Reflections on society as borderline mother. (2024)

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Introduction

While training as a clinical psychologist in 2003, I completed asix month internship at a large hospital that caters to the residents ofa township outside Johannesburg. The population of the townshipcomprises mostly black South Africans, and the majority of these peopleare poor.

During my time there, a woman (whom I will refer to as Ms X), wholived in a rural part of the country, disclosed to her partner andfather of her three-month old child that she and the baby were HIVpositive. The partner chased them out of their home saying that he didnot want anything to do with people who were sick. The woman travelledwith her child to Soweto to be with her mother. After disclosing her andthe baby's HIV status to her mother, she was once again thrown out.She presented at the hospital late at night with a sick, hungry andcrying baby, but was not helped. It is not clear exactly whathappened--whether she was told to return in the daytime to see a mentalhealth practitioner, or whether she was simply turned away. Shepresented herself to the hospital on the next two nights, but each timeshe left unattended. Eventually on the third morning she walked slowlydown the corridor which led away from the casualty department and endedup outside the inpatient psychiatric wards. There were unsubstantiatedreports that she was seen trying to smother the child along the way.When she reached the end of the corridor the baby was screaming, it wasin the same nappy it had worn for three days, was probably hungry andtired and would not be comforted. The mother held it by its legs andbanged its head into the cement floor until it was dead. She then satdown quietly next to her dead baby clutching her yellow hospital file,and remained there passively until she was taken away by police. Thebaby remained where it was for another few hours until it was eventuallyremoved by the morgue services.

There was initially a lot of confusion around what had happened,but when the story was pieced together, a number of the psychiatristswho worked at the hospital arranged that the woman be placed on awaiting list for psychiatric assessment. While waiting for theassessment some of her fellow inmates heard about what she had done, andbeat her very severely. She was taken to the same hospital'scasualty ward for treatment where she died of her injuries.

There were no words to describe the horror and distress I felt as anew clinician having experienced this incident. The events stayed withme and have subsequently shaped my thinking. It was the theories ofpsychoanalysis which held me at the time, having been shocked by theviolence and the horrific sight of the dead baby. The shattering of MsX's capacity to function and her consequent actions were echoed bythe hospital. Senior staff delegated the managing of the trauma and itsaftermath to the junior staff working at the coalface--a commonoccurrence in such situations. There were also hurried attempts atbrushing the incident aside and making it look like nothing--as thoughthe group was colluding to name it something it was not. I managed tosurvive the situation by doing what Ms X had been unable to do--linkingin with my internal and external objects and asking for help. I couldnot do it alone, although I felt pushed to do so. I now understand thosefeelings as a social projective identification of Ms X'sexperience. The help I received enabled me to organise a servicetogether with some of my colleagues. The candles, flowers, prayers andsongs at the site of the violence provided some symbolism to hold thehorror and give it meaning. It seemed at that event that the wholehospital was attempting to grieve and mourn and trying to make sense ofwhat had happened.

It was this experience, together with another aspect of my workthat was peculiar to this hospital, which led to the ideas explored inthis paper. As an intern at the hospital, my duties included assessingthe mental state of patients admitted after attempting suicide and whowere now medically stable. I was to assess their suicidality and thethreat of self-harm and determine whether the patients were emotionallyfit to return home. While interviewing these patients, and attempting tounderstand what had driven them to their actions, I was struck by thenumber of extremely trivial reasons given as the trigger for theimpulsive act. These included, for example, one young woman who ate ratpoison after her mother refused to buy her a very expensive pair ofjeans. Another woman drank bleach after discovering that her brother hadeaten the last piece of polony. The 'parasuicides', as thesepatients were called, were usually seen a day or two after admission. Bythis time they typically were no longer depressed nor had any thoughtsof suicide. What was unusual about the situation was theinstitutionalised way in which these patients were treated. There weresignificantly higher volumes of parasuicides than at other primary carestate hospitals, and they were seen as patients who needed to be'processed' as quickly as possible. It seemed that it was theduty of the psychology department to rubber stamp the doctors'decision that the patients were fit to be discharged, and that thisaction was an attempt to cover the hospital rather than a real attemptto make sense of what was happening in the patients' lives. Thepatients were made to wait outside the psychologists' offices, andwere fitted in around the psychologists' other appointments, oftenreceiving sessions of only 15 minutes. The vast majority of thesepatients were female, between 18 and 25 years, and would have met manyof the criteria of Borderline Personality Disorder (APA, 1994).

I began to wonder about all of these women. They had little problemsolving ability, were emotionally labile, had no hope for a betterfuture and no belief that they were in charge of their own destinies.Apartheid had ended almost 10 years previously, and while there was somuch hope being pinned to the idea of the 'Rainbow Nation',there was still so much horror and desperation in the lives of thepeople I was seeing. What happens to make someone so desperate that shecommits an impulsive act which ends the life of her child and ultimatelyher own life too? What makes life so cheap that it is worth throwingaway over a piece of cold meat? Why was there so much more horror inthis population of patients than in the other hospital settings in whichI had worked (such as a psychiatric hospital which serves apredominantly white population in a much more affluent area)?

In an attempt to make sense of what I was seeing, and to givemyself a bearing in the overwhelming sea of these patients, I returnedto theories of the genesis of personality disorders (specifically thatof Borderline Personality Disorder) in order to look for an explanationfor the labile affect, poor problem solving, impulsivity and unboundemotions I was witnessing. I started to think of these patients as allpresenting along a continuum of borderline illness, from the almostpsychotic, murderous mother on the one end, to the patients presentingwith a pernicious form of violence aimed at the self at the other end.Borderline behaviour has long been understood as a communication, wherethe hurt and distress are pushed into the other in an attempt to get ridof the feelings and to make others feel them (Rinsley, 1978). This isdone when mentalizing is impaired and the only option left is to harmthe self or harm another.

Many theorists take what is referred to as a'biopsychosocial' approach to the question of aetiology(Kaplan and Sadock, 1998), explaining in essence that a child is bornwith a genetic predisposition to the highly emotional way of being ofthe borderline. This predisposition, combined with a familial setting ofabuse, neglect and separation, results in the development of thebehaviour patterns associated with the disorder.

I was left unsatisfied with this explanation as it did not help meto understand why the phenomenon was so prevalent in this particularcontext, and I began to believe that the 'social' context ofthe 'biopsychosocial' explanation was not considered broadlyenough. Was there perhaps something about the greater socio-economic andpolitical context that was operating as a form of 'societalparent' which was affecting the psychological development of thesewomen?

Suchet (2004b) supports Lacan's view that the self is embeddedin socio-political processes, and that our past saturates our psyches,creating common internalised narratives. Fonagy (1989) also rehearsesthe Winnicottian idea that infants are part of a social world from theirearliest moments, and that they come well-equipped to develop thecapacity to comprehend the emotions and behaviour of those around them,as well as the thought processes which underlie those actions. It iswith this in mind that I would like to explore the context around thefemale patients I saw at the hospital and to attempt to explain what Iwitnessed there. I will start by briefly re-examining somepsychoanalytic ideas around borderline illness.

Some thoughts about borderline illness

Borderline pathology is a reflection of arrested development ofmany of the ego-functions, which creates a'stable-instability' in the personality. The borderlinepatient demonstrates depressive symptoms which are linked to feelings ofisolation and are demonstrated in angry demandingness. These patientsreport experiencing depersonalisation, anxiety, paranoia, and somaticsymptoms. They have unstable object relationships which are oftenhostile and transient (Cary, 1972) and which lack mutuality (Blechner,1996).

The borderline patient experiences such high levels of dread thatthey can become paralysed into inactivity. At the same time they alsofeel extreme pressure to act, even if they are not clear what theyshould do. They have a tendency to hurt themselves and others in orderfor the other to feel the same unbearable emotions that they experience.They rarely give any one solution a full chance, but rather jump betweena series of poorly conceived solutions (Blechner, 1996).

Most often an individual's primary internal objects have afigurative character. Such objects may have a good, bad or bizarrequality but will always be called to mind in the form of an'other'. It is Bollas' (1996) view that the internalobject of the borderline patient takes a form that is different to this.He suggests that in these individuals, the primary object (which isformed in the first year and is the template for all other objects) isnot simply a disruptive one, but is in fact disruption or emotionalturmoil itself. Whether these individuals had an innately disturbedpsyche, or were disrupted by their environments (or both), their primaryobject is a recurring affect. When the self then calls upon the objectby thinking about it, it experiences emotional turmoil and chaos. Inother words, instead of an ordinary, material object, theborderline's primary internal object consists of chaotic emotions.This means that when the borderline caves into an unbearable state theyfind themselves in a difficult paradox: although that state is dreaded,it is at the same time the individual's primary object and istherefore desired. Any emotions felt by these patients hint at theobject's presence and thus the borderline is always tempted to findthis object by escalating any ordinary feelings into powerful ones. Theobject eventually grows into a more complex form and becomes thetemplate for thinking, speaking, affect and the inner shape of the mind(Bollas, 1996).

Having briefly discussed some analytic theories of the origins andpsychic functioning of borderline pathology, I will now give somethought to the impact of society on psychic functioning.

Society's impact on psychic functioning

While historically psychoanalysis has been interested mainly in theindividual's internal mechanisms and how they affect psychicdevelopment, there has been a recognition of the role played by societyfrom early on. Freud (1921) commented: 'Each individual is acomponent part of numerous groups, he is bound by ties of identificationin many directions, and he has built up his ego ideal upon the variousmodels. Each individual therefore has a share in numerous groupminds--those of his race, of his class, of his creed, of hisnationality, etc.--and he can also raise himself above them to theextent of having a scrap of independence and originality' (Freud,1921, p. 129). This quote makes the point that individuals cannot beconsidered separate from their context, but that individual differenceswill determine how they respond to these circ*mstances.

Reflecting on the effects of society on psychic development,Carveth (1993) concludes that in the same way that some caretakers willbe better able to foster feelings of basic trust, security and cohesionin a child, so too will some societies be more successful at providingtheir members with a coherent world view and feelings of confidence,belonging, meaning and value which are the foundations of both personalidentity and social order. In situations of rapid social change andsociocultural displacement, a society is less able to integrate andsocialize its members and offer them a meaningful identity. This resultsin individuals experiencing identity diffusion as well as feelings ofisolation, meaninglessness, fragmentation, diffuse anxiety anddepression (Carveth, 1993).

More specific to the context in which I was working, I found theideas of Kirshner (1994) particularly helpful. He extends thepsychoanalytic concept of the 'second skin' (Bick, 1968),proposing the concept of the 'third skin', which is providedby beliefs and cultural values and can potentially provide psychicsafety. These systems underpin the structure of an individual'sinteractions both internally and with others, and also optimally protectthe internalised good object. In harmful situations this third skinmight contribute to the fragmentation of the individual and may even bedesigned to do so, in which case these situations attack the psychicintegrity of people and rupture the protective third skin. Thisthreatens the symbolic framework which would usually protect theinternalised good object (Eagle & Watts, 2002). This idea presentsus with way of integrating conventional, well accepted psychoanalyticconcepts that focus on the individual's internal world with arecognition of the impact of their social circ*mstances.

With this understanding of the importance of the circ*mstances inwhich one grows up for psychic development, the social context in whichthese patients lived will now be explored.

The social context

The patients I saw in this setting lived in a society fragmented bypoverty, violence, neglect and abuse. Were that not enough, that samesociety was beset by rampant HIV, with no treatment provided by thestate (even though there were treatment protocols available). Suspicionand mistrust abounded around issues of 'white' medicine andHIV testing. The denial of the illness as well as the denial of the needfor treatment perpetuated the discarding and negation of those in needby both members of the community and frustrated members of the medicalcommunity. It could be argued that this in itself created a murderous,even genocidal, societal template.

The level of violent crime in South Africa was also amongst thehighest in the world, contributing to high levels of hypervigilance,trauma and loss. In the years preceding my time at the hospital, theyears in which my patients were growing up, reports indicated that SouthAfrica had an extremely high incidence of rape, murder and seriousassault (Louw, 1997).

Perhaps the most important social factor, however, is the legacy ofApartheid and the damage it caused to the collective psyche,particularly in terms of wealth inequalities and racial tensions.

I would like to explore this social context (specifically racialoppression, violence and poverty) in more detail and examine somepossible ways that these social circ*mstances influenced the patientsthat presented during my time as an intern.

Oppression on racial grounds

In her paper about attitudes to race, Suchet (2004a) suggests thatthe concept of race refers to a complex range of both psychological andsocial experiences. The race and the racial identity of an individualare socially constructed and are dependent on the history of theindividual. She goes on to say that race gains meaning from the currentsocial context, and this context in turn carries with it thesignificance of the past.

I found many of Gump's (2000) ideas derived from theinvestigation of the impact of slavery to be relevant and applicable toaspects of race relations in South Africa. Gump (2000) explored how thepsychological effects of slavery are transmitted between generations. Inher elegant explanation she begins by describing how the slaves neededto be completely dehumanised in the mind of the slave owner, andconsequently in their own minds. The achievement of this state wouldobliterate any possibility of an empathic response to the slave'sneeds. Once the slave's subjectivity was negated all their feelingsbecame totally meaningless (and were in fact forbidden). Without anempathic other who can help to bear the unbearable, the only way tosurvive is to negate and disavow any pain. These disavowed emotionscontinue to exist, however, but become unreachable and inaccessible andcannot be tempered by cognition or by the restorative effects ofexperience. They are also unable to provide the individual with animportance source of information about the world. As affect is crucialto the development of the psyche, the prohibition of affect will limitand distort the personality's development. An individual with apsyche that has developed in such a way will not be able to soothe achild, and will thus try to prevent the child's expression ofdisturbing emotions as they are unable to contain them. Such damagedparents will attempt to stamp out any subjectivity in the child, whichwill be experienced as threatening to both themselves and the child.These parents will not be able to tolerate in the child the veryemotions that they themselves have not been allowed and this disavowalof any feeling is reinforced again and again, perpetuating anintergenerational pattern.

In a paper about the intergenerational transmission of violence bysurvivors of the Holocaust, Prince (1985) noticed that the usualchildhood changes and developments with regards to separation andindividuation are complicated by the parental need for symbiosis andfear of loss and separation. Added to this, the deep mistrust of theexternal world (caused by the realities of the past experience)strengthens any normal developmental anxieties. Thus issues of trust andmistrust become central in the life of the child of the survivor.Children of holocaust survivors also had difficulties with ideas ofcontrol and shame, were sensitised by the images of parentalhelplessness and degradation and occasionally re-enacted these withinthe family (Prince, 1985).

In conveying his ideas about the container-contained, Bion (1959)stressed that containing is not a passive function; it involves bothpartners in an active interrelationship which is dynamic and mutuallyinfluencing. He emphasised that an infant needs more than just duty froma mother--it needs a mother who can feel the baby's disturbance,and to a degree become disturbed herself. An understanding mother isable to experience the dread her baby strives to deal with by projectiveidentification, and yet to keep a balanced mind (Bion, 1959). Therelationship is a flexible one in which the contained enters thecontainer and has an impact on it, whilst the container and its shapeand function also modify the contained. It is an ongoing process ofmutual influence and adaptation. The central dimension of thecontainer-contained relationship is the 'balance of mind'.When a mother fails to achieve this balance, she becomes a containerthat is either too rigid or too fragile. In either case the infantreceives back its own projection with the implicit message that afterall, as it feared, its state of mind is not tolerable and it suffers, inBion's terms, a 'nameless dread'--i.e. a state of mindthat is not thinkable.

I believe that the mechanisms described by Gump (2000) and Prince(1985) expand Bion's container-contained ideas, and are relevant tothose affected by the systematised negation and dehumanisation ofapartheid. The draconian laws of apartheid, which were often randomlyapplied, created a state of terrible unpredictability and could beconsidered to be analogous to the uncontaining environments which theliterature associates with the development of a borderline psyche. It isargued that the context of Apartheid South Africa and its legacy, withits parallels to the repression of slavery and of the holocaust, leftmany parents unable to contain the difficult emotions shown by theirchildren as they themselves had not had those same emotions contained.In some, this may then have resulted in the poorly developedego-structures typical of borderline pathology.

Children who are exposed to fearful environments in a sustained waymay not show the usual anxieties which follow acts of hostility andcruelty (Berman, 1992). Such environments may lead to sociallydestructive traits in individuals who may not be able to learn fromexperience, or may be emotionally unresponsive, or may even demonstrateaggression to the point of homicidality. These children may feel likevictims, may be hostile and bitter, and may feel cheated in life. Stein(1996) links the Apartheid system to insecure attachments, feelings ofrejection, disturbed relationships, and poor inner controls. He statesthat some children who grew up under the Apartheid regime have poorlydeveloped psychological and emotional functioning and may have been leftwith a chaotic and destructive inner world, and as a result of this maylack the ego and superego development which contains this innerconflict. They may instead turn to the external world, demonstratingacting out and pathological behaviour.

One of the consequences of the Apartheid system was the povertythat was experienced by the disenfranchised. Bychowski (1970) exploredthe psychological consequences of living in poverty and observed thatpoverty impacts young children's cognition severely enough tocreate a picture of intellectual dullness in the tasks of reading andwriting. Projective tests revealed isolation, alienation, andsuggestions of emotional coldness. Children who grew up in seriouspoverty had difficulties forming constant object relationships and theirmood tended to be apathetic, depressed and sullen. These deficits areconsidered a result of the combination of emotional, nutritional andmaterial deprivation.

Hostility in poor individuals is also cultivated by anger at beingneglected, or fear of being abandoned, as a result of the familysituation (Bychowski, 1970). Many black children were separated fromtheir parents under Apartheid, as the parents may have needed to liveand work in other areas and were often not allowed to live under thesame roof.

The high possibility of abandonment and other disappointmentscreates anxious object relationships. This deprivation is expressed inmoods of hopelessness, apathy and depression. These moods are intermixedwith outbursts of anger and, on occasion, physical aggression. However,even at early stages, hostile aggression may be turned against the selfand may be demonstrated in somatisation or self-destructive behaviour(Bychowski, 1970).

With this background set of ideas in mind, it is credible toimagine that Ms X may have had no template for caring for, or soothing,an inconsolable baby. The baby's desperate cries would have calledto mind those desperate feelings that had been dangerous for her to haveexhibited previously and which would have been stamped out. She wouldhave had the urge to act, but not have been able to work out theappropriate way to do so. Ms X was very obviously not contained by herprimary objects (her mother and her partner), but she was also notcontained by the 'brick-mother' of the hospital (Rey, 1994) orby the 'mother' of society. This eventually led to herfragmentation and violence.

The same can be said for some of the 'parasuicides'. Withmothers who were unable to bear their child's demandingness, theywould not have developed an ability to bear disappointment when theywere not given what they desperately wanted. Needing to do without whatwas desired would have felt unbearable and would have precipitated anoverwhelming and unbounded rage at the other for not supplying it, andat the self for wanting it in the first place. Such feelings may wellhave precipitated self-destructive behaviour in the form of suicidalgestures.

Together with the racial oppression experienced during the years ofApartheid, there were also high levels of violence. The next sectionconsiders some of the psychological effects of living under suchcirc*mstances.

Violence

The violence in the townships in the time of Apartheid and thecrime and violence following that time is well documented. DuringApartheid people disappeared, were attacked by the police, were brutallyuprooted and were involved in civil unrest between different factions(Straker, 1992).

Children exposed to the trauma of war or community violence maysuffer injury themselves and may witness violence or injury done toothers or to property. They may be forced to participate in suchviolence and may also experience loss or separation from loved ones(Gensler, 2002). All of these experiences may leave the childtraumatised. The experience of trauma erodes an individual's senseof safety, which is developed through a history of secure experienceswith others. Trauma may cause a sudden slashing of emotional connectionsor even a complete annihilation of any affirming bonds. Communitieswhich are exposed to ongoing trauma may begin to demonstratedisintegration and adaptation similar to the coping strategies oftraumatised individuals. Traumatic events do not only affect the psychicstructures of the self, but also the attachment systems joining theindividual and their community (Borg, 2004).

In his paper exploring the psychological effects of socio-politicalviolence in Argentina, Puget (1988) writes that it is the parents whogive meaning to a child's early experience of violence, and themeaning they give represents and reinforces the social macro-context.The immature infant must rely on its parents for meaning until it isable to create its own meaning. However, if early violence is excessive,the child's mental apparatus may not develop the ability tosymbolize and bind anxiety associated with exposure to violence. Duringtimes of social disaster, violence and death, individuals may enter a'state of threat' which causes them to become disorganised. Inthis state the ego loses its capacity to realistically discern thedegree of danger from the external world. In attempting to determinewhether the perceived attack is imaginary or real, the ego confuses whatis external and what is internal and thus exactly what the enemy is. Theindividual's mind is washed with perceived danger and by circular,repetitive thoughts which compromise mental functioning (Puget, 1988).

Berman (1992) explored the effects of living with violence andconcluded that humans have the tendency to move in one of twodirections: either that of change and distance from the situation ortowards a desire to join with the violence and become part of it. If thesecond option is chosen by a community, members of that community becomeapathetic and lose hope and interest in life. The horror in thissituation is that there is apparently no horror experienced about thedeath and destruction, which becomes commonplace.

Parson (1995) researched the effects on children of living inviolent inner-city settings. He found that children exposed tointrafamilial and community violence resemble those suffering thetraumatic neurosis of wartime. A societal context where traumatisationis endemic can produce a form of 'combat fatigue' in a child,which further overloads the ego because of the perceived constant threatof danger. Parson (1995) stated that this creates a pattern of'biopsychic' trauma symptoms where the ego's normalmental protective shield is ruptured as a consequence of overwhelmingevents, which strain the victim's psychic and biologicalcapacities. This in turn results in deficits in taking the perspectivesof others and thus in the capacity for empathy.

This occurs because from the very beginning of an individual'slife, the nature of their intersubjective relations is internalised andinfluences the quality of the psychic links which they develop in theirinternal world. In violent family or social situations early phantasiesof retaliation are likely to eventually crystallise into more stableidentifications with the aggressor (Maiello, 2001). State violencelegalises persecutory relationships, and this perverts transsubjectivelinks and identifications. Traumatic experiences in such circ*mstancescreate traumatic expectations and these prevent the individual fromrevising or modifying their experiential patterns, and thus a result oftrauma is a reduced flexibility and openness to change of both internallinks and external relationships, thereby creating an endless loop ofrepetition (Maiello, 2001).

The principal victim in the trauma is thus the individual'sego and its functions, which are weakened and become ineffectual. Theego is no longer able to bind the drives or to integrate experiences.The individual therefore operates in a primitive, regressed state. Inclimates of ongoing violence the individual experiences danger aspersisting both externally and internally, and this creates a situationof ongoing hypervigilance. The defences established to manage thesesituations include aggressive, split-off and dissociated mentalprocesses and these are associated with primitive anxieties and fears.The state of hypervigilance is consequently damaging to psychologicaldevelopment and results in a compulsion to repeat the experience inorder to master it (Parson, 1995).

Violence is easy to internalise and repeat, but it is difficult tounlearn. The nearly irreversible effects may be almost constantlyreplayed and remembered if the victim is not able to defend the psycheby making use of dissociation, repression, or identification with theaggressor (Adams and Arnow, 1996).

All of the research discussed above clearly demonstrates thedevastating effects that ongoing violence has on the ego apparatus of anindividual. It is my suggestion that a chaotic and violent socialenvironment can form the template of the primary object of theborderline as described by Bollas (1996), as well as the ego-deficitsand defences common to borderline illness.

While the personal histories of Ms X and many of the parasuicidesare not known, I believe that it is fair to assume that, while growingup as a black person in the rural areas of South Africa soon after theend of Apartheid, these women were regularly exposed to ongoingcommunity violence and the constant threat of more danger. This couldexplain their impulsivity, lack of empathy, lack of hope for a differentfuture and the poor problem solving ability of a handicapped ego. Thechaotic situation may easily have formed the template of the chaoticemotions, and there would certainly be a sense of familiarity with suchan emotional state--reminiscent of Bollas's (1996) primaryborderline object.

In addition to community violence, some of the'parasuicides' described how the poverty and oppression oftheir childhood also fostered boundary violations, as families andindividuals had to make do with very little. Parents needed to leavetheir children to find work far away (often as miners or domesticservants who were expected to live at their places of work) and thisfurther promoted feelings of neglect. The patients described living incramped environments with strangers and little or no privacy. Thisproximity creates a perverse form of intimacy with strangers, in whichgirl children end up bathing and changing in front of adult males whomay desire to harm or use them rather than to protect them. This kind ofabuse is a breach of taboo boundaries. Many of the patients also gave ahistory of severe and sustained violence (both sexual and physical)perpetrated against them. The nature of this kind of violence ishumiliating and crosses all boundaries and hierarchical socialstructures which would usually protect children. The effect of such anupbringing is also well documented in the literature on the aetiology ofborderline pathology. Several researchers report that as many as 86% ofborderline patients were found to have been childhood victims ofincestuous boundary violations, compared to 34% of the generalpopulation (Gartner, 1996).

Discussion

It is my hypothesis that the women who were presenting as patientsat the psychiatric department at the hospital grew up deprived in allways: they were 'told' by the laws at the time that they werenot human, they were abandoned by mothers who needed to get work andwere surrounded by others similarly impoverished, which prevented themfrom coming into contact with other ideas or adaptive models of problemsolving behaviour. Being surrounded by high levels of violence literallyput their lives in danger every day. Those who were sick with a deadlyvirus were unable to receive the treatment that would save their lives.Thus they were left with feelings of life not being in their control andof their destiny not being something that they could manipulate ordirect. They were not able to develop mental structures which would havebeen able to help them to tolerate the situation or to find solutions toit. They would also not have been given any experience of processing andbearing difficult emotions without harming themselves or others. Thismeant that the simplest of frustrations left them feeling overwhelmedand with little hope that engaging in their world would result in apositive outcome. With no hope that they could do anything that wouldimprove their lives, there was little to stop them when struck bythoughts of suicide or homicide. They were not 'held' orcontained by society, healthcare structures or by their own families.They were surrounded by chaos and turmoil, and constantly had theirboundaries impinged upon. I believe that the combination of thesefactors resulted in the large number of patients presenting somewhere ona borderline continuum between an almost psychotic murderous rage anddespair and self harm. Their social circ*mstances can thus be likened toa toxic third skin which damaged emotional development and psychicstructures (Kirshner, 1994).

The case of Ms X demonstrates how the state had let down thehospital (with staff shortages, lack of provision of requiredmedication, neglect and mismanagement), which in turn let down themother by offering her no assistance. She then let down her baby in themost heinous way imaginable: after having been let down by all thestructures supposedly there to support her, and those closest to her,and having no capacity to find a way out of the situation, she wasovercome by rage, hatred of the demanding baby and out of sheerdesperation she felt as if she had no option but to kill her infant. Herinexplicable choice becomes somewhat more understandable, however, givenhow she had been atomised and isolated by all the structures which weresupposed to contain her and to help her to make sense of her world. Itis my assertion that in order for us to have good enough mothers we needto have a good enough society--an environment which can receive, absorband metabolise horror, violence, hate and pain. It seems that we stillhave a long way to go.

The exploration of these issues raises important questions such as:

* For every patient who presented in the ways described, there werecountless others who had overcome similar circ*mstances and had notdeveloped the same ways of engaging in the world. What are the factorsthat protect some and precipitate pathology in others?

* What happened in the structures of the hospital to allow this tohave occurred? The work of Isabel Menzies Lyth (1958) and her researchinto defence structures used by nurses in hospitals might be helpful tounderstand how someone in such need was turned away.

* What is important to consider in the future treatment of patientswho present with the histories and circ*mstances described?

* How do we prevent such events from continuing to occur inpost-apartheid South Africa?

While these questions are important to continue to explore, my aimin writing this paper was to attempt to understand the patients whopresented in the ways described and to provide for myself and others aframework of meaning. But I also wrote it to honour the women from whomI learnt so much, and to say publicly that I saw and felt the horror.

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I would like to thank those who reviewed and assisted me in thewriting of this paper. I would also like to thank Susan Levy (mysupervisor at the time of the incident) for her support and help inthinking at a defining time in my life.

Karen Gubb is a clinical psychologist working in a psychoanalyticprivate practice in Johannesburg. She is currently completing her PhD atWits in the area of somatic complaints. Email: [emailprotected].

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