does not capture the real situation. This is especially true in the case of substance abuse which in many cases is a criminal offence in South Africa. Nevertheless, the study remains significant because it does contribute to important data in a field that has been largely neglected in South Africa.
Dealing with the substance abuse problem among Sesotho speakers will not be easy. Next to fighting the abuse of alcohol, as in most cultures, the high incidence of cannabis is an additional aggravating and complex factor. The use of cannabis by black South Africans, and therefore also Sesotho speakers, has been part of cultural practices for centuries (like for example, wine drinking among Whites in especially the Western Cape). It is also used in certain cultural rituals, while there is a strong belief in the healing power of the drug. The cultural prescriptions regulating the use of cannabis no longer serve to protect people as it did historically. The fact that cannabis is also cheaper than both alcohol and nicotine adds to the dim picture.
Special programmes that take the unique cultural value systems into consideration should therefore be developed. However, such programmes can only succeed if they are based on thorough empirical research concerning specific targeted groups. Such research is therefore strongly recommended.


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