South African Psychiatry - February 2019

FEATURE
IT STRIKES ME THAT WHAT FREUD (1938)
DESCRIBES AS THE SPLITTING OF THE
EGO IS AN ORGANISED STATE AND
THAT THIS MAY NOT BE POSSIBLE FOR
INDIVIDUALS WHO HAVE LOWER LEVELS
OF INTERNAL STRUCTURE, INTEGRATION
AND CONSTANCY AND WHO ARE THUS
MORE ESSENTIALLY DISORGANISED
PSYCHOLOGICALLY.
Perhaps Wilfred Bion (1957) and Andre Green (1999,
2001, 2003) offer pictures of the ‘psychic poverty’
which may ensue in such situations. Green argues
that it is possible early in life for primary identification
to be soldered not in relation to an object but, rather,
in relation to a black hole, a hole nevertheless with
a potent charge. The original object then only has
a negative existence. Green (2002) describes how
thoughts, images, passions and impulses flicker on
and off, often loaded with terror and dread looking
for a name and a place, but, finding only a bleak,
harsh, heavy, silent core. The mental activity which
gives birth to substitute representations and free
associative pathways in the mind is under the threat
of being destroyed as the black hole in the mind
attracts and destroys thoughts and substance and
structure are swallowed up.
THIS IS NEGATIVE NARCISSISM WHICH IS
PERVERSE AND ALIENATING. THE DRIVES
ARE THEN EXPRESSED THROUGH ACTION
AND SOMATIC DISCHARGE RATHER
THAN IN WORDS.
Similarly, for Bion (1957) destructive attacks on
links with feelings, parts of the self, objects and
reality as a result of a certain set of circumstances
during the initial developmental stage lead to the
predominance of associations which appear to
be logical, almost mathematical, but are seldom
emotionally reasonable as a result of excessive
projective identification. In Differentiation of the
Psychotic from the Non-Psychotic Personalities Bion
(1957) argues that the thoughts which arise are
severed, fragmented, isolated and concrete and, yet,
they are experienced with certainty and are devoid of
true curiosity. This is actually a highly confused state.
JUSTICE MOSENEKE TRIED REPEATEDLY
TO ASSIST DR MANAMELA WITH HER
DIFFICULTIES IN TERMS OF HER RIGID,
ILLOGICAL, CIRCULAR THINKING. FOR
EXAMPLE: “WE WILL NEED SOMEONE TO
LEAD YOU IF YOU GO ON IN AN OPEN
ENDED WAY,” AND LATER “I WANT BASIC,
SIMPLE SENTENCES WITH A SUBJECT
AND AN OBJECT.”
This incoherent thinking and confounding of reality
is clearly illustrated in the following transcript from
the arbitration. Dr Manamela, appears to have no
appreciation of cause and effect and thus problems
cannot be stated let alone solved, as described by
Bion (1957).
Dr Manamela: ‘Justice I’m giving you the procedure
as it happens. That’s what I’m trying to give to these
proceedings. Because I felt I must tell you what
events took place before I come to the questions.
Now it’s two way. I must answer the question and tell
you what happened. The unfortunate part some of
the people who came before me some of them who
didn’t understand the process they told you what
they told you and it’s like now I come as an accused.’
Justice Moseneke: ‘I’m going to ask the question
again. What did you do?’
Dr Manamela: ‘What I just explained is what we did.
Should I explain again?’
There is a sigh from Justice Moseneke: ‘I don’t know
what you are saying. Yes you would have signed it or
no I wouldn’t have signed it? What are you saying?’
Dr Manamela: ‘Justice what I was saying is how did it
happen. That’s the truth I know.’
Counsel Groenewald: ‘I am putting it to you that you
are shifting blame...Take responsibility. And say well
there was a number of issues and I shouldn’t have
issued these licences and I know it now.’
Dr Manamela: ‘Counsel, it was presented to me that
the NGOs can be able to manage..you don’t deliver
by yourself all the time...’
Justice Moseneke: ‘No, but listen to the question. Do
you know now according to you what you did not
know then? But do you know now that you should
not have issued the licences? That’s what counsel is
asking you. What is your response to that?’
Dr Manamela: ‘I know now but I still saying I didn’t...’
Justice: ‘No, no, do you know now that you should
not have issued the licenses?’
Dr Manamela: ‘That is what these proceedings are
saying but I...’
Justice: ‘No! No! No! No!’
Dr Manamela: ‘But I..’
Justice: ‘Counsel wants your answer. Do you know now?’
Dr Manamela: ‘I know now although I don’t agree with
the now because at the time when I issued the licenses
the NGO were eligible to take care of the patients.’
Justice: ‘No as you sit where you sit now knowing
your statutory responsibilities... knowing that now do
you think the right thing in issuing the licences where
143 died? That is the question.’
Dr Manamela: ‘But I said at that time I knew at that
time it was right. Now I know that you are saying it
was not right.’
Justice: ‘You are saying that?’
Dr Manamela: ‘I am saying according to the legal
document I have I still know there that was no
request that I be delegated. Last week I was told that
what I know is not right. That’s what you said to me.’
SOUTH AFRICAN PSYCHIATRY ISSUE 18 2019 * 23