Servicios sanitarios adaptados a los jóvenes

In terms of narratives of chaos and uncertainty the impact of substance abuse and the associated chaos was felt by nearly all of the participants. Thirteen of the participants identified substance abuse (either alcohol or drugs) as having a direct and negative influence on the quality and security of their lives. Substances use and abuse has an impact on economic stability (substance abusing behaviour causes job losses or decreases the opportunity for obtaining employment), interpersonal relationships (violence and aggressions as a consequence of substance intoxication disrupts family structures) and increases exposure to crime and criminal activities (either in pursuit of obtaining drugs for personal use or as part of the drug economy). None of the participants identified themselves as substance abusers. However, thirteen had partners, parents or siblings who were using substances (marijuana, methamphetamines or alcohol) which was causing emotional and/or financial distress. Two of the participants had husbands whose heavy and regular drinking negatively impacted on the family functioning either in terms of relationships or family income and physical security.

Mavis had lost her home largely as a consequence of her husband‟s drinking. She also had to regularly intervene between her husband and her children when he became drunkenly abusive or they gave voice to their resentment about their deterioration in living conditions resulting from his alcohol abuse. While I was unable to record her first interview (her presenting symptom was one of aphonia16) I made notes of her response to my questions about her relationships with her husband. She said, “He used to be a good man, he provided for us, we had a good life, but now (.5) [didn‟t finish sentence].” His constant disparagement of her while drinking eventually caused her to stop engaging with him in anyway – she would invariably walk away when he became verbally aggressive. And at the time of her first interview with me, she literally had no voice.

16

Aphonia is the medical term for the loss of voice. Usually aphonia occurs as a consequence of an underlying organic condition such as inflammation or injury. No cause for Mavis’ aphonia was ever established.

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Rivka’s husband, who in other ways she described as “supportive and loving”, drank heavily over weekends. She was finding it increasingly difficult to negotiate her roles of mother and employee because she could not rely on her husband as a responsible caregiver for their children because of his regular weekend binge drinking, “He is just a spoiled brat, he do (.2) he do whatever he want to do. That is how his mother brought him up (.4) and I am always worried about my children and are they fine when I am away at work.”

While the situation was not current, as she was separated and in the process of divorce, Maryam described the bouts of severe physical abuse when her husband had been drunk. She reported that when he had been sober he was a kind and loving man, but the alcohol changed his personality. “He was sometimes a good, but mostly if he

drink, he, he was like he want throw me with the stuff in the house, everything that‟s heavy. He hits me, he take my head and (.4) bump it through the wall and (.3) . . .”

She never knew what the day would bring and how his mood and condition would evolve. “I never knew (.2) [looks sad and confused] nothing was good enough for him. I think he will, he just do what he want to do (.3) and I never know.” She survived twenty years of unpredictable physical and emotional abuse before divorcing him. Retrospectively she still couldn‟t understand where she had done wrong, “But I was a good woman and that cook the food, clean and everything was on its place. But nothing was good enough for him.” Living on her own at the time of our interview she expressed ambivalent feelings – of relief but also of loneliness. While we did not talk about it, as she did not attend a follow-up interview, I did wonder afterwards whether her regular visits to the hospital outpatients department in an attempt to get an explanation for her symptoms, did no fulfil a dual, but unrelated, function for her: somewhere to go, a place to speak to people (other patients as well as the staff) and perhaps also a place of safety and predictability.

Sometimes participants described domestic situations where they were forced to defend one family member against the actions of intoxicated relatives. Nambitha was only 19 when I first saw her in a clinical capacity. Her life was being impacted on not only by her own unemployment and issues about her health but a very real concern for the safety of her grandmother. Two of the grandmother‟s children (Nambitha’s aunt and uncle), a daughter abusing alcohol and a son who used tik on a daily basis,

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either stole the grandmother‟s pension money or became violent towards her. “I need to look after my grandmother, she is like my mother, they abuse her.” When Nambitha first saw me, despite no underlying organic etiology, her somatic symptoms appeared to closely mimic those of cardio-vascular disease associated with stress. Eventually in the period between the end of her therapy and the retrospective interview Nambitha negotiated alternative accommodation and found that her symptoms reoccurred only when she went home and was exposed once more to the chaos.

Allison was in a similar conundrum with her father and brother regularly becoming intoxicated with tik or alcohol and either stealing from her mother and herself or becoming violent when they were unable to do so. The widespread abuse of tik (methamphetamines) and dagga (marijuana) in the low-income areas on the Cape Flats is increasingly having a hugely destructive effect on family structures and relationships. Both drugs are widely available17 and relatively inexpensive18. This affects many families directly. Caroline and Kamila both had sons who were using drugs so regularly that they had lost jobs but who had also become abusive and violent. Kamila felt particularly vulnerable after she realised her one son was part of a notorious gang, “When I saw that tattoo I felt scared, I didn‟t feel safe anymore . . . I felt scared in the way that he would attack.” Both her sons had been physically violent, “Both my sons [attacked me]. I even went so far to make a court case against them (.3) and that. (.1) And he [the magistrate] just told me it was because of the drugs.”

While initially Caroline had refused to acknowledge or discuss her sons‟ drug abuse, she eventually returned to see me therapeutically after an absence of several months during which she described her life of constant uncertainty, “I never know what I am going to come home to. I am so frightened. They fight, the one, the younger one has threatened to petrol bomb my house if I put him out.” Descriptions of her symptoms

17

Figures supplied by South African Community Epidemiology Network on Drug Use (SACENDU) from: www.sahealthinfo.org/admodule/sacendu.htm

18

Figures given for the street value of tik and dagga were obtained from the Addictions Division of Psychiatry and Mental Health as well as the Department of Criminology who indicated that there is 100% price disparity across the various areas, e.g., a gram of tik costs R150-R160 on the Cape Flats to R300 in an affluent area in central Cape Town. Most people buy less – amounts of .15grm to .25grm that may cost between R30 to R50. Marijuana (locally called “dagga”) would cost on average R50 for a matchbox. Other common “hard” drugs (heroin and cocaine) cost R300 a gram.

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which had receded to some extent became foregrounded as her domestic situation became more chaotic.

Davina reported she was afraid of her son. He had been abusing drugs for almost eighteen years. He was unemployed and periodically aggressive, “I‟m always, I‟m always scare that he can attack me.” “Because he threatened us, gonna (.2) burn us, gonna kill us, and all that”. Her symptoms had started when she had been forced to evict him from her premises after she found she could no longer tolerate his antisocial and unhygienic behaviour.

My participants‟ descriptions of drug-fuelled violence are similar to those which I hear almost on a daily basis in my clinical work. I recall one particular encounter with a woman, a patient not a research participant, who had been forced to call the police when her son attacked her with a knife. He was consequently convicted and jailed in a notorious prison in Cape Town. What I remember so clearly was the poignancy of this mother describing, with tears rolling unchecked down her prematurely wrinkled cheeks (she was only fifty but looked at least two decades older), what a “good son” he was when he wasn‟t on drugs. However, her feelings of guilt at having her son taken to prison were overwhelming. She and many other of my patients reflect the desperate parental dilemma which was acted out in the high profile case of Cape Flats woman, Ellen Pakkies, who murdered her son to protect herself and the rest of her family from his unremitting violence19.

Another participant, Ingrid, who experienced no substance abuse issues within her own biological family, was coping with the fallout of the drug use of a couple entirely unrelated to her. A child of this couple had been virtually abandoned by his drug- abusing parents when he was two months old. Ingrid, her husband and daughters had taken the baby in and were attempting to adopt him. This had been preceded by a period when they had merely fed him and provided his basic needs, but almost surreptitiously baby Brian had become an intrinsic part of their family, “His (.4) his

parents, his biological parents are drug addicts . . . he was extremely, extremely ill as

19

The high profile court case which followed when Ellen Pakkies handed herself into the local police station after murdering her son, generated huge publicity including a highly acclaimed play and documentary. In a controversial ruling, she was sentence to 3 years imprisonment which was suspended for three years and requirement of doing 280 hours community service.

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a baby, due to his mother using drugs . . . No, it‟s [the biological mother and father] not family. And um, then his parents were put out [evicted] and they had nowhere to go . . . I used to send my daughter to fetch him everyday. So that I could bath him, feed him because she wasn‟t taking care of him. And when they had nowhere to go, they came to ask me if I could keep him there for the night until they had a place. (.2) And he‟s been in my home ever since [becomes tearful] . . . That is almost (.2) four years ago.”

This informal “taking in” of children in need is not an unusual occurrence in the areas in which I worked. Most commonly it is a member of the extended family who will incorporate an abandoned or neglected child into the nuclear or extended family. Frequently there is no formal process of adoption. However, in the case of Ingrid and her family, the lack of blood connection made the “adoption” particularly tenuous and Ingrid lived in fear that the parents would return to claim him, “We went to see a social worker and we went to court and we got him, because we didn‟t want them just to come and take him away and put him back to that.” However, at the time of the interview nothing had been achieved as the parents would not sign any papers despite having no contact with their child, “At the moment we are stuck because they have no communication with him, they are not interested in him, they walk past my house

every day!” The accumulated uncertainty of the situation with the baby, together with

the family‟s financial vulnerability as well as the fragility of her marriage, seemed to have reached a critical point six weeks prior to my interview, and simultaneous with the patient‟s attendance at the emergency room where a heart attack was disproved by the clinical examination and investigations. As a codicil, the biological mother with a subsequent premature baby were admitted to Waterstroom Hospital, to the Kangaroo Maternal Care unit, while I was still seeing Ingrid in a clinical capacity. Both the child‟s premature birth and the mother‟s subsequent abscondment from the ward and the consequent abandonment of the second baby, were drug related.