Efectos de la diversidad familiar

Poverty is not just about material deprivation, but about relative deprivation as well. It is about shame and self-derogation and exclusion.

(Prilleltensky. Introduction. In L. Smith, 2010).

Endemic and widespread poverty continues to disfigure the face of our country. It will always be impossible for us to say that we have fully restored the dignity of all our people as long as this situation persists. For this reason the struggle to eradicate poverty has been and will continue to be a cornerstone of the national effort to build the new South Africa.

(Mbeki, 2004)

While the issue of poverty may initially be seen to be peripheral to the participants‟ experiences of their process through the hospital system and their eventual diagnosis with a somatoform condition, it is in fact a central consideration. As I will attempt to illustrate, poverty and the sequelae were fundamental to the participants‟ self- perception, their interpersonal relationships, general levels of anxiety and the defences they used to manage these, both from a bodily and psychic perspective. The experiences of other women presenting with medically unexplained symptoms, in different socio-economic circumstances, may be different and future research would be helpful in this regard.

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By whatever standards one measures economic poverty, all the participants on the study were poor6. Before they had even arrived at the portals of medicine, the participants‟ lives had all been marked, complicated and restricted by poverty. Codicils of poverty permeated the day-to-day experiences of the participants, coloured their social interactions, their interpersonal relationships, their choices of activity, including access to employment, impacted on their levels of anxiety and affected their help-seeking mechanisms.

Of the twenty participants only five were employed and all were living in circumstances constrained by food, shelter and clothing shortage as well as criminal and drug activity which are so closely allied with economic insecurity in this and many other contexts. Income sources varied and were uncertain and precarious. Casual work could be arbitrarily terminated, grants could be discontinued and earning partners or family members might die through illness or violence or leave and abandon the family in other ways. The opportunity to obtain employment outside of the home was constrained in some cases by limited education and training, and in others to the physical availability of suitable employment. To two of the participants, the hope of work and the possibility of my intervention is what brought them to the initial appointment.

Housing amongst the participants varied from brick RDP7 houses, to so-called separate entrances to shacks made out of corrugated iron or wooden structures called Wendy Houses8; sometimes a single room housed an entire family. Often economic pressures or local crime and violence had forced the participants and their families to move frequently.

6

South Africa remains a country in transition and definitive methods of measuring and defining relative states of poverty are ongoing and challenging. The reader is referred to the article Magasela et al. (2007) The Measurement of Poverty in South Africa Project: Key issues, for a clear exploration of this process. For the purposes of this study poverty was taken to include the following core

considerations: poor educational facilities, unemployment and food and housing scarcity.

7

The Reconstruction and Development Programme (RDP) was a post-apartheid initiative the aim of which was to attempt to redress some of the socio-economic inequalities entrenched by the previous regime. In attempting to address the enormous shortfalls serious attempts have been made to provide low-cost housing to previously disadvantaged communities. The term RDP housing is ubiquitously used to describe these structures.

8_{In a largely illegal “entrepreneurial” activities, in the back yards of many residences, including the}

government-sponsored RDP houses, wooden or tin structures are erected and rented out to supplement family income.

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I routinely ask my patients what three “wishes” they would hypothetically like to realise – what three things would they most like to see materialise, issues to perhaps change or improve in their lives. The answers invariably provide insight into both priority as well as possible areas of underlying anxiety, which may not be acknowledged or elicited by more direct questioning. I introduced the same question during my interviews with the participants. To give some indication of the centrality of physical security to the mental and physical wellbeing of the individual participants I provide their answers in Table 4.1:

TABLE 4.1

The Three Wishes

Participant 1st Wish 2nd Wish 3rd Wish

Raabia To be a teacher, to

have a job that I love. To have a respectful husband. To go for Haj. Davina To go on a holiday. To go away from here.

Peace and quiet in life. To live in a nice place.

My son [addicted to methamphetamines} to be sorted out. For him to be a nice grown-up.

Gail To get married to

Melvin [her long- term partner and father of her child].

To get a place [to live] of our own.

To get a better job. A

permanent one.

Caroline To get rid of the pain – to be myself again.

To have my sons

stop whatever

they are doing [both on drugs].

For my father to be alive. I miss him a lot.

Angela To be able to

provide for my daughter – food and education.

To get a job. To move to a place of my own. Shanaaz To do my matric [school leaving certificate required for many employment opportunities]. To have a nice job to help provide for my parents. To live in a better environment.

Allison A house for me and

my family.

A work. Just to stay healthy.

Rivka To get healthy – for

the pain to go away.

For my husband to drink a bit less.

To be a stay-at-home mum.

Patricia I couldn‟t get Patricia to answer this question. She initially said that she didn‟t understand the question but later denied that she had anything to

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wish for. However, during the course of our interviews, the family‟s living conditions in a hostel built for single migrant labourers was

something that she found distressing and she expressed the desire to have a home of her own.

Nambitha To get a tertiary

education.

To get a job, a really good job.

To have a tombstone raised for my mother in the Eastern Cape.

Maryam To be financially

established.

To have a good husband.

Just for health and strength from God. Petunia To improve my education. I want to be a radiography[er]. To renovate my house.

To help children to further [tertiary] education. Lianne To accomplish my studies [complete matric]. To stay somewhere peaceful – I love the sea.

To forget about everything. The past.

Mavis My husband to stop

drinking.

To have a nice place to live, where my children will be happy and safe.

To finish my matric so that I can get training as a teacher or maybe a social worker.

Amelia To have a “normal”

life – that is happy and comfortable.

Stability – financial and personal.

Respect.

Ingrid To make a success

of my life. To accomplish my dreams and train as a nurse.

To be successful and have a happy marriage.

To be able to give my kids the things I wasn‟t able to have. To be able to pay for their further education.

Nomsa To own my own

business as a job consultant. To take my son to university and to be with him as he is growing.

To have my own car and a big house in Cape Town.

Elisha To know who my

father is. To have happiness – a happy family with more children and closeness. To do my matric – to train as a psychologist or social worker.

Kamila To own my house

where I could invite friends and have social stuff and be safe.

My partner to love and care for me.

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While I am not discounting the role of interpsychic mechanisms, when I looked at the collection of participant answers, the majority related around issues of physical survival.

11 wishes connected to the longing to have a home/living in peaceful surroundings 10 related to work and the desire to find employment and need for financial stability 10 concerned education – either self-education or to ensure children‟s education 8 connected to relationships – family wellbeing, intimate partners, support, respect 3 only related to physical health (.2) or the specific wish to be pain-free (.1)

2 included spiritual connectedness as a priority in their lives General wishes related to non-specific circumstances

As a consequence of this apparent emphasis on physical or environmental issues, in the section below I consider in detail the impact of the socio-economic circumstances on the lives and symptoms and healthcare management of the participants.