The politics of mental health provision in a liberal democracy

By Sipho Dlamini

The recent discussion between Eusebius McKaiser and Mazibuko K Jara on the place of liberalism in South Africa sparked an interesting question on mental health provision in a liberal democracy such as ours. In reading these discussions, I was reminded about a simple and yet incisive point about liberalism given by Professor Lewis Gordon, at the Unisa Decolonial Summer School in Tshwane earlier this year, in which he noted that the problem with liberalism is that it reduces the political to the individual. This is an important consideration in light of the Life Esidimeni tragedy. Additionally, it raises a number of questions about the provision of mental health services in our 24th year of democracy.

The aftermath of the Esidimeni tragedy in Gauteng was the setting up of a Commission of Inquiry to find, amongst other things, what resulted in the loss of lives. However much of the public discussion centered on the less than apologetic Qedani Mahlangu, former MEC of Health in Gauteng. This aspect of public discourse showed the immense focus on individuals within South African society rather than the largel lack of political will that created the Esidemeni crisis in the first place. Mahlangu was by no stretch of the imagination free of any personal responsibility; however, the focus on her as an individual has allowed us to lose sight of the larger political problem that created the conditions of possibility that led to the crisis.

The concern for the livelihood, not just in mental health, of poor and working class South Africans is political issue rather than one that can simply be reduced to individuals.

Liberalism, or (to introduce some nuance) a specific kind of liberalism, in mental health, straddles psychiatry and psychology for a match made in heaven. The two disciplines, psychiatry and psychology, play a significant role in mental health provision in South Africa but are based primarily on the centrality of the individual. Psychology has been criticized time and again for ignoring social conditions that often make it ripe for certain mental conditions to manifest and allow these mental conditions to go uninterrupted.

Some writers within Psychology have noted that psychological disciplines thrive under liberal conditions. The relationship between psychological disciplines and liberalism should be a cause for concern as that means the tragedy that we saw with Life Esidimeni is not that far away from happening again. Two issues make tragedy imminent in mental health.

The first is the issue of personal responsibility. We place the responsibility to access healthcare on individuals, who must find a way to access (often remote) mental health facilities that are adequate, even as we see that public infrastructure is crumbling. Simultaneously, access to expensive private mental health facilities is next to impossible for the majority of the country’s poor and working-class people. The second issue is about political responsibility. It does not only rest within the state. This means that those psychologists and psychiatrists in private practice, publicly funded institutions, and those in university spaces, must take an active stance in shaping mental health provision for the majority. These two conditions always leaves us as a country in the precarious position wherein we only react after tragedy.

We can, and should, focus on both personal and political responsibility. For example, in the context of Life Esidimeni, we should both find the persons responsible and hold them to account, whilst also changing the political landscape to be more just. However, the dominant form of liberalism as it stands right now asks us to do one or the other.

It takes a special kind of people to know that the political is an important instrument in achieving social change. Organisations such as Equal Education, and earlier in the current millennium the Treatment Action Campaign, have already shown the importance of a change that occurs at the level of the political. The fight for ARVs for HIV-treatment in this country can serve as a blueprint of civil organisations, ordinary South Africans, and some within government fighting to rectify a critical issue. Primarily, we should all be concerned about adequate mental health provision within public institutions as was the case with ARV’s, mostly because of the high number of people who rely on the public institutions for health in general, and the rates of private practice psychologists.

The full answer to the issues facing mental health provision in this country should not be reduced to individual responsibility without rectifying social conditions of many South Africans. It is disheartening to watch how little, in particular, psychology is involved in engaging with issues affecting the poor and working-class communities who often the bare the brunt of liberal politics. Poor and working-class people, who through the turn to individualism, continue to be progressively left behind both economically and socially. We cannot afford to let the crisis of Life Esidimeni move into the distant memory if we allow it to be spot in the countries memory we are also likely to forget to rectify the political issues that often lead to large-scale tragedies.

Sipho Dlamini is a Counselling Psychologist, a PhD Candidate, and a researcher at University of South Africa in the Institute for Social and Health Sciences.